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CYCLOPEDIA
OP THE          £u&
PRACTICE  OF   MEDICINE.
Edited by Dr. H. von ZTTVSSEN.
  PBOFESSOB OF CLINICAL MEDICINE IN MUNICH, BAVABIA.
                  VOL. II.


ACUTE  INFECTIOUS  DISEASES.

   By PROF. THOMAS of Leipzig, DR. CURSCHMANN of Berlin,
     DR. ZUELZER of Berlin, PROF. HERTZ of Amsterdam,
          and PROF. VON ZIEMSSEN of Munich.

                  ©ranslaterj 63

JAMES C. WHITE, M.D., AND EDWARD WIGGLESWORTH, Jr., M.D., of Boston;
  EDWARD W. SCHAUFFLER, M.D., of Kansas City; and A. BRAYTON BALL, M.D.,
  J. HAVEN EMERSON, M.D., GEORGE H. FOX, M.D., EDWARD FRANKEL, M.D.,
           and JOHN C. JAY, Je., M.D., of New York.
ALBERT H. BUCK, M.D., New York,
      EDITOR OF AMERICAN EDITION.
                      NEW YORK:
          WILLIAM  WOOD AND COMPANY,
                   27 GREAT JONES STREET.
                          1ST5.
i 

 Entered according to Act.of Congress, in the year 1875, by
            WILLIAM WOOD  &  CO.,
In the Office of the Librarian of Congress at Washington.
ALL  RIGHTS  RESERVED.
    John F. Trow & Son,
  PRINTERS AND BOOKBINDERS,
205 to 213 East Twelfth Street,
          NEW YORK. 
i
   TriE Editor takes pleasure in acknowledging the great assistance he has received
from Dr. Frank P.  Foster, in preparing the present volume for the press. 
 
BIOGRAPHICAL  SKETCHES OF THE  AUTHORS.1
    Louis Thomas was born January 22d, 1838, at Mockern, near Leipzig,
where his father was a school-teacher.  He was prepared for the " Gymna-
sium," by private tutors, and left that institution in 1855.  He underwent his
first medical examination in November, 1857, and in 1858 became Clerk of the
Medical Clinic, which  position he  held until 1860.  He was~"graduated  in
December, 1860, and  was immediately appointed Assistant  at  the Surgical
Clinic at Rostock, but  in 1861 was made Assistant at the Medical Clinic.at
Leipzig.   This position  he  held  until  1865.  During  this period (1863  to
1865) he was Instructor  in Medicine.   In July, 1865, he was made Director
of the Polyclinic at Leipzig, and in  August, 1868, Professor.   His writings
on clinical subjects  are  numerous, and are contained  in the  " Archiv fiir
Heilkunde."

    Heinrich  Curschmann,  born  June 28th,  1846, at Giessen, in Hessia,
attended the Gymnasium of his native city, and studied  at the University in
1863.  He was graduated in 1868, after having served, during his last term,
as Assistant at the Polyclinic.  He was then appointed Assistant Physician
of the City Hospital  at Mayence, which included the  position of Second Phy-
sician to the Invalid Hospital.  During the great epidemic of  small-pox  in
1870  and  1871, which was very severe in Mayeiice, he was commissioned  as
city small-pox physician.  After three years' service in these positions, he left
Mayence, in order to prosecute his scientific studies in Berlin.  Somewhat
later he began practice in the latter  city.   His first scientific  paper, histologi-
cal in character, appeared in 1866,  in Kblliker's " Zeitschrift fur wissentsch.
Zoologie."   His later  articles  are partly  of an  experimental, and partly of
a clinical character, and may be found in the " Archiv fur klin. Medizin,"
and the " Archiv fiir Psychiatrie und Nervenkrankheiten."

   Wilhelm Zuelzer, Instructor at the University of Berlin and Director of
the Charite, was born  at  Breslau, November  10th, 1836.   He studied  in
Breslau and Berlin, and, after passing his examinations,  in Vienna and Paris.
      1 Very kindly furnished by Prof, von Ziemssen, for the American edition. 
 VI          BIOGEAPHICAL  SKETCHES  OF THE AUTHORS.

 On his return, he served in All Saints' Hospital, in Breslau, and subsequently
 went to Berlin again, to continue his studies.   From there he went to Russia,
 in 1865, in order to study the epidemic of relapsing fever which was  prevail-
 ing there.  In 1866 he went  to England, where he devoted  himself to the
 matter of hospitals and sanitary affairs.   With  the object of establishing, a
 basis for the etiology of infectious diseases, he founded  the  " Weekly Journal
 of Medical Statistics and Epidemiology," which was continued until  the out-
 break oi the late war.   He paid special attention to the manner in which epi-
 demic diseases spread in Germany, although the conditions at large did not
 escape his notice.
    He published a dissertation entitled " Examination of the Structure and
 Functions of the Stomach," and the following articles: " On Absorption by
 the External  Skin" (Wien. med.-chir. Rundschau);  "On the Subcutaneous
 Administration of Various Remedies " (morphine, quinine, strychnine, etc.)
 (Berl.  klin. Wochenschrift, and Wien.  med. Halle,  1861, 1862,  1863,  et
 seq.);  "On  Excitants" {ibid.,  1870);  "On the Action of Derivatives"
 (Deutsche Klinik,  1865); "The Theory of  Uremia " (Berl.  klin. Wochen-
 schrift, 1865);  "On Putrid Infection" (ibid., 1869).  In 1867 he published
 a German translation of Murchison's " Treatise on Continued Fevers," as also
 a report of the epidemic of relapsing fever at St. Petersburg.   He also pub-
 lished, in 1870, " Contribution  to the Etiology  and Pathology of Typhoid
 Diseases," Vol. L   His articles on the etiology of spotted fever appeared in
 the "Berliner  klinische Wochenschrift" for 1872 and  1874,  in the " Cen-
 tralblatt fiir d. med. Wissensch." for 1874, and in  Eulenburg's " Vierteljahres-
 schrift"  for 1868, 1869, and  1873.   His "Contributions to the Pathology
and Therapeutics of Variola " appeared in  the " Berl. klin. Wochenschrift"
for  1872  and 1874; and his article on the peculiar development of the  cholera
poison, in the same journal  for 1874.  Some other essays by him have been
published in the Transactions of the Berlin Medical Society.

   Henry Hertz,  the  son of an innkeeper at Greifswald, was born  Jan-
uary 20th,  1832.  It being  his  father's desire that he should learn the book
trade, he left the high school of his native  town in 1847, having advanced to
the second class.  He served his apprenticeship of four years, and then acted
as clerk for one year in Greifswald, and for  two years in Berlin.   Having
 determined to  abandon his occupation,  he now returned to  Greifswald in
 order to prepare himself for the necessary college examination,  which'he
 passed  successfully in the spring of 1856.   In the  autumn  of the same year he
 was matriculated as a student  of medicine  at. Greifswald.  He  afterwards
 went to Wiirzburg, and, during his  spring and summer vacations, to  Berlin 
             BIOGRAPHICAL SKETCHES OF THE  AUTHORS.         vii

Prague, and ATienna.  Having completed three courses, he returned to Greifs-
wald, where he was graduated July 28th, 1860, his thesis being entitled, " De
nonnullis chemicis cerebri elementis."  In the following winter he passed his
" State  examination."  During the  latter years of  his curriculum he  had
assisted at  the  Medical Polyclinic  of Niemeyer and Riihle.  After having
passed his examination, he was made Assistant at the  Pathologico-Anatomical
Institute, under Grohe.   In  the  spring of 1861 he  gave private instruction
in pathological anatomy;  and towards the end  of  1867 he was called to the
chair of Pathological Anatomy at  the Athena3um in Amsterdam.   A year
and a half afterwards he was intrusted with a division of the  Medical Clinic,
and subsequently with the chair of Clinical Medicine and Physical Diagnosis,
and, after Schrevoogt's death, in 1871, with that of Psychiatrics.
   His literary productions consist  of contributions  to journals, on subjects
relating to  normal  and pathological histology (of the lungs, the kidneys, the
teeth,  the  nerves,  etc.), and  to  clinical  medicine, in Virchow's " Archiv fiir
pathology Anatomie," and in the " Deutsches  Archiv fiir klinische Medizin." 
ERRATA.
   Vol. I p. 161, eighth line from top, for " trifacial" read " facial."
   Vol. II. p. 399.  For formula for chloral enema, read :  Chloral, from one and a half
to two drachms ; gum arabic mucilage, water, each eight fluidounces.
   Also, for formula for Stokes's Cognac mixture, read :  Best brandy, distilled water,
each two fluidounces; the yolk of one egg] syrup,  one fluidounce. 
CONTENTS.
                                   THOMAS.

            Varicella,  Measles,  Rubeola,  and  Scarlet Fever.
                                                                          PAGE
     Introduction............................................................   3
Varicella.................................................................   5
     History.................................................................   6
     Etiology  ...............................................................   8
     Pathology..............................................................   10
        Anatomical  changes.................................................   10
     Symptomatology.........................................................   15
     Diagnosis...............................................................   22
     Prognosis..............................................................   29
     Complications...........................................................   29
     Treatment,.............................................................   30
Measles...................................................................   31
     History.................................................................   36
     Etiology................................................................   37
     Pathology...............................................................   62
        Anatomical changes.. .*...............................................   62
     Complications...........................................................   90
     Sequela;................................................................. 102
     Diagnosis............................................................... 106
     Prognosis............................................................... 109
     Treatment.............................................................. 116
Rubeola.
                           (Rotheln, German Measles.)
    Historical  notice......................................................... 130
    Etiology................................................................ 134
    Symptomatology.......................................  ................. 141
     Complications........................................................... 147
    Prognosis............................................................... 147
     Treatment.............................................................. 147
                 (Translated by Edward Wigglesworth, Jr., M.DJ
Scarlet Fever.
    Introductory remarks.................................................... 158
    History......................................................  .......... 159
    Etiology................................................................ 161 
X                                CONTEXTS.
                                                                           PAGE
    Pathology...............................................................  20~
        Anatomical changes.................................................
        Different forms of scarlet fever......................................  "^
        Course of the disease in its usual forms................................  ^  '
        Affections of the lymphatic glands.....................................  *^2
        Affections of the joints........................ ......................  243
        Scarlatinal nephritis.................................................  '"44
        Irregular course of scarlet fever......................................  *5U
    Complications...........................................................  274
    Sequela, . ..-.............................................................  283
    Diagnosis............................................................... 284
                      (Translated by Edward Frankel, M.D.)
    Prognosis...............................................................  287
    Treatment..............................................................  297
                      (Translated by John C. Jay, Jr., M.D.)

                                CURSCHMANN.
Small-Pox.
                   (Variola,  Varioloid, and other modifications.)
    History.................................................................  320
    Etiology...............................................................  325
    Pathology...............................................................  340
    Symptoms and course of the  disease........................................  340
        Regular course of  variola vera........................................  355
        Variola confluens.................................  ..................  366
        Variola hemorrhagica pustulosa.............^........................  369
        Varioloid...........................................................  372
    Complications and sequelm................................................  378
    Anatomy...............................,...............................  380
    Diagnosis ..............................................................  388
    Prognosis.......................................................'........  391
    Ireatment and prophylaxis...............................................  395
        Vaccination.........................................................  401
                      (Translated by George H. Fox, M.D )

                                  ZUELZER.
     Erysipelas, Miliary Fever, Dengue, Influenza, and Hay Fever.
Erysipelas.
    Definition................  ..............................................  423
    History.................................................................  423
    Etiology................................................................  425
        Exciting causes......................................................  432
     athology...............................................................  441
        Anatomical changes..................................................  443 
                               CONTENTS.                                 XI

                                                                           PAGE
    Symptomatology.........................................................  451
    Complications and sequela ...............................................  465
    Diagnosis...............................................................  470
    Stages and duration.....................................................  472
        Relapses............................................................  473
     Varieties...............................................................  474
    Mortality and prognosis..................................................  476
    Treatment..............................................................  477
Miliary  Fever.
    Introductory remarks....................................................  486
    History and epidemiology.................................................  487
    Etiology................................................................  491
    Anatomical changes......................................................  495
    Symptomatology.........................................................  497
    Diagnosis...............................................................500
    Mortality and prognosis..................................................  501
    Treatment..............................................................  502
                       (Translated by James C. White, M.D.)
Dengue.
    Definition...............................................................  506
    History and etiology.....................................................  507
    Symptomatology........................................................  510
    Treatment.............................................................  514
Influenza.
    Definition...............................................................  516
    History.................................................................  517
    Etiology................................................................522
    Pathology...............................................................  527
    Symptomatology.........................................................  528
    Diagnosis...............................................................  535
    Mortality and prognosis..................................................536
    Treatment..............................................................  536
Hay Fever.
    Introductory remarks....................................................  540
    Etiology................................................................  542
    Symptomatology.........................................................  547
    Diagnosis...............................................................  551
    Treatment..............................................................  551
                     (Translated by J. Haven Emerson, M.D.)

                                    HERTZ.
Malarial Diseases.
    History.................................................................  557
    Geographical distribution................................................  559
    Etiology...............................................................  563 
Xii                                CONTENTS.
                                                                            PAGE
    Pathology..............................................................
    General course of the disease...............................................
                                                                             588
        Simple intermittent.................................................
        Masked fevers......................................................  598
        Pernicious fevers....................................................
        Remittent and continued malarial fevers...............................  614
        Chronic malarial infection............................................
    Patlwlogical anatomy.....................................................
    Analysis of individual symptoms.........................................   "30
    Course and sequelae of the disease..........................................  "47
    Prognosis...............................................................  "5"
    Diagnosis...............................................................  "^"
    Treatment.............................................................  "^
                   (Translated by Edward W. Schauffler, M.D.)

                               von ZIEMSSEN.
Epidemic Cerebro-Spinal Meningitis.
    Introduction............................................................  687
    History.................................................................  687
    Etiology................................................................  690
    Pathology..............................................................  697
        General description of the disease.....................................  697
    Pathological anatomy....................................................  703
    Analysis of individual  symptoms.........................................  707
    Complications and sequela................................................  721
    Diagnosis..............................................................,  730
    Course, duration, and terminations........................................  732
    Prognosis..............................................................  733
    Treatment..............................................................  733
(Translated by A. Bray ton Ball, M.D 
VARICELLA, MEASLES, RUBEOLA,



             AND




    SCARLET  FEVER.
THOMAS. 
% 
INTRODUCTION.
   The conception of acute exanthematic diseases,  in the sense
of specific morbid processes, is an abstraction belonging to recent
times ; the physicians of antiquity and of the middle ages, so far
as they paid any attention to the occurrence of acute exanthems,
regarded these as merely individual manifestations of that '' pes-
tilent fever" under which they classified no small number of  epi-,
demic diseases,—a way of  looking at morbid  phenomena which
renders it difficult, and often impossible, for the investigator of
modern times to profit by  the records of those observers, and to
derive any exact information with reference to the manifestations
of the acute exanthems, as they occurred at that time.
   The  term acute  exanthems  is applied  to those  infectious
diseases characterized by a regular sequence of individual mani-
festations which arise from a specific  contagion,  and are distin-
guished  by typical morbid appearances  of  the  skin.  These
properly comprise Measles,  Rubeola,  Varicella,  Scarlet Fever,
Variola,  and Vaccinia.  As to Erysipelas, doubts  may  be  still
entertained.
   The common character,  especially of the first-named diseases,
expresses itself  in the facts,  I. That a  feverish condition pre-
cedes or accompanies the appearances upon the  skin,  with  the
exception at most of the  lightest cases;  II.  That the appear-
ances upon the skin are developed in a definite order, at definite
periods ; III. That the participation of the organism, as a whole,
is  shown  by the occurrence  of definite morbid phenomena pro-
ceeding from various organs and systems;  IV.  That these  dis-
eases, with rare exceptions, attack the same person but once.
   For the sake of clearness, it is customary to divide the course
of the acute exanthems into single stages, and  to distinguish: I. 
4
INTRODUCTION.
The  stage of incubation, of latency, or of the latent affection
(these two terms not being always properly applicable), from the
moment of infection to the beginning of well-marked  and gen-
erally feverish symptoms ; II. The prodromal or precursory stage,
stad. prodromorum, from  the commencement of  positive dis-
ease to the  distinct appearance of  the typical  eruption; III.
The stage of eruption, that of the forming and formed exanthem,
divided accordingly by many, for the sake of distinction, into the
stages of eruption and florescence ; IV.  The stage of retrocession
of the essential exanthematic  process (stad. desquamationis,
exsiccationis, decrustationis), which begins  as soon as the exan-
them has  passed  its maximum  of development, and convales-
cence occurs, recognizable by the disappearance of  all local and
general (febrile) symptoms. 
VARICELLA.
Vidus Vidius, Ars univ. med.  Venet., 1596.  P. LT. L. Xffl. cap. 6.—Sennert, Med.
    pract.  1. IV. c. 12.—Riviere, Prax. med.  Lugd., 1660.   T. II. p. 685.—Diemer-
    broek, De variolis et morbillis, c. 2.—Heberden, Med. Transact,  of  the  Coll. of
    Phys.   Vol. I., 1767, p. 427.  Comment de morb., c. 96.— Willan, Ueb. d.
    Kuhpockenimpf.,  libers,  v. Muhry,  p.  62.—Heim, Horn's Arch. 1809.   B&.
    X. pag. 183.  lb., 1825, pag. l.—Hufeland, Huf. Journ.  1824.   4. Oct. p. 19.
    —Thomson,  An Account of the Varioloid Epidemic,  etc.   London, 1820.—
    Hesse,  Ueb. Varicellen, etc.   Leipzig, 1829.—Schonlein's Path. 5. Aufl.  1841.
    II. p.  247.—Canstatt, Handb. d. med.  Klin.   II. p. 76.   Erlangen, 1847.—
    Lowenhardt, Cstt. Jahresb.  1850.  IV. p.  144.—Trousseau,  Med. Klin,  iibers.
    von Culmann.   I. p.  89.   Gaz. des Hop.  1842, p. 147.  Union mfe'd.  1850, p.
    A79.—Delpech, Journ. deMed. 1846, p. 1, 33.—Simon, Hautkr.  Berl., 1848.—
    Bdrensprung, Arch. d. V. f. g. Arb.   II.  p.  308, 1856.—Qintrac, Journ. deMgd.
    de Bord. im Joum. f. Kinderkrankh. 1858, Bd. XXX. p. 221.—Hebrain Virch. sp.
    Path.  Bd. m.  1. Aufl. 1860.  2. Aufl.  1872.—Kuttlinger, Bay. Intelligenzbl. VII.
    p. 35,  I860.—Tungel, Klin. Mitth. f. 1858.   Hamb., 1860, p. 27.— Vetter, Arch.
    d. Heilk. 1860.   I. p. 286.  Virch. Arch.  Bd. XXXI.  p. 401.—Plagge, Memo-
    rab. IX. p. 78.—Hauner, Beitr. z. Piidiatr.  1863,  p.  54.—Thomas,  Arch. d.
    Heilk. VIII. p. 376.  Memorab. XV. p.  209.  Arch.  f. Derm., I.  p. 329.—
    Locher,  Krankh. d.  Haut.    Erl., 1867,  p.  161.—Bockshammer, Wiirt.  Corr.
    1867, p. 243.— Ranke, Arch. f. Derm.   I.  p. 99.—Quntz, lb., p. 633.—Korber,
    Pet. med. Zeitschr. XT1I. p. 319—Forster, Jahr.  f. Kindhlk.   N. F.   I. p. 131.
    —Henoch, Virchow-H.  Jahresb.  f.  1868.   II.  p. 642.—Czakert, Zeitschr. d.
    Wundarzte Oesterr. 1869.   No. 49.—L.  Meyer, D. Klin.  1870.  Nr. 6 ff.—
    Eisenschitz, Jahrb. f. Kindhk.  N. F.  IV. p. 205.—Fleischmann,  lb.  ILL p.
    444.   Wien. med. Woch.   1870.  Nr. 51.  Arch. f. Derm.  III. p. 497.—
    Kaposi,  Arch.  f. Derm. 1873.  V.  p.  255.—Kassowitz, Jahrb. f.  Kinderhk.
    VI. p. IGO.—Douillard,  Un. mgd.  139,  1872.  Jbch. f.  Khk. VI. p.  187.
    1873.    West, Kindkh. 5. Aufl. Deutsch  von Henoch, 1872.— Obermeier, V.-H.
    Jber.  1872.   II.  p. 272.— Cantani, Ibid. p.  272.— Boeck, Norsk  Mag. for
    Laegevid.  3. R. III. 10.  Ges. Verh. p. 126, 1873.—Steiner, Kinderkh. 2. Aufl.
    1873.—Kuster, Kunze's Zeitschr.  f. pr. Med.  1874, p. 11.

    There can  be  no  doubt of  the propriety  of regarding Vari-
cella as a  peculiar and  independent  form of disease.   It  is  true 
6                  THOMAS.—VARICELLA.
that this is  still contested by physicians of eminence, but upon
such unstable and easily controvertible grounds that it  seems
almost wonderful  that these can be so repeatedly brought  for-
ward.  It is pre-eminently variola  with which  varicella is con-
founded, and it is to the lightest forms of  that  disease that the
name varicella is applied by the opponents of a specific varicella.
It is therefore necessary,  in reading about varicella,  to always
understand  clearly whether the author believes or doubts the
independent nature of varicella;  since heedlessness in this re-
spect has already given rise to very  serious confusion.

                          HISTORY.

   Varicella appeared first,  according to Hesse's elaborate trea-
tise (1829), under the title of  Crystalli, and received by degrees a
multitude of different appellations,  such as variolse  nothse, spu-
rise, illegitimse, hybrids, crystalline, pseudovariolse, false vari-
ola, pointed-pox, wind-pox,  water-pox,  chicken-pox,  etc., that
is, appellations pointing universally to  a certain resemblance to
variola.  The most usual and appropriate name is varicella,  and
this  is now universally employed by the upholders of its specific
nature, coupled at most with the adjective " true" to distinguish
it from the light form of variola, for which—to avoid confusion
—the use of some other name, on the part of the adherents  to the
identity of the two, would be most desirable.
   Varicella appears to have been  known in old times, but to
have been but little regarded, on account  of its mildness ; still,
undoubted evidence of this does not exist.   The first one in Ger-
many to give an exact description of it was Sennert;  in France,
Riviere (1660) is regarded  as the first one who gave it a careful
investigation ; in England this pre-eminence  belongs  to Harvey
(1696), and in Holland to Diemerbroek.   In general, however,
but little was known of varicella until the  time when the  inocu-
lation  of variola  began to  prevail.  When, for instance, the
opponents of this reproached it continually with not affording to
those inoculated a  sure protection  against the infection of  nat-
ural variola, they frequently committed  the  error of regardino-
as true variola an  attack of varicella, occurring after the inoc- 
HISTORY.
7
ulation;  and  vice versa, the defenders of inoculation regarded
as varicella light subsequent  attacks of variola.   It  became,
therefore, quite necessary to establish a more accurate  differen-
tial diagnosis between  variola and varicella,  and especially to
pay more heed to the former.   In every respect that view is
entirely  erroneous which  regards varicella  as having  first ap-
peared since the inoculation of variola,—a view which  is based
upon  the fact of the continual confounding of varicella with
light  forms of variola.  Heberden (1767) was the first  to insist
upon a more exact distinction between the two diseases, and his
work  excited, of course, great opposition.   Universal attention,
however, was only then directed to varicella, after the introduc-
tion  of  vaccination, when repeatedly cases  of variola  were
observed recurring in persons who  had been vaccinated.   Here
also it was  often the case that an attack of true varicella  was
regarded as variola,  and especially that a variola occurring after
vaccination showed, in many points, a closer resemblance to vari-
cella  than the variola of an unvaccinated person.  A more care-
ful study of varicella was now undertaken by Willan, and in par-
ticular by Heim.  This decided advocate of  its specific character
pronounced at first all variolous affections of vaccinated persons
to be varicella, or if such an one were really variola, that it was
due to imperfect vaccination, and he sought, therefore, in particu-
lar, to establish a means of differential diagnosis between the two ;
even  later, when compelled to admit that a person  might have
variola, after proper vaccination, he in no way changed his opin-
ion in regard  to the specific nature of varicella.  It is due to
Heim's influence that the individuality of varicella has been main-
tained in Germany ; while in England Thomson's active advocacy
of the identity of the contagious element in variola and varicella,
added to the increasing lack of confidence in the inoculation of
cow-pox virus, on account of frequent attacks occurring in vac-
cinated persons, has produced a certain perplexity and indiffer-
ence in regard to the diagnosis of varicella, and  consequently a
neglect of it.   The case was similar in France.  A little later,
indecision began to appear also in  Germany.   Hebra,  namely,
declared  roundly, in spite  of all opposing  facts, that  varicella
was the lightest form of variola, and maintains this convenient 
8
THOMAS. —VARICELLA.
 though incorrect position with inconceivable persistency to the
 present day; no  wonder, considering the authority which the
 teacher of  dermatology  at  the Vienna University with  good
 right possesses, that his opinion has found new adherents.   The
 grounds adduced by him and  by his scholars will be discussed
 when we come to consider the symptoms.  Notwithstanding this,
 it may be assumed that the majority of physicians in Germany
 who are specially interested in children's  diseases,  or who are
 clinical teachers, uphold the separate nature of varicella, a belief
 which has been especially supported by Trousseau, in France,
 but has not, as it  seems, met with universal acceptance  in  Eng-
 land.

                          ETIOLOGY.

   Varicella is a disease  of  childhood, and attacks by  prefer-
 ence young children, and  even sucklings.   In children over ten
 years of age attacks are  infrequent, and I never saw an adult
 suffering from varicella.  Yet it cannot, of course, be maintained
 with certainty that every predisposition to it is absent in the
 case of older children and of adults, for so wide-spread is the dis-
 ease, that these  may possibly have had it in their earliest child-
 hood and no impression have been left upon either their memo-
 ries or their skins, and in this manner the individual predisposi-
 tion have been destroyed.  But at all events it  is very striking
 that, in contrast with the measles, which  by no means unfre-
 quently attacks  even adults, varicella is rare even in the case of
 children of advanced years, and it may be that the correct expla-
 nation is that  of diminished susceptibility after the tenth year,
 and its cessation at the time of puberty.  In favor of this is the
 fact that the few maladies of elderly children  are, as a  rule  of
 but moderate severity.  The explanation given by Kassowitz__a
 believer in  the identity of variola and varicella—of  the circum-
 stance that young  children are almost never attacked by  vari-
 cella, is excessively forced.  He attributes it to the greater  deli-
 cacy of the young skin, and especially to the thinness  of the
 epidermis, which permits the local inflammatory process__in vari-
 cella a less intense one at all events than in variola__to express
itself by the  extremely rapid  formation of a serous fluid  the 
ETIOLOGY.
9
evaporation of which allows a much  more rapid disappearance
of the local trouble.  This is  readily disproved, inasmuch as an
adult with a  thick skin has  never contracted a variola from a
properly diagnosticated case of varicella in a child,—an occur-
rence which must needs have taken place were the  two identical.
Furthermore,  it is well known that unborn  children—-even where
the mother escapes the disease—readily fall ill of true variola, in
spite of their very delicate skins,  while  no child has ever been
born with true varicella.  This is probably  due  in part to  the
absence of susceptibility to varicella in the mother, the necessary
vehicle of infection.
   Varicella occurs, according to the indisputable testimony of
country physicians, at one  time sporadically, at  another as a
moderate epidemic, without any connection with cases of variola.
In large cities such epidemics occur,  not after the manner how-
ever of epidemics of  variola or measles,  namely, at tolerably
regular intervals of several  years, but almost annually, or even
twice  a  year,—with  us,  for example, with  great  regularity
shortly after the opening of the  " Kindergarten."   Their extent
and  intensity are consequently never remarkable, nor  their in-
crease and retrocession and general course  so characteristic as in
the other two  diseases. While variola often  diminishes and seems
almost  to disappear for years at a time (at  least after systematic
vaccination),  individual cases of  varicella are always  present,
though perhaps not brought to the notice of physicians from  the
slight inconvenience they occasion.  The needful conditions  for
the  dissemination of varicella exist without doubt throughout
the whole year, which cannot be the case with variola, since this
is observed especially in the spring months.  Its contagion is,
like  that of scarlet fever, endemic in thickly populated districts.
   With regard to the vehicle of the contagion nothing is known
absolutely; it is supposed that the communication takes place
chiefly  through the organs of respiration.  Its infecting power,
however, does not appear to be great,  which explains, in part at
least, the limited spread of its epidemics.
   The  contents of the varicella vesicles must, in  contrast with
those of variola pustules, be  regarded as, practically, not inocu-
lable.   According to  Hesse's compilation, inoculation produced 
 10                  THOMAS.—VARICELLA.

 no  result in  eighty-seven  cases,  in  seventeen was  followed
 by  a  merely local, and in nine by a general eruption.  Apart
 from the fact that in most of the cases a  negative  result was
 obtained, it may be remarked with regard to the successful inoc-
 ulations, that almost all of them possess these elements of doubt,
 viz., they do not exclude the possibility of spontaneous transmis-
 sion in the usual way ; in the next place the nature of the result-
 ing eruption suggests  the probability  that  the varicella  virus
 takes no part in its genesis ; and, finally, it should be remembered
 that where the results were merely local,  no further attempt
 was made at inoculation, as especially noticed by Wunderlich.
 The contents of well-marked varicella vesicles have been inocu-
 lated with negative results  by Heim, Vetter, Czakert,  Fleisch-
 mann,  and myself.  This  of   course does  not controvert the
 experience which  proves varicella to be contagious, but merely
 the possibility of transmission  by the method employed.  Per-
 haps the failure was due to the  small amount of matter inserted;
 perhaps the contagious properties are not in an  active condition
 in the clear contents of the vesicles, which of late  have been
 exclusively employed to prevent interchanges with the matter
 of variola; perhaps the incision exercises an injurious influence
 upon  the inoculation ;—these are points, concerning  the nature
 of which we know as little as we do of the contagion itself.   It
 is also possible that in many  cases the peculiar susceptibility
 necessary to the formation of disease products has been absent,
 thus preventing  the possibility of a  varicella eruption.    In
 marked contrast  with  the difficulty, or even impossibility  of
 an inoculation of varicella,  stands  the facility of its  dissemina-
 tion among little children and its capability of infection.

                          PATHOLOGY.

                     Anatomical Changes.

    The  exanthem of varicella is, in its appearance as a whole  so
'characteristic that the  disease can hardly be mistaken if seen at
 its acme of  development.  A false diagnosis only results  as a
 rule, from the fact that the patient is seen for the first time when 
ANATOMICAL  CHANGES.                  H
the eruption is rapidly disappearing.  The eruption consists of
a varying number of vesicles, from the size of a pin's head to
that of a large pea, or even greater, mostly round, and seated,
in marked  contrast with the pustules of variola, very super-
ficially.  They become very exceptionally, and only in isolated
spots,  true  bullse, from the  size of a dime to that  of a  silver
dollar, but, as a rule,  retain nearly their original dimensions.
They vary in  number  as a rule from two hundred to fifty, but
often noticeably exceed the number of pustules observed in light
cases of variola, as many as  eight hundred having been counted
or estimated ; or they may be very few in number (from ten to
thirty).  They are discrete, or in rare cases two neighboring vesi-
cles may become confluent.  Once in a while,  on  single parts of
the body, especially on the extremities, never, so  far as I  have
observed, upon the whole body, there occur unusually small but
characteristic groups of  varicella vesicles, arranged somewhat in
the manner of a zoster, and with no tendency to run together ; in
the neighborhood of  these groups, however, we find, as a  rule,
plenty of single, large vesicles.  They develop usually upon a
slightly hypersemic, and faintly or not at all infiltrated roseola,
in such a way that the vesicle finally is surrounded for the most
part by a more or less broad areola, though often  this is absent.
The initiatory hypersemic spots may interfere with the diagnosis,
especially when exceptionally high fever is present;  yet even in
this stage measles, etc.,  may be excluded by the dissimilarity oi
these spots as  to size and dissemination, and their smaller num-
ber.  All doubt is removed,  however, by the speedy appearance
of small isolated vesicles.  The development of these  from the
initial  hypergemia begins  in its centre, and completes itself by
peripheral extension, often within a few hours ; it  is  rare that a
longer period than a half or an entire day is required.
   The fully formed vesicles are clear as water, or  light yellow in
color,  and  rise, tightly stretched by  their contents,  above the
level of the skin, like  blisters from cantharides or from a burn.
They are not umbilicated, doubtless from the rapidity and pro-
fuseness of  the  exudation, and from their superficial situation
When a fresh vesicle  is punctured,  it gives  out a  clear, or al
most very  slightly turbid fluid,  at  first  small in amount, but 
12
THOMAS. —VARICELLA.
later  comparatively  considerable, yet never  sufficient to cause
complete  collapse of the vesicle ;  it is  evidently  not a simple
vesicular formation, but possesses originally delicate septa subdi-
viding it  into  single fans, which nevertheless can  finally run
together in whole or part from the tearing open of  their parti-
tion walls.  Cell layers, lying rather deeper than those which are
situated immediately under  the horny layer,  also doubtless par-
ticipate, in many cases, in  the formation of the vesicles,  as  is
shown  by the pigmentations and  very faint cicatrices which
remain, often  only temporarily, but sometimes permanently.
Accurate anatomical investigations  are impracticable, since vari-
cella  is not a  fatal  disease.  The vesicle  generally  contains  a
clear, serous fluid, in which are a few pus-cells,  and possesses a
reaction which is weakly alkaline, according to Hebra, strongly
so according to Fuchs and Schonlein,  and  neutral, according
to Canstatt;  never, therefore, acid, as in sudamina.   In  rare
cases, when desiccation is unusually protracted, the contents may
acquire a  somewhat thick, whey-like character, due to mod-
erate  increase of the pus-cells;  but this, nevertheless, always
resembles  a very diluted pus,  rather than the thick matter of
the variola pustules.  Apart from this  we may find, although
the characteristics of the exanthem as a whole are unchanged,
here and  there a formation of pus, but only in a few tightly
stretched, or more frequently flaccid vesicles, which have persist-
ed for an unusually long time ; such vesicles are generally found
upon  the  sole  of the foot,  a place where, on account  of the
extremely thick epidermis, the pustules  of variola also undergo
a more protracted involution ;  they are very rarely found at the
same time elsewhere, and the contents are never pure pus.   This
pus-like condition of the contents of the vesicles, attributable
solely to their age, is, moreover, never observed in most cases of
varicella, since involution occurs before it can take  place.  It is
therefore,  totally unjustifiable, on account of a few not perfectly
clear  vesicles, or the not perfectly characteristic nature of the
exanthem in single cases, and under circumstances  which easily
explain any deviation  from the  rule, to at once confound vari-
cella in its totality with the specifically different variola.  On
the other  hand, I must regard those patients who  exhibit  vari- 
ANATOMICAL  CHANGES.
13
cella-like vesicles  on particular parts of the body, such as the
face, extremities, or back, but at the same time manifest on some
of  these  parts the  characteristic  pustules of variola scattered
among the  vesicles, as having variola without ihe  thoroughly
typical and universally distributed variola pustules.   To admit
the possibility of varicella under such circumstances we should
have  to suppose that the two specifically different diseases were
simultaneously present in the same individual, as in the combi-
nations of other acute exanthems, a condition which I have not
as yet observed in  regard  to variola and  varicella, but which
must be possible, though of course only in children, especially
young ones who  are unvaccinated.  Such  a case, according to
Trousseau,  was published by Delpech in 1845.  At times the con-
tents  are said to be somewhat  bloody,  though  I have myself
never  observed it.   When air exists under the roof  of the vesi-
cle, it has  always entered  from outside  through  some aperture
(var. ventosae, emphysematosae, wind-pox).
   The duration of the vesicles is brief.  Half a day after  their
maximum, therefore possibly only one day after the formation of
their roseola, they are frequently found,  from partial absorption
of their contents, flaccid  or (though only from external causes,
pressure,  especially scratching) burst and drying  up,  their rose-
ola also fading away. Drying, in the case of undisturbed vesicles,
begins usually in their centres.  They leave behind a small yellow-
ish or clear-brown horny crust, which shrivels gradually and falls
off in a few days, leaving the skin either normal or slightly red-
dened  or pigmented ; slight  cicatrices may also occur, the appear-
ance of which may be very similar to that of a very shallow vari-
ola scar.  These slight superficial depressions disappear shortly,
often  leaving no trace, but may, even years later, be in some
places  so apparent as to give rise to the suspicion that the patient
may have had variola, if  we simply take  into account the exist-
ence of the scars, and the circumstance that the patient once had
an eruption resembling that of variola.   The formation of scars
occurs,  however,  if  at all, in varicella in only a few scattered
spots  (from ten  to fifteen at most), or at least it never follows
nearly so many vesicles  as it does pustules of variola, owing
doubtless to the very slight  depth and intensity of the affection 
14
THOMAS.—VARICELLA.
of the skin;  the  consideration,  therefore,  of the number and
character of the existing scars has certainly some  value in deter-
mining subsequently what disease has been present.   According
to Heim the varicella scar is always white, whiter even than the
rest  of  the skin,  perfectly smooth,  always  hairless,  generally
round, and feels quite soft, unlike the scar from variola.
   The  development of the skin affection does not, however, fol-
low this course invariably.   I stated that as a rule the formation
of the characteristic vesicles  of varicella takes place upon slightly
or not at all elevated roseola?, never upon nodular ones.  In some
very slight cases, however, the majority of these roseola? varicel-
losa? simply fade away again, without any appreciable formation
of a vesicle taking place, and this is especially apt to be the case
also with single roseola? toward the close of an eruption ; or, very
imperfect and irregular vesicles of  the size of a millet-seed may
be formed.  In one case, rendered sufficiently  certain  by the pre-
vious characteristic malady of a sister,  I even  saw all of the
numerous roseola? disappear, after a duration of about thirty-six
hours, with no formation of vesicles anywhere.  The use of spe-
cial names for eruptions progressing  beyond the formation of
roseola?, but falling short of the fine, tensely stretched vesicles of
varicella, is unnecessary.
   In contrast with these cases,  an unusually intense develop-
ment  of the varicella eruption  sometimes occurs.   It  is fre-
quently observed  that small  vesicles  enlarge somewhat by pe-
ripheral growth, while at other times the eventual size may even
correspond to the original foundation ; the formation  in question
must, notwithstanding, be still designated as  a vesicle.  In tol-
erably rare cases,  however, single vesicles attain by peripheral
extension such a  considerable extent that they become bulla?.
These remain for the most part about the size of a dime, but may
become as large as, and even larger than, a silver dollar.   This
expansion  of a vesicle into a bulla is most likely to take place
when it is still fresh; it may, however, not begin until the  crust-
ing of the former has already  commenced.  In the first case the
bulla possesses the shape of a simple, always more or less flaccid
sac;  in  the second, this sac has a central adhesion from  which
it  stretches outwards in all directions.  The  epidermis covering 
                      SYMPTOMATOLOGY.                    15

the bulla is  excessively thin  and delicate ;  I have never seen it
tensely stretched by profuse fluid contents, like perhaps the blis-
ter of a  pemphigus or burn,  or like the original vesicle.  The
epidermis of the periphery becomes gradually more and more
raised, and in this way the bulla may still increase even after its
roof has been torn and its contents have partially escaped ; in
fact, it can even make rapid progress in spite of this.  How super-
ficial the alterations of the skin are, when bulla? are formed, is
shown also by the healing process in these.  At  times, after the
bulla is emptied of fluid, its dry, thin, epidermal covering may be
seen lying upon and in connection with the newly formed epider-
mis, and separating itself only after the completed new formation
of the latter.  In general the healing process is disturbed  by the
tearing off of the epidermal roof, and the bulla becomes an open
excoriation.  In  both cases, however, a little crust now forms—
always at  least in the case of bulla? of any special magnitude,
—in  the centre of the diseased spot, on the site of  the original
vesicle, where alone  the affection of the skin extends  to any
depth; and around this, often very speedily, a ring of normal,
thin,  pale  skin  appears, already covered again by epidermis.
The peripheral margin of this appears at first  somewhat excori-
ated,  but at  other times it is often in a suppurating condition,
the shrivelled and sometimes crusted remains of the roof of the
bulla being still attached to it.  ~No marked ulceration, as  seen
by  Hesse and Lowenhardt, ever appeared upon the site of the
bulla, and only in the case of small blisters did a thin crust cover
the whole basis  of the same.   There commonly  remained upon
the site of the bulla a moderate pigmentation of the skin, which
decreased only  very gradually,  while  scar-formation,  limited
always to the site of the central crust, was, after  this had fallen,
frequently observed.  The healing of the bulla  was always quite
rapid, everything being dried up within a few days.   In several
very typical cases (all the children in one family) the cicatrices
had entirely disappeared at the end of a couple  of years.

                       Symptomatology.

   The period of incubation seems to be of more  variable length 
16
THOMAS. —VARICELLA.
in varicella than in variola or measles.  With regard to this I
can only adduce observations of cases where the disease spread
from one child to another in a single family or house, and where,
therefore, it is impossible to specify exactly the moment of infec-
tion.  If I estimate it, however, from the time of the eruption of
the child first affected, I find  unusually often that, before the
eruption of the next child  appears, a period.of from thirteen to
seventeen days elapses, and we may  justly,  therefore,  consider
the period of  incubation to be of about this duration, and conse-
quently longer than in variola or measles.   The same  estimate
is made  by Trousseau,  Korber, Hesse, and others.   While the
stage  of  incubation lasts, the general health is, as  a rule,  per-
fectly satisfactory, although,  as in measles,  variola, etc., there
may occur, during the  whole  or  any part of this time, slight
fever  and other general symptoms, such as lassitude, headache,
chills, and loss of color.
   In most cases the eruption of  vesicles is the first symptom
which marks  the disease.  Even very careful  and anxious moth-
ers usually notice no prodromal  stage,  and assert that their
children,  up  to the  time of the eruption, have  been perfectly
healthy.   At other times, and likewise by the testimony of  non-
medical witnesses, an actual precursory stage of  some duration
appears to have existed.  Medical observation has shown that in
by far the largest number of cases of varicella, with the usual
light,  regular, that is to say, normal course, no precursory stage,
or, at most, one only of  a  few hours'  duration exists, and  it is
therefore  of  no importance.   It is truly impossible that in the
very first hour of  the  disease the vesicles  should exist fully
formed ; yet by the precursory stage of an infectious disease is
understood a febrile movement of at least one day's duration
without any  specific manifestations of disease.   Exceptions of
course, exist  here also, as  in all diseases of children, but under
conditions which exclude  a  normal course  of  the disease  or
which even—where  reported by  defenders  of  the identity of
variola and varicella, and especially when occurring in children
of an advanced age,—permit the suspicion that the case was not
at all  one of true varicella.  And yet, even such as recognize the
specific nature of varicella have  observed, in very exceptional 
SYMPTOMATOLOGY.
17
cases, a fever lasting several days, with severe nervous complica-
tions, even delirium and convulsions; the possibility, therefore,
of a precursory fever in cases with  an abnormal course, cannot
be  denied.  For this  very reason, however,  special emphasis
must be laid  upon the fact that the normal course of varicella
excludes  any prodromal fever, a supposition which  is  also in
some measure justified by this, that the subsequent exanthem in
those cases was  often altogether  disproportionately slight, and
frequently even ran its course with a normal temperature, as in
perfectly normal and common cases.  The possibility exists also
that no prodromal  fever was present, but merely some febrile
complication,  casually coincident with the inception of the vari-
cella, and such as often occurs in little children.  Careful exami-
nations, made once or  twice daily, of  the  temperature as it
existed before the attack during the last days of the incuba-
tive stage, furnished the following results:—A precursory stage,
manifested by an increase of  temperature before the appearance
of the eruption,  does not in most cases exist; in a few rare cases
it can certainly be assumed,  but is insignificant, and of only a
few hours' duration.   Should an  essentially more extended pre-
cursory stage  appear to have existed, upon the authority of non-
medical and consequently untrustworthy observations,  yet this
cannot be regarded as the rule, and will, a  little further on, be
explained.  On the other hand,  the positive absence of a prodro-
mal stage of noticeable extent, lasting even half a day for exam-
ple,  can be alleged with great  certainty in  a number of other
cases.  I found, for  instance,  before the eruption, the skin being
perfectly healthy, a normal temperature  (or very exceptionally,
as also frequently  occurs in  perfectly healthy and uninfected
children, a  minimal increase, say of 1.8° to  0.54° Fahr.), and
noticed, a few hours later, simultaneously with the first  increase
of temperature, that the eruption had already begun.  In these
cases, therefore, the  fixed beginning of the eruption and of  the
increase of temperature were coincident, very different from what
occurs in variola.  Not has there been found, in the majority of
other cases measured from the  beginning of the eruption, any
more marked  initial increase  of  temperature; on the contrary,
this was often on the first day of the eruption normal, or nearly
          2 
18                  THOMAS.—VARICELLA.
 so.  This occurred, moreover, not only in cases which ran their
 course with a normal temperature, or with but a slight increase,
 but  also in such as rose later to, for varicella, a markedly high
 degree.  In only two or three exceptional cases was  there any
 decided initial increase.
   The eruption, which is therefore generally the first symptom
 of the disease to appear, either alone or at least simultaneously
 with a slight increase of temperature, begins, as a rule, rather
 irregularly on the upper half of  the trunk, and spreads rapidly
 to the  extremities; here, if not upon the  first day, certainly by
 the second, single scattered  vesicles may be seen.  The  face is
 usually, though not always, the first to  be attacked, and  the
 statement, that it in most cases escapes entirely, is incorrect.
 The  hairy scalp shows the exanthem simultaneously ;  a careful
 examination will rarely fail to find it here, and then only when
 the  general eruption is very  limited.   Near  the first vesicles
 faint, red points, of variable size, soon make their appearance,
 and  these often by the next  morning will have  become in their
 turn fully  developed vesicles, new roseola?  in the  meantime
 having formed between the older eruptions.  This always occurs,
 however, more sparingly upon the head, the part first  attacked,
 and  so upon the upper half of the trunk, while  the formation
 upon the extremities is  more profuse,  and progresses steadily
 toward the fingers and toes.  Soon,  in accordance with what has
 been stated in reference  to the brief existence of the individual
 vesicles, it is only here that we can find  any which are character-
 istic  of varicella, those upon the head and trunk having vanished
 or become scabbed  over.  It is,  in general, only at  the com-
 mencement  of the disease that all  the  roseola?  develop rapidly
into  larger or smaller, but always tense varicella?; towards the
 end they tend always more and more to simply fade, or produce
at best but very small and almost  uncharacteristic vesicles.  The
intensity of the disease seems to diminish,  in most cases with
 the eruption on  the first and second day;  that which ensues
does  not  usually manifest the  designated type to the  same
degree.  Frequently, by the third day, more often by the fourth
or fifth, everything is fading, with the exception perhaps of a
few  flaccid, discolored  vesicles,  as large as  lentils, upon the 
SYMPTOMATOLOGY.
19
hands and  feet,   More rarely there appears,  even at this late
period, and in connection with the original affection, a more pro-
fuse, fresh eruption on various parts of the body, lasting rarely
for more than a day, and  never beyond  the  beginning  of the
second week after the appearance of the first vesicles.
   In accord with this, the  duration of the increase of tempera-
ture in cases of varicella is  a variable one.  In about two-thirds
of the cases it covers a period of two or three days,  in a sixth, of
one day, in the remainder, of four days,  or more ;  in a few cases
the disease runs its course without any increase of  temperature.
Except in unusually intense and profuse eruptions this increase
of temperature lasts longer than from four  to five days only
when some  complication  exists,  and in those  rather rare cases
which lead to a more or less extensive development  of bulla?.
   Although the  appearance of the varicella eruption is only
exceptionally accompanied by any  considerable increase of tem-
perature, yet as the disease progresses this may reach a degree
worthy of regard.  The maximum temperature  of  a case  is
usually one or two  degrees above the normal, but sometimes
reaches a noticeably higher point. It was insignificant  or normal
in only a few very light attacks with moderate eruption.  In this
also, as in all feverish diseases, there is usually some remission
in the morning, and some exacerbation at evening, though this
rule is frequently violated by intercurrent elevations coinciding
generally with the appearance of  numerous fresh vesicles.  With
any considerable increase of the exanthem, the temperature usu-
ally  rises, or at least remains at about  the height to which it
had previously attained, so that, not infrequently, the conclusion
of the eruption is marked  by the maximal,  or certainly by a
well-defined rise of  temperature.   Any frequent coincidence  of
maximums of temperature and exanthem can hardly be expected
in a disease which, properly speaking, shows only in exceptional
cases a simultaneous maximum of the exanthem on all parts of
the body.  The increase of temperature ends by a defervescence,
often slight,  from the moderate  intensity  of the fever, but yet
always rapid.  Any considerable increase  of the exanthem, by
the production of  numerous fresh vesicles, during or at the con-
clusion of defervescence, has never been observed.   A few very 
20
THOMAS.—VARICELLA.
small and indistinct vesicles and roseola? may, even at this late
period, make their appearance, possibly because the commence-
ment of  their development was of an earlier date.  After the
expiration of the defervescence no  further spread of the exan-
them takes  place in connection with the development  of the
principal malady.  If new increases of temperature take place,
as now and then occurs,  they are, in part,  ephemeral  distur-
bances of the convalescence,  in part due  to complications, etc.
Generally convalescence is brief, with speedy exfoliation  of the
little crusts  and perfectly normal  temperature;  there  is total
absence of any subsequent fever like the suppurative fever in
severe forms of variola.
   The eruption may be limited to  the outbreak of a few small
but  perfectly typical vesicles, or all parts of the body may be
thickly  covered by them,  and the  successive proruptions take
place throughout a  week.   The head and trunk, as also the
upper parts of the thigh  and arm, are usually covered  rather
thickly, and  tolerably uniformly, with vesicles; the face, how-
ever, shows fewer than in variola.
   A subsequent eruption of the exanthem is often spoken of in
treatises  upon varicella.   If we understand by  '' subsequent
eruption" the renewed appearance of  vesicles  after the com-
pleted formation and progressing convalescence of the previous
eruption, my observation  has shown  only the appearance of a
few,  usually  not very typical, vesicles,  the comprehension of
which under the conception varicella admits  of  some  doubt,
though  their connection with the   disease is worthy of regard,
and justifies the assumption of their close relation to it.   I have
seen single vesicles appear a month even after the beginning of
the eruption.   And yet I cannot admit the propriety of designat-
ing the undeniably typical formation of the exanthem—charac-
terized as it is by several rapidly succeeding outbreaks,  each of
which, after the first, occurs before  the previous one has become
fully developed, and in which, consequently, are to be found at
the end of the eruption, simultaneously, vesicles in all stages of
development  and retrogression,—as a primary eruption  and a
subsequent formation or recurrence.  A true relapse, that is the
renewed  appearance of the disease in question in  its totality as 
S YM PTOMATOLOGY.
21
reported, for example, by Kassowitz, I have never seen.  Accord-
ing to Trousseau  and Canstatt, relapses in varicella are frequent.
   The visible mucous membranes are also attacked by varicella.
My attention  has frequently been  drawn,  by their interference
with micturition, to vesicles upon the genital mucous membrane
of girls, while upon the prepuce of boys they are less common.
The mucous membrane of the buccal cavity, and of the throat,
is invaded as  a rule, though often only moderately.  The vesi-
cles are especially evident upon the hard and soft palates, where
they may often be seen for a short time as  flaccid vesicles upon
a somewhat hyperaemic ground, though here later,—as is  also
the rule  elsewhere, as e.g., upon the lips,  tongue, and mucous
membranes of the cheeks,—they very soon lose their epithelial
covering, and are recognizable only as excoriations.   A more  or
less pronounced diffused redness occurs around the vesicles ; cir-
cumscribed spots like roseola? are less often seen.  The formation
of skin upon  the spots deprived of their  epithelium is always
very rapid.  I have never seen, as in the case of bulla? upon the
skin, any  extension or ulcerous development  of  the  spots  of
mucous  membrane attacked  by varicella.   The conjunctiva  I
have seen attacked only in continuity with  the  skin  of the eye-
lids, and in like manner the nasal mucous membrane only at the
nasal orifice;  both parts, furthermore, being attacked only  in
rare cases.  Henoch has noticed varicella of the conjunctiva and
of the gums.  I once noticed,  just before the outbreak of a light
case of varicella  with  ephemeral though intense fever (106.88°
Fahr.  in the rectum),  the appearance of a universal erythema,
of short duration, as with variola and measles.   I can assert that
I have carefully  watched  for  the appearance of  such eruptions,
but have never observed any except in this case.  The state-
ments of  authors, that during a precursory fever lasting several
days, erythematous and  measle-like eruptions  have frequently
been present,  refer most  probably  not to true varicella, but  to
light cases  of variola.  I  have never seen other affections of the
skin or of the mucous membranes.
    In regard  to  symptoms on the part of other organs, there is
little to be said.  In normal, light cases the children are usually
perfectly cheerful, or, at the utmost, it is only in the evening, 
22
THOMAS.—VARICELLA.
 during the exacerbation of the fever, that their general condition
 is at all disturbed.   Slight excitement and restlessness by night,
 sleepiness perhaps  by  day,  moderate thirst and  some  loss of
 appetite, are often the only other signs of disease,  and it is only
 with difficulty that they are kept in bed.  Some itching may be
 present, and temporary difficulty in swallowing, and frequently
 the lymphatic glands of the throat and neck are somewhat swol-
 len.   Headache is usually entirely absent, as is generally the case
 with young children, nor are there any signs of excessive implica-
 tion of the nervous system, such as shivering, convulsions, faint-
 ing, etc. ;  vomiting,  too, is rare.   Symptoms on the part of the
 thoracic  organs may certainly  be regarded as complications;
 and, furthermore, varicella? of the lining membrane of the respi-
 ratory passages are conceivable.  If, here and there, in the de-
 scriptions of varicella,  essentially different and especially more
 severe symptoms are adduced, it is quite possible that this is due
 to the fact  that the description  is based upon the epidemics of
 other places and other times; as a rule,  however,  it arises from
 the confounding of  true varicella with an attack of  variola which
 resembles varicella.  The distinction between the two cannot be
 too strongly insisted upon.

                         Diagnosis.

   It  cannot be  denied that many variola efflorescences, and
 especially single  eruptions  not  developing  into true pustules,
 have  a certain resemblance  to varicella.   I have never yet been
 in any doubt about the  diagnosis of variola in such  cases,  especi-
 ally since the great epidemic of variola in 1871, when my experi-
 ence with the disease was very extensive.  Eruptions resembling
 varicella in adults  always indicate variola, as is shown not only
by the age of the patients, but also by a scrupulous investio-a-
 tion of all  the symptoms of the  disease, and certainty is often
eventually established by the character of subsequent cases due
to infection from the one first existing.   According  to my experi-
ence it is especially the very light cases  of variola, with  only a
moderate  exanthem, occurring in vaccinated adults, and  by the
 mildness of their course resembling varicella, which  may <nVe rise 
DIAGNOSIS.
23
to mistakes.  The pustules  here are scanty  and imperfectly
developed, and dry up sooner than  usual, and instead of pure
pus, as in  fully  developed pustules,  their  contents  are  sero-
purulent.   There  may even exist one or two pustules with toler-
ably clear  contents, like those of a clouded varicella vesicle, and
after the commencement of desiccation a differential diagnosis is
difficult.  A careful examination will however always detect the
nodular formation on the site of  the variolous  eruption, in con-
trast with the scarcely swelled basis of the varicella vesicle, and
will also discover  that  it is a  question merely with regard to a
few suspicious pustules, almost never to  a universal eruption on
all  j>arts of the body.  Furthermore, there never occurs any—I
will not say pure, but only approximatively pure—varicellous
character  in a very profuse exanthem of  variola, while even the
most intense eruption of varicella is perfectly typical, at least as
to the nature of  the vesicles.  Those vesicles which  form fre-
quently around the little pustules  in true  small-pox, especially in
the case of very young children, and which possess clear or light-
yellowish contents, and are of course thickly crowded together,
so that they form when drying yellow gummy crusts like those
of eczema or mellitagra flavescens, can hardly be regarded by
any one as a proof of the varicellous nature  of the eruption of
variola, the characteristic  constitution  of which is proved by
countless  other  pustules in the same case.  If we take the char-
acter of the skin alone into consideration,  serious difficulties,
when sufficient care is exercised, can therefore at most only arise
in the case of the most rudimentarily developed forms of the two
diseases, those, namely, which barely proceed beyond the forma-
tion of roseola?.   The diagnostician, however, encounters similar
difficulties, as is well known, in all cases  of uncharacteristic dis-
ease products.   No opinion can  be deduced in very  old  cases
from scanty and slightly depressed cicatrices, while profuse and
deep scars never result from varicella.
   The measurement of the temperature is of great importance
for  a differential diagnosis.  But this must of course  be taken
during the whole course of the disease, if  decisive conclusions are
to be deduced from them in a single case; for the difference per-
tains chiefly to the state of the temperature before the eruption. 
24
THOMAS.—VARICELLA.
In variola  this is increased during the precursory stage, which
lasts  several days,  and is marked even in light cases; while in
varicella such  an increase is entirely absent, or,  what is more
rare, lasts only a very short time, scarcely more than a few hours.
Moreover, in light cases of  variola, with which alone we are con-
cerned,  the increase of temperature  ends with the outbreak of
the exanthem,  or this last may even not appear until deferves-
cence has commenced.  Sometimes, it is true, the elevated  tem-
perature lasts  for a half or a  whole day  longer,  and deferves-
cence accordingly appears  only when the exanthem is already
partially developed ; at all events, however, its eruption attains
its climax  with a falling or already  normal temperature, and
it is often  only after the conclusion  of the fever that new pocks
appear  to  any extent.   Thus  the feverish period, even of the
mildest  variola, with the most scanty exanthem,  lasts always
several  days.  It is very  different  in varicella,  in  which by
the absence of  the precursory stage,  the period of fever is just so
much shortened and the eruption is ended at the  conclusion of
the defervescence ;  and when the eruption lasts several days, the
temperature, at a later  period  of the  same, tends rather to rise
than  to become normal.  Those  who confound both diseases
deny positively this  typical conduct of the fever for  the two affec-
tions, although it has been established by accurate observation,
and they adduce,  in confirmation of their assumptions, single
exceptional cases in which this peculiar action has been absent.
They forget, in  so doing, that the temperature in diseases is never
determined from a single point,  and that, moreover,  in the case of
children (especially  susceptible  as  to conditions of  temperature)
very many and various influences  must be  regarded.  Not  a
single one  of the numerous, recognized, characteristic, typical
fever-curves has been constructed from a single case ;  each is the
result of  a comparative examination of  numerous individual
cases.   ISTo one can  therefore justly make the claim that in every
single case  all peculiarities of the course of the disease in ques-
tion must be present in an unequivocal manner.  He who desires
the characteristic variations of the course of the fever in varicella
and variola must take the trouble  to prove his assertion on the
ground  of a careful observation of a large number of pure and 
DIAGNOSIS.
25
uncomplicated cases of both diseases, and must show that, as the
result of  these  observations,  the curve of temperature  of the
two diseases is to be  differently constructed from what it is at
present;  this proof has, however, never yet been furnished by
the advocates of the identity of variola and varicella.  It must
here be emphasized that the typical course of the fever of vari-
cella is best studied, not in the lightest and briefest cases, which
run their course with either an ephemeral elevation of tempera-
ture or none at all, but  in more severe cases, where the  eruption
lasts at least three days and where no complication exists.  Nor,
in investigations upon the temperature of the normal course of
the fever of varicella, can cases be regarded which evince  such
manifestations as are, for so  mild a disease, unusually  severe.
When, for example, children with varicella  remain for days un-
conscious, and are attacked by convulsions, and manifest severe
nervous or other grave symptoms,  it may be justly  assumed
that their temperature  is modified more by this condition than
by the light varicella which appears a few days later.  In such
cases an anomalous condition of the  temperature need excite no
surprise.
   The proofs adduced from  the symptoms and course of vari-
cella  and variola are truly sufficient to establish  categorically
the specific differences of the two diseases ; we must nevertheless
consider  a few more  important differential  points  in their
pathogeny and etiology.
   Vaccination  exerts  no  influence  upon  a  predisposition to
varicella.  Unvaccinated children who have had varicella  can be
vaccinated with  the best results, and those who have been vac-
cinated are liable at  any time to an attack of varicella.  Vac-
cinia  and varicella have therefore nothing in common.  The
result of  the cow-pox inoculation  may be  perhaps slightly
retarded  by  varicella, as  by  other  diseases,  but is otherwise
unquestionable,  even though  vaccination is performed during,
or just  subsequently to, an attack of varicella.  Czakert reports
an interesting case where  he  obtained a successful result from
vaccination—in a boy four years of age,  who had  been three
times vaccinated to no effect—by inserting the vaccine  lymph
into the opened  vesicles of a  varicella which casually occurred. 
26
THOMAS.—VARICELLA.
 Unfortunately  he took no lymph from  the  resulting cow-pox
 vesicles to establish its infecting  properties.   Again, the  typi-
 cal course of varicella has never been suppressed, even where its
 first  manifestations have  coincided in time  with  the maximal
 development of vaccinia.   Such cases must be regarded in the
 same light as those in which, according to existing observations,
 varicella has developed during the  period of florescence of a  scar-
 let fever,  or the latter during the progress of a varicella.  The
 case  is different with variola.   Here everything depends  upon
 the success  or  failure of the vaccination.  Young children who
 have  been vaccinated are rarely attacked by variola, and the
 susceptibility to this is only subsequently reacquired at the  very
 time  in which that to varicella disappears.  The advocates of the
 identity of the  two diseases endeavor to diminish the force of
 this circumstance by a comparison of the percental proportions
 of the vaccinated  and unvaccinated cases of varicella and  vari-
 ola, a  demonstration which should be utterly rejected, being
 based upon false premises.   They also make the following asser-
 tion :  " The mere appearance of vaccinia after varicella,  or  vice
 versa, is no  reason for not regarding  the latter as variola ; for
 it is  well known that even  variola does not afford us absolute
 protection  against vaccinia, and vice versa—whence the  advisabil-
 ity of revaccination.  Vaccinia takes after a varicella, but it also
 takes after a variola, and a limited experience in this  respect
 arises from the fact that vaccination  is rarely performed after a
 patient  has gone through an attack of small-pox.   With regard,
 therefore, to the protection by one  against the  other, it is a mere
 question of a difference in time, for  varicella can immediately
 follow vaccinia, while variola as a rule can only be contracted
 after  the lapse of a longer, or exceptionally only a shorter space
 of time, when the soil has,  as it were, again become suitable.
 One can only  say: vaccinia is no absolute protection against
 either variola or varicella, and  vice versa.  Such facts  are how-
 ever,  insufficient to stamp varicella as  a specific disease."  In the
 same  way  it can  of course  be  demonstrated that, e.g.  scarlet
 fever  or typhus is identical with variola, since these  afford no
protection  against vaccinia,  and vice  versa.   The advocates  of
the identity  of the two diseases disregard  here  the  fact  that 
DIAGNOSIS.
27
 vaccinia does not, as a rule, protect from varicella, while it does,
 as a rule, protect from variola (and generally,  with good lymph,
 for a long time), and single  rare exceptions are not sufficient to
 overthrow a rule.
   The fact that one attack of an acute exanthem almost always
 destroys  any susceptibility to a new attack of the same disease
 applies as well to  varicella as to variola.   Since  in the former
 case this predisposition is wont to vanish of itself spontaneously
 about the eleventh year, literature furnishes only scanty and not
 always incontestable examples of two attacks of varicella, while
 such of two, or even more cases  of variola, though the latter is
 rare, are much  more frequent.  Gerhardt treated a  child  for
 three attacks, even,  of varicella.  Heim  reports a similar case.
 According to Vetter, a child  of  a colleague was twice attacked,
 with an interval of fourteen  days of perfect health ; Kassowitz
 saw an interval of a year and a half.  Boeck has seen  a second
 attack.  Hufeland, Canstatt,  and Trousseau report  repeated
 attacks in the same child as not infrequent.  I have never met
 with such.  If now the contagious principles of variola and vari-
 cella, which as  yet are unknown, were identical, they ought to
 afford,  at least for a number of years, immunity, each against
 the  other, which  is not the  case.  Unvaccinated varicella  pa-
 tients, who have been treated by the identity-advocates in  the
 small-pox wards of hospitals, are  often, immediately after  the
 termination of the varicella,  attacked severely by variola; and,
 on the  other  hand, there is no lack  of cases  in which  unvacci-
 nated children, soon after a severe attack of variola, go through
 the most exquisite attacks of varicella.  This would occur more
 frequently, but for the tendency to disappearance of the suscep-
 tibility  in older children.  How do the identity-advocates meet
 this  fact?  They allude to the occurrence  of single rare cases
 in which variola  also has broken out for a second time, a little
 while after  the  termination  of  a properly diagnosticated case
 of variola, and take also into  account the similar, but  less tho-
roughly confirmed  relapses of measles and  scarlet fever.  They
overlook the circumstance that a second attack of variola, fol-
lowing soon after a first, is very rare; while  variola following
varicella, where  so  excellent an opportunity is afforded as in the 
28
THOMAS.—VARICELLA.
small-pox wards for infection, is the usual condition of things ;
they also forget that, by such inferences, the identity could be
proved of any two diseases whatsoever, for  example, of variola
and measles  (which last disease is also often confounded with
variola, so that the patients are sent to the small-pox wards and
are naturally attacked subsequently by variola).
   The specific  nature of varicella necessarily involves the fact
that varicella can cause only varicella, just as for the same rea-
son variola can give rise to variola alone.  The identity-advocates
deny this fact also, and allege in disproof of it that it is  quite
common  for  the mildest cases of varicella to give  rise to  most
severe  attacks of variola.  Such statements are always based
upon false diagnosis.   If true varicella and a variola resembling
varicella are classified under  one name, it  is  self-evident that
many a "varicella," which is, in fact, only a misnamed mild case
of variola, should give rise to variolous infection.  The true vari-
cella of the advocates of non-identity has never given rise  by
contagion to  anything else than another true varicella. We may
once more  allude  to the fact that  it is not always possible to
make an absolutely certain diagnosis in every case, e.g., where
the formation is rudimentary or the  eruption already desiccat-
ing, etc.   Such  doubtful cases can never be positively conclu-
sive.
   From all  these arguments  we draw the conclusion that vari-
cella is a specific disease, and  has nothing in common with vari-
ola.   Only the superficial resemblance of  the skin affection and
the erroneous interpretation of certain facts have led easy-going
and reluctant observers to defend the opinion that varicella  is the
mildest form  of  variola.  This view should be opposed, not only
on account of its falsity, but  chiefly because it is the principal
cause of the totally unjustifiable reproach  that the protection
afforded by vaccination is entirely problematical.  To destroy con-
fidence in vaccination is nothing less than favoring the spread of
variola, and forcibly bringing on misfortune which might be pre-
vented.   Trustworthy vaccination statistics are only possible
when all physicians recognize  and rightly diagnosticate varicella
as a specific disease.
   As the practical rps^ilt of what has been said, it  becomes the 
                 PROGNOSIS.—COMPLICATIONS.                29

duty of every physician to bring about as soon as possible  the
vaccination  of unvaccinated  children who have  varicella, and
never to omit this on account of  any diagnostic difficulties what-
soever.  For by vaccination in such cases  one  not only benefits
the child,  but also at the same time confirms his own diagnosis.
Above all things, never expose a case of varicella to an infection
by variola, by referring it to small-pox hospitals.


                         Prognosis.

   The prognosis in varicella is  thoroughly favorable.   The  dis-
ease,  as a  rule, runs  so mild a  course that the physician is not
called in,  even to young children, and  there are weighty impedi-
ments to overcome, if one desires to study the malady.  Accidents
of a  severe nature, from intense exacerbations of the fever, are
rare ; such mishaps, moreover, are usually very temporary, in so
far as they are not occasioned by some complication.  Grave  dis-
turbances of the health, of an  indefinite nature,  however, have
been  reported as sequela? of varicella, but such have never come
under my observation.  Eczematous, and even ulcerous  processes
may arise  self-evidently from gross neglect of the local  distur-
bance of the skin, especially with that  form of varicella in which
the small vesicles develop into extensive bulla?.


                       Complications.

   Finally, the combinations of varicella with other acute exan-
thems deserve  special mention.   Among these, that with scarlet
fever and measles has been repeatedly authenticated  in  former
times  (Le Roux, Reuss,  Bohm, cited by Hesse) and at a more
recent period, and in  these cases each disease has been observed
to be the first to appear.   That  varicella can be present simulta-
neously with vaccinia, has been stated, but whether  with true
variola has not yet been proved, and would also be difficult pro-
bably to prove convincingly.  Some (M. Kohn-Kaposi) deny the
correctness  of  the diagnosis of  measles or scarlet fever in the
above cases, and declare them,  on  insufficient  grounds, cases of 
30
THOMAS. —VARICELLA.
variola marked by erythemata or  roseola?, a thoroughly euro
neous and untenable supposition.

                        TREATMENT.

   In accordance with the favorable prognosis, the treatment
may be, as a rule, purely expectant,  and directed, apart from
the diet, only to, at most, a few somewhat annoying symptoms,
though the affection of the skin may demand a little attention.
Any prophylactic isolation of  the patient is quite needless, on
account of the innocuousness of the malady. 
MEASLES.
Compare article "Masern" in the manual and text-book of pathology, etc., by S.  G.
    Vogel (2  edit. 1794).—Conradi (1813), Reil (1815),  Richter (3.  Aufl.  1821), J.
    P. Frank (fibers, von Sobernheim  1830),  Berndt (1830), Puchelt (1831), Nau-
    mann  (1831), Eisenmann (Krkhtsfam.   Pyra, 1834),  Baumgdrtner  (2. Aufl.
    1837), Schonlein  (5. Aufl.   1841),  Fachs (1845),  v.  Gaol (Diagnostik 1846),
    Canstatt  (1847),  Wunderlich (2.  Aufl. 1856), Lebert (1859),  Leubuscher (1861),
    F. Niemeyer (5. Aufl. 1863), Lazansky (1864),  Trousseau (1866), .Zci/Wer (Thera-
    pie, 3. Aufl. 1867), Kunze (2. Aufl.  1873); in den Werken iiber Kinderkrank-
    heiten von  Girtanner  (1794),  Rosenstein  (6. Aufl.  1798), ScMffer  (1803),
    Henke (3. Ausg.  1821,  4. Ausg. 1837),  Capuron-Puchelt (1821), Wendt (1822,
    3. Ausg. 1835), Billard (1829), Jbrg (1836),  Frdnkel  (1838),  Ferwra  (1838),
    Bressler  (1842),  Schnitzer  und  TP"^ (1843),  Meissner (3. Aufl. 1844), .Rt'ZZiei
    und Barthez  (1844 fibers,  von Krupp,  1856  von  Hagen),  Friedberg  (1845),
    Coley-Holder  (1847),  Underwood-Schulte (1848), Hartmann  (1852), West-Weg-
    ner (1853), .Seofaar (1856), Gerhardt (1861,  2. Aufl. 1871), Bouchut-Bischoff
    (1862), .HS&mip (3.  Aufl. 1864),  Rummel (1866),  F^eZ  (5. Aufl.  1871), TF**«-
    Henoch  (1872), Steiner  (1872),  Kormann (1873);  sowle  in den Werken fiber
    Hautkrankheiten  von  Willan-Friese  (1806),  Cazenave und   Schedcl  (1829),
    Rayer-Stannius (1837), Alibert-Bloest (1837), Bateman-Calmann-Blasius (2. Aufl.
    1841), Simon  (1848), Fuchs (1841),  Mayr-Hebra (1860), Hebra  (1872), Neu-
    mann  (3. Aufl.  1873).   Good catalogues of the  literature upon this subject,
    with  especial reference  to that of  former times, may be preferably found  in
    the works of  Willan, Berndt, Eisenmann, Rayer, Canstatt, Naumann, Barthez
    and Rilliet,  also  in Meissner (Investigations of the Nineteenth Century, third
    and sixth parts, Children's Diseases).—See also the Encyclopaedia of Medicine,
    of Meissner and Schmidt (1832, article  On Measles, Guersent), also that of Prosch
    and Ploss (1855, Art. by Hennig).—In the following summary of journal articles
    and monographs, may be found either such original articles as were accessible to
    me, or, where these could not be obtained, a designation simply of the sources of
    which I have availed myself, as I have no wish to immoderately extend  the bibli-
    ographical table.  Discussions and anonymous treatises may be found in  the Jour-
    nal fiir Kinderkrankheiten 2, p. 74 ;  4, p. 239 ;  7, p.  78 und 398; 13, p.  457 ;  30,
    p. 172; 40, p. 75 und 77 ;  p. 430 ; 44, p.  454; in Schmidt's Jahrbfichsrn 1  Supplbd
    p. 189 ; 86, p. 237; in Canstatt's Jahresber. 1861. IV. p. 204 ; im Wurtemb. Cor- 
32                         THOMAS.—MEASLES.

    respbl. 1841 Bd. 11, Nr.' 23. 24 und 1861 p. 348; in Hecker's Ann. 1829 Bd. 13,
    p. 428; in Rust's Magazin 27, Bd. 1, p. 192.—Single treatises have been written
    by Abelin, Schm. Jb. 94, p. 72.—Albers,  Schm. Jb. 9, p. 290.—d'Alves, J. f.
    Kdrkh. 9, p. 213.— Backer, J. f. Kdrkh. 41, p. 126.—Barensprung, Beob. aus d.
    med. Gesch. v. Halle 1854.—Baillie, u. a. cit. in Dorp. med. Zeitschr.  III. p.
    205.—Barbieri, Cst. Jber. 1864, IV. p. 128.— Le Barbillier, Schm. Jb. 92, p. 90.
    Canstatt's Jahresbericht fiir 1856. IV. p. 303.— Bartels, Virch. Arch. 1861. 21.
    Bd. p. 65 u. 129.— Bartscher, J. f. Kdrkh. 47, p. 28.—Battersey, J. f. Kdrkh. 5,
    p. 339 ; Cst. Jber.  1845. IV. p. 167.— Baur, Wurt. Corr.  1861. p.  295, u. 1862,
    Nr.  37.—Becquerel, Schm. Jb. 36, p.  114 u. Pr. Vrtljschr. 82, p. 94.—Beger, Cst.
    Jber. 1860.  III. p. Ol.—Behier, Dorp. m. Z. III. p.  205.— Behrend, J. f. Kdrkh.
    10,  p. 37.— Behr,  Naum. Pathol.  III. 1. p. 690.— Bentley, J.  f. Kdrkh. 9, p.
    155.—Berton, J. f.  Kdrkh. 1, p. 383.— Besnier, Schm. Jb.  140, p. 313.— Bidault
    de Villiers, Alibert I.  p. 297.—Bierbaum,  J. f. Kdrkh. 41, p.  168 u. 178; 42, p.
    221.—Bins, Jahrb.  f.  Kdrheilk. K F.  I. p. 223.—Blanckaert, V.-H. Jber. 1868.
    II.  p.  256.— Boning, Jb. f. Khk.    1871.   IV. p. 121;  aus D. Klin. 1870.
    Nr.  30-33.—Bohn,  Konigsb.  med.  Jahrb.  1859.   I.  p.  175.—Bouchut,  Cst.
    Jber. 1856.  III. p.  361, und J. f.  Kkh. 39, p. 113.— Boulay u.  Caillou, J. f.
    Kdrhk. 20, p.  284.— Bourdillat, Schm. Jb. 140, p. 67; Med. chir. Rundsohau
    1868.  I.  p. 108.—Prattler, Beitr. z. ITrologie.   Schm. Jb. 104,  p. 12.—Braun,
    Wfirt. Corr. 1854.  XXIV. p.  237.— Bresseler, Cst. Jber.  1841.  p. 58.— Brous-
    sais, Schm.  Jb. 62,  p. 313.— Brown, J. f. Kdrkh. 25, p.  235 ;  Schm.  Jb.  88,  p.
    335; Cst. Jb.   1855.  IV.  p.  249.— Bruckmann, Dorp.  m.  Z.  III.  p. 205;
    Meissn. Forsch.  III. p. 314.—Brunniche,  Schm. Jb. 131, p. 298.—Brunzlow,
    Casp. Wochenschr.  1841.  Nr. 25.— Bufalini, J. f. Kdrkh. 56, p.  282.—Burse-
    rius, in Berndt's Fieberlehre  II.  p.  286.—Carroll, Oestr. Jahrb. f. Piidiatrik
    1870.  I.  p. 61 An.— Causit, Virchow-Hirsch Jber. 1866.  II.  p. 247.—Chin-
    nock, Gers.  u.  Jul. Mag. 1832.  XXIII.  p. 133.—Chomel,  J.  f. Kdrkh. 6, p.
    126  ; 8, 375 u. 459; Prager Vtljschr. 15, p. 64.—Christian, Centralbl. 1874.  p.
    95.—Claims, Meissner Forsch. 4, p. 128.—Clemens,  Cst. Jber. 1850.  IV.  p.
    141; J. f. Kkh. 34, p. 28.—Coley, J. f. Kkh. 7, p. 123.—Constant,  Meissner
    Kdrkh.  III.  p. 561.—Cornaz, J. f.  Kdrkh. 34, p. 302.—Corrigan, J. f. Kkh.
    5, p. 250.— Corson, V.-H. Jb. 1872.   II.  p. 255.—Coulson, J. f. Kkh. 34, p.
    440.—Coze u. Feltz, Schm. Jb. 154, p. 240.—Cramer, Pr. Vtljschr.  1 An. p. 113.
    — Cullen,  Girtanner,  Kdrkh.  p.  238.—Daniell, Cst. Jb. 1852.  IV.  p.  210.—
    Danis, Diss. Strasb.   1864.— Denizet, V.-H. Jber.  1868.  II.  254.—van Dieren,
    Cst.  Jb. 1848.  IV. p. 142.— Drake, Schm. Jb. 90,  p.  372.— Dubini, Cst. Jber.
    1843.  Cstt. Spec.  Path. p. 219.— Duchek. Pr. Vtljschr. 37, p. 95.— Dumas, V.-
    H.  Jber.  1872.   II. p. 251.—Duncan, Dubl. Journ., Sept. 1842.—Dusevel, Cst.
    Jb.  1864.   IV.  p.  129.— Dyrsen, Schm.  Jb. 28,  p.  129.—Edicards, Cst.  Jb.
    1851.  IV.  p.  UG.—Eiselt, Dorp.  m.  Z.   HI. p.  205—Emmert, Wfirt. Corr.
    1861.  XXXI.  p. 112 u. 144.— Engel, Cst. Jber.  1845.  IV.  p. lU.—Erichson,
    Bateman-Blasius 2. d. Ausg. p. 80.—Espinouse, V.-H. Jb. 1869.   II. p. 244.—
    Faber, Wurt. Corr.  1852.  XXII. p.  221.— Faye, J. f. Kkh. 40, p.  233, u. 41, p 
BIBLIOGRAPHY.
33
125 ; Norsk. Mag. 3 R.  III. 10. Ges. Verh. p. 126.  1873.— Feith  und  Schroder
van der Evil; Schm. Jb. 107, p. 238.—Fichtbauer, Wfirt. Corr. 1841. p. 189.—
Fischer, Pr. Vtljschr. 24, p. 62.—Flechner, Zeitschr. d. Ges. d.  Aerzte  z. Wien.
8. Jahrg.  1852. 2. Bd.  p. 354; Disc. ibid. p. 184-.—Fleischmann, Jb. f. Kdrhk.
1871.   IV. p. 458.—Flemming, Arch. d. V. f. wiss. Heilk.   HI.   1867, p. 200.
—Forster, Jb. f. Kdrhk. 1868.  I.  p.  138 u. Pr. Vtljschr. 84, p. 63.—Fouquier,
J. f. Kkh. 6, p. 66.— v. Franque,  Wien.  med. Presse 1867.  VUL p.  581.—
Fricher, Wurt. Corr.  VIII.  1858.  p.  390.— Frolich, Hufel. Journ. Supplbd.
zu 1822.— Gauster, Momor. 1869.   XIV. p. 270  u. Med.  Jahrb.   XIX.  Jahrg.
I.  p. 73.   1863.—Geisslcr, Kfichenm.  Ztschr. f. Med.  N. F.   I.  p. 353. 404.
1862; D.  Vtljahrschr.  f. off. Gespfl.   III. p. 46,—Gerhardt, Jen. Zeitschr.  III.
p. 118;  D. Arch. f. kl. Med.   XII. 1. u. 2. H.—Gierke, Jb. f.  Kdrhk.  I.  p.
276.  Fall 18.—Girard, Ctrbl. f.  d.  med. Wiss. 1865  p.  863 ; aus Un med.;
V.-H. Jbr. 1869. II. p. 244 u. Arch. f. Dermatol.   II. p. 263 aus Gaz. d. Hop. ;
Oest. Jb. f. Pad.  I. Bd.   p. 221.  1870 aus Gaz. med.—Glcy, Arch.  d. V. f.
wiss.  Hkde.  1867.  III.  p. 313.—Golis, Meissn. Forsch.   III.  p. 315.—Gott-
wald, V.-H.  Jbr. 1872. II. p. 255.—Gratzer, Kkh. d. Fotus. Breslau,  1837.  p.
46.—Graves, Dubl. Journ.  XVIII. Bd.   1841. p. 238.—Gregory, Ausschlagsfie-
ber, fibers, von Helfft  und Behrend.  1845.   p. 92 ff.;  J. f. Kkh. 4,  p. 45.—
Gruel, Wfirt. Corr.  1862.   XXXII. p.  21.—Gunsburg, Schm.  Jb.  68,  p. 50;
Pr.  Vtljschr. 28, p. 8G.—Guersent,  Meissn.  u.  Schm. Encycl. 9, p. 36 :  J. f.
Kkh.  3, p. 45;  Schm. Jb. 6, p.  110.—Gummers, Arch. d. Ver. f. wiss. Hkde.
II.  1866.  p. 486.—Haartman, Rosenstein,  Kdrkh.  p.  323.—Halnsreutinger,
Schweiz. Ztschr. f. Med. 1856. p. 50.—Hacker, Schm. Jb.  1   Suppl. p.  196.—de
Ha'en, Rat.  med. cont. T. 3. p. 352, aus Rosenstein p. 323.—Hdser, Schm. Jb. 5
Suppl. p.  7.—Hallier, Arch. f. Derm.  I. p. 51;  parasitol. Unters. Leipz. 1868.
Centralbl. 1868. p. 161.—Hannon, Schm. Jb. 70, p. 65.—Harnier, Rust's Mag.
XXIII.  p. 260.—Hartmann, Wfirt. Corr. 1854, XXIV.  p. 200  u. 1862, XXXII.
p. 76.— v.  Hauff, Wfirt, Corr.  1862.   p. 323.  330.—Hauner, Jb. f.  Kdhk.  VI.
p. 119-150 u. Ctrlb. 1864.  p. 48 ;  Beitr. z. Pad.   I.  1863.   p. 58 ff.—IIayden,
J.  f.  Kkh.  25,  p.  424.—Heberden, Willan.   III.  p. 178.—Hebra, Hautkkh. 2.
Aufl.  p. UQ.—Hedrich,  Ztschr. f. Geburtskunde.  XV. 3. H.—Heim,  Hufel.
Journ.  1812. 3. St.  p. '02.—Heinecke, Kfich. u. Ploss's Ztschr.  VII. p. 188.—
Hi-lfft, J.  f.  Kkh. 1, p. 10.—Henoch, Beitr. z Khk.  N. F. 1868. p. 30%.—Heslop,
Schm. Jb. 141, p.  298.— Hey/elder, Schm. Jb. 24, p. 237;  11, p. 217.— Hilda-
nus, Obs.  Chir. 56, Cent. IV.—Hildenbrand jun., Naumanns Hdb.  III.  1,  p.
Q88.—HilHer, J. f. Kkh. 39, p. 389.—Hochmuth,  Diss. Leipzig, I860.—Horing,
Wfirt. Corr.  1841,  p.  186; 1856, p. 304;  1857, p. 183.— Hofmann, Ztschr. f.
Paras.  III.  1872.  p. 105.—Holmes Coote,  Schm. Jb.  124,  p. 303.— Home,
Rosenstein Kdrkh. 6.  Aufl. p.  353.—Hood, J.  f. Kdrkh. 5,  p.  264.— Huguenin,
pathol.  Beitr.  Zfirich, 1869.— Huxlmm, Reil's  Fieberl.   V. p. 225.— Imbert-
Gourbeyre, Cst. Jb. 1857.  IV. p. 223.— Jaccoud, V.-H. Jbr. 1871.  IL p. 250.
—Jahn, Entexantheme. p. 42.—Jenner, J. f. Kkh. 55, p. 12.— Jorritsma, Gerson
u. Julius Mag. 1830.  Bd. 19.  p. 1.—Jutting, J. f. Kdrkh. 3. p. 250.—Just, Cst.
         3 
34                         THOMAS.—MEASLES.

    Jber.  1860.  HI. p.  91.-Kapff, Wfirt. Corr. 1838.  8. Bd.   p. lS.-Karajan,
    Med.  Jahrb.  XXI.  Jhrg.  2. Bd.  p. 17.-Karg,  Woch. d. Wien.  Aerzte.
    1866.   Nr. 49. 50; 1870, Nr. 35. 36. 37.—Kassowitz, Jb. f. Khkde.  N. F.  VI.
    p.  165.-Katona, Oest. med. Woch.  1842.  Nr.  20.-Kaufmann, Bair. Intell.
    1862.   Nr. 20.-Kaurin, V.-H. Jbr. 1868.  II.  p.  252.-^ Keghel, V.-H., Jbr.
    1869.   II. p. U5.-Kelln*r, Frank! Jber. !  1858.  II. p. ZO.-Kennedy, J. f.
    Kkh. 25, p. ±17.-Kerschensteiner, Jb. f. Kdhk. 1858.  I.   p. 54, Anal, oder Pr.
    Vtljschr. 57, p. G8.-Kesteven, Schm. Jb. 135, p. 239.-Kierski, Berl. kl. Woch.
    1868.   p. 32G.-Kjellberg, J. f. Kkh. 54, p. lQS.—Koch, Wurt. Corr. 1863.  Bd.
    33. p. 255.—Kohler, Wfirt. Corr.  1841.  p. 190.— Kostlin, Arch. d. V. f. wiss.
    Heilk. II.  1866.  p. 338 ;  Wfirt. Corr.  1856.  p. 31 und 1862, p. 197.— Kohn,
    Wien. med. Woch.  1867.  Nr. 41-43.—Kolb, Wfirt. Corr.  1841.  p.  190.—
    Krieg, Cst, Jbr. 1843. p. 219. Spec. Path.—Kronenberg, J. f. Kdrkh. 4, p.  243.—
    Krug, C. A., Diss. Leipzig, 1841.—Kuttner, J. f. Kkh. 30, p. 182.—La/aye, V.-
    H. Jber.   1868.   II. p. 257.— Laveran, Schm. Jb. 118, p. 184 ;  Pr. Vtljschr. 71,
    p. 67; Cst. Jbr.  1861.  IV.  205.—Ledelius, Ephemerid.   Dec. n.  Ann. III.
    1684. ' Observ. 97, p.  204.—Lees, Pr. Vtljschr. 8, p. 50; J. f. Kkh. 3, p.  333.—
    Lehmann, Schm. Jb. 139, p. 240.— Levy, Schm. Jb. 62, p.  311; Cst. Jbr.   1847.
    IV. p. 99.—Lewin, J.  f. Kkh. 42, p. 95.— Lievin, D. Vtljschr. f. off. Gespfl. IIL
    p. 358. 362 ff.—Liverani, J. f.  Kkh. 56,  p. 291.— Loschner, Pr. Vtljschr.  3,  p.
    37; Prag. med.  Woch.  Nr. 24,  p. 192.  1864; Epidem. u.  klin. Stud.   Prag,
    1868.  p. 26; Jbch. f. Khk.  1865.  VII.  1. H., p. 12  und 3. H., p. 45. 57;
    Jbch. f. Kdhk.  1868.   I. iG8.—Luithlen, Wfirt.  Corr. 1854.   XXIV. p. 207.—
    Luzsinsky, J. f. Kdrhk. 32, p.  296.— Majer, J. f.  Kkh. 56, p.  161.—Malmsten,
    V.-H. Jbr. 1869.  II. p. 246.—Marsden, J. f. Kkh.  12, p. 301.—Martineau, V.-
    H. Jbr. 1866.  II. p. 246.—Masarei,  Oest. med.  Jahrb.   Bd. 63.  1848.   I. p.
    173.—Mason, Schm. Jb. 155, p. 68.—Mauger, V.-H. Jber.  1866.   I. p. 237.—
    Mauthner, J.  f. Kkr.  12,  p. 447; 21, p. 289.—Mayo, Cst. Jbr.  1844.  III. p.
    229.—Mayr, Wien. Ztschr.  1852.  VIII.  I.  6. 97.  p. 193.  II.  Bd. p.  193.—
    Mertens, Cst. Jbr. 1852. IV. p. 210.—Meltenheimer, Arch. d. Ver. f. wiss. Hkde.
    III.   1867.  p.  343;  J. f. Kkh.   1872.  58. Bd.  p.  1.—M-yer-Ahrens, Pr.
    Vtljschr. 54, p.  144.—Meyer-Hoffmeister,  Schweiz.  Ztschr. f.  Med.  1849.  p.
    i08.—Michaelsen, Schm. Jb. 8, p. 291.—Michele,  Cst. Jbr.  1861.  IV. p. 204.—
    Mombert, Schm.  Jb.   2. Suppl. p. 153.— Monti, Jb.  f. Khk.   1864.  I.  p. 52;
    Ibid.  1865. VII. p. 52; 1869, N. F. n. p. 77; 1873, VI.  p. 20.— Moore,  Schm.
    Jb.   3 Suppl. p. 457; J. f. Kkh. 17, p. 3G3.—Midler, Schm. Jb. 72, p.  271.—
    Midler,  R.  L., Diss.  Leipzig, 1870.—Midler,  Jen. Ztschr. !  Med.  IV.  p. 167.
    1868.   Mugnier, Schm.  Jb.  136,  p.  140.—Naunyn, Berl. kl. Woch.  1868, p.
    237.—Neisser, J. f. Kkh. 3, p. 196.— Neumann, V.-H. Jbr. 1869.   n. p. 244.—
    Neureutter, Oest. Jb. f. Piid. 1871.   II. p.  115.—Nicola,  Beob. u. Abh. ost.
    Aerzte.  II.  Wien, 1821.  p.  361.—Nicolai, Schm.  Jb. 10, p. 156.— Obermeier,
    Virch. Arch. 54, p. 545.— Oesterlen, Cst. Jber. 1841-42.  n.  p. 13.— Ottoni, Cst.
    Jber. 1861. IV. p. 204.— Osiander, Stark's Arch. f. d. Gebh.  5. Bd. 3. St. Jena,
    1794.  p.  572;  Hdb.  d. Entbdgsk.  I. p.  596.—Pank, J. f. Kkh. 4, p.  379.— 
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35
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  Kkh. 3, p.  239 u. 317; 15, p. 429; 21, p. 123 ;  35, p. 398  u.  Schm. Jb. 104, p.
  191; Cst. Jber. 1852.   IV. p. 203.— Tungel,  Klin. Mitth. f. 1860.  Hamb.. 1862.
  p. 19.—Tufnell, Jb.  f. Kdrhk.  1873.   N. F.  VI p. 186; V.-H Jb. 1S72.  II 
36
THOMAS.—MEASLES.
p. 255.— Veit, Berl. kl. Woch. 1868.  p. 452 ff.; Virch. Arch. 1858.  XTV. p.
GL-Vogel, Arch. f. Derm. 1870.  II. p. 408; J. ! Kkh. 19, p. 109.—Voit, Jb.
f. Kdhk.  1872.  N. F.  V. p. 256. — Volz, Hiiser's Arch.  VI. p. 316.  1844.—
Walz, Prager, Vtljschr. 40, p. 72;  Cst. Jber.  1853. IV. p. 1G9.—Weber, Varies
Zeitschr. 11, p. 36.- Weber, H,  Schm. Jb. 133, p. 332;  Arch. d. V. ! wiss.
Hkd.  1866.  II.  p.  358.— Webster, Gregory,  Ausschlagsf.  p. 103.— Weil,
Schweiz. Ztschr. f. Med. 1850.  p. 275.— Weineck, Die Epidem. d. Stadt Halle.
Halle, 1872.— Weisse,  Schm.  Jb. 18, p. 375 ; J. ! Kkh. 9, p. 368 ; 27, p. 52.-
West, J. f. Kkh.  12, p. 117; 39, p. 408; Pr. Vtljschr. 24, p. 24.— Williams,
Schm. Jb.  21, p. 141.— Wilson, Berndt Fieberl.   II. p. 286 ; Heck. Ann. 1828.
Nov. XLI. p. 353.; Jahn Entexantheme, p.  42; Jbch. f. Kdhk.  1858.  I. p.
46.— Wisshaupt, Pr. Vtljschr. 22, p. 101.— Wolf, Arch. d. V. ! w. Heilk. 1864.
I. p. 433._ Wood,  Centrbl. 1868, p. 841.— Woodward, Schm. Jb. 124, p. 121.—
Wunderlich, Arch. f. phys. Heilk.  1858.  XVH p. 14; Arch. d. Heilk. 1863.
IV.  p. 331;  Eigenwarme  in Kkh.  II. Aufl.  Leipz., 1870.— Wunderlich und
Weil, Arch.  d. V. f. wiss. Hkd.  1867.  in. p. 196.—Zavizianos, V.-H. Jber.
1866.  II.  245.—Zehnder, Schw. Ztschr. f.  Hkde. 1863.  II.  p. 425.—Ziemssen,
Greifsw. med. Beitr.  I. p. 117.
                            HISTORY.

   Measles were certainly recognized  in old times.  We need
have no hesitation, according to Hirsch, in pronouncing as mea-
sles  the eruptive  disease described by  Rhazes under the  name
of Hhasbah, and there is no  doubt that many observers in all
parts of the world during the fourteenth and sixteenth centuries
were acquainted with measles and described it under the  name
of morbilli or blaccise.  At the same time its  specific nature was
mostly unknown.   Many other acute macular exanthemata were
confounded with true measles, and a true portrait of it is there-
fore rarely recognizable in  the descriptions.   The first  indispu-
table records of true epidemics of measles are furnished, accord-
ing to Fuchs, by Forest (1563), Lange (1565), Ballonius  (1574-5),
and Schenk (1600); accurate knowledge of these, however, has
been  more especially furnished by Sydenham and Morton (1670-
74), though  even they have not  distinguished it with sufficient
accuracy from  scarlet fever.  Only since the  middle of the last
century, however, has measles been regarded as an unquestion-
ably specific and independent disease.
   Where measles  originated, when and how it spread, and  to 
ETIOLOGY.
37
what  extent it has prevailed of old in the inhabited portions of
the earth, are questions which do not admit of  even a tolerably
grounded hypothesis.  Probably it is of exotic origin.

                          ETIOLOGY.

   Daily experience  teaches  that measles  is  contagious.   It
needs, as a rule, only about a week, when the disease has been
introduced by a patient into  a family, or body of persons living
together, for those among them who are predisposed to it  to
become infected.   The usually rapid increase of  such individual
foci occasions an epidemic, the extent of  which depends, in gen-
eral, upon  the number of those exposed  who have not already
had the disease.   The contagiousness is  furthermore somewhat
shown  by  the positive  results  of inoculation.  On the  other
hand, it is  not likely that measles  nowadays  develop sponta-
neously.  There exist, at any rate, large tracts of country never
as yet  visited  by epidemics of  measles,  doubtless because the
contagion has  not yet reached  them (Australia); while others
under the most varying  conditions of climate have been spared
either completely, or for long periods, and then finally have been
visited by the disease.  If now and then  cases have been related
where persons, for a  long time removed from  all  intercourse,
have fallen ill of the measles, yet this circumstance by no means
proves  that this has arisen spontaneously, and not been commu-
nicated by any infected person.  In  many cases the  infection,
which beyond a doubt has occurred, cannot be pointed out; but
this proves  nothing, since where a contagion is so volatile and
diffusible we must expect that it will attach itself or become
adherent to material objects.   In the case of contagious diseases
it must never be asserted as  impossible that the infecting mate-
rial has been introduced by means of  clothing, furniture, or even
the physician  himself (especially after  a long   stay in a sick-
chamber).  It may be mentioned in  this connection that Mayr
believes himself justified in  denying  any excessive tenacity  of
the contagion, since he could not ascertain that  the  disease was
communicated by the garments and  underclothing  of patients
brought into the hospital with measles, when such clothes,  after 
38
THOMAS. —MEASLES.
being aired, were made use of for other children in  the  build-
ing.   All  these  questions cannot, of  course, be  decided with
absolute certainty before we have acquired an accurate  know-
ledge of the nature of the contagion, its mode of  extension, and
the conditions  of  its existence  and activity.  We can,  at  all
events, reject absolutely the old hypothesis, according to  which
measles was to be regarded  as  a catarrhal  process,  peculiarly
modified  by atmospheric  influences solely,  and indicating a
highly developed catarrhal constitution in the person affected.
   The  nature  of  the contagious principle of measles  is still
entirely unknown.  From the results—which are by no  means
free  from  suspicion—of inoculations,  the propriety  has been
inferred of regarding it as present in the blood,  especially that
of the measle-spots upon the skin, in the contents of the miliary
vesicles which develop upon these spots, in  the  tears, and the
secretion of the nasal mucous membrane, perhaps also  in the
saliva and in the sputa.  A peculiar smell was ascribed to it by
Heim and other older authorities.
   Direct examinations of the blood  and the secretions have
thus far furnished thoroughly contradictory results.  Hallier
found in the sputa, and also in the blood of  measles  patients a
tolerably large number of free cocci, mostly with  a tail-like end,
movable and  colorless, smaller than those in typhus ;  single
blood-corpuscles only were infested or filled with micrococci.
These fructified, in his attempts at cultivation, upon various sub-
stances  or  fluids, and produced always one and the same fungus
(mucor mucedo verus Fres.).  Vogel contests most decidedly the
possibility of proving  these statements.   Salisbury ascribed
measles to a fungus-spore found upon decaying straw ; inocula-
tions  with this parasite were alleged  to produce an exanthem
bearing a close resemblance to measles. He asserts that  he has
also  found that several people,  in the neighborhood of  those
upon whom measles had thus been, experiments causa,  gener-
ated,  manifested the same disease after a  period of incubation
of from one to two weeks ; while the eruption showed itself after
the lapse  of from thirty-four to seventy hours in the cases of
those who had handled  the  decayed straw.   On the other hand,
Pepper inoculated twenty-two persons,  who  had not yet had 
ETIOLOGY.
39
measles, with this fungus, without any result.   Coze and Feltz
found in the blood of measles patients numerous  bacteria of
great activity and extreme delicacy.  They noticed also that,
in man, the blood which was richest in bacteria came from those
spots where the  exanthem  was most pronounced.   The nasal
mucus contained, in the stage of invasion, numerous  similar
elements.   The inoculation of the blood of  measles upon rabbits
produced, however, a fever of two or three days' duration, with
speedy recovery,  and clearly of a very different nature from the
measles of man.   The attempts, therefore, to demonstrate the con-
tagious principle  of measles, have thus far proved unsuccessful.
   The successful inoculation of measles, by means of the blood
as a vehicle, was first attempted in 1758,  in  Edinburgh,  by
Home, at the instigation of Monro.   He laid for three days, upon
fresh cuts  in the upper arm  of a healthy person,  rags  soaked
in blood which  had been  taken  from cuts made through  the
spots of measles, upon the day  of the  disappearance  of  the
disease.  The resulting affection was very  mild, differing essen-
tially from the  severe  type  prevailing at the time.  The rags
soaked in blood retained their infecting properties only ten days.
Willan states that he once inoculated the fluid of a  miliary vesi-
cle of measles without success, while Wachsel, on the contrary,
was  successful.  Subsequently the tears of  measles patients were
employed,  by moistening  lint with them and laying it upon
slight incisions in the arm  of the subject of the  experiment;
saliva  also, and  the branny desquamation of the  skin,  have
been made use of.  Themmen tried inoculation in  1816, at von
Thuessink's  suggestion, but  with no result;  it was  tried in Phi-
ladelphia in 1801, tears, blood, mucus, and epidermis being em-
ployed ; also by  Albers, who doubted the credibility of  Home's
experiments, because these had been made  in  a hospital con-
tinuously  occupied  by patients  with measles, and the infec-
tion might therefore have arisen in some other way.  Speranza,
however, in 1822, confirmed the experience of Home  ; he  himself
was  inoculated most successfully.  Bufalini likewise made in
Italy,  in   1854,  successful  experiments in  the inoculation of
measles, and reports similar experiences  on  the   part of  his
countrymen Locatelli, Rossi, Figueri, also of Horst and Perci- 
40
THOMAS.—MEASLES.
val.   In 1842  Katona published numerous (1,122) inoculations,
which mostly  succeeded and produced throughout only a mild
disease, whilst otherwise a severe epidemic was prevailing.  No
inoculated person died, and only seven per cent, of the inocula-
tions failed. The inoculations were made chiefly with a mixture
of blood and of  the contents of miliary vesicles, sometimes with
tears, in the same manner as vaccination.  Around the point of
incision was formed a red areola, which gradually disappeared,
as did also the mark of the incision ; and the prodromes, which
were ushered in  by fever on the seventh day  after the  inocula-
tion, were followed by the appearance of the eruption of measles
on the ninth, or at the latest tenth day after  inoculation, the
disease  then running  a customary though  exceedingly mild
course.   On the fourteenth day the fever usually disappeared,
and on the seventeenth the patients might be regarded as well.
Mayr inoculated successfully in 1848 and in 1852.  In opposition
to these observations, Jorg asserts that measles from inoculation
ran in no case any lighter course, and declares these therefore
as useless ; Wendt is of the same opinion.  The question there-
fore  of the inoculation of measles cannot yet  be regarded as
sufficiently elucidated.
   That the nasal mucus carries the contagion,  has been shown
by Mayr.  At  the close of an epidemic of measles in the city,
he  placed freshly secreted mucus from the  nose,  and some
which had been  preserved  in a glass tube,  upon the mucous
membranes of  two children.  The first signs  of catarrh mani-
fested themselves, in the former case, after eight, in the latter,
after  nine days,  and two  days later fever followed.   The out-
break of an eruption of measles succeeded, in both cases, on the
thirteenth day after infection occurred, and  the disease ran  a
regular course.
   On the other  hand, the attempts made by Mayr, with epider-
mis scales from children in the stage of desquamation, failed, as
had already before happened to Monro.  Yet Berndt asserts that
Monro and Look inoculated successfully the desquamation the
tears, and the saliva of measles patients.  In  this respect the
exfoliative product of measles differs essentially from the crusts
of variola, which readily communicate this disease. Cullen states 
ETIOLOGY.
41
that children have eaten the scales of measles without detriment,
as Girtanner relates.
   Every object which has in  any way come into contact with
infected persons, or has been in their atmosphere, may serve as a
vehicle of contagion.  Even a healthy physician  can, by means
of his clothes, or of any other thing he carries with him, occasion
infection, as in several instructive cases mentioned by Panum.
So, for instance, measles  broke out in a house which had had no
intercourse with the rest of the world, except that a physician
had spent the night there a fortnight before, he having come from
an infected district four  miles away, and  been compelled, more-
over, to travel in an open boat, in stormy, rainy weather ; in the
same  way, it is alleged, has the disease been  introduced  into
uninfected houses by a midwife just recovered from the measles.
Other observations seem to show that contagion does not neces-
sarily follow when the  contact with the infected clothes, etc.,
has been brief.  Thoresen asserts that transportation by a healthy
person rarely takes place, since the contagion of measles does not
readily  adhere to clothes,  it being very different in this respect
from that of scarlet fever.  Thuessink assures us that he knew
of a case where the infection was occasioned by a letter;  and
another where it  was attributed to an engraving sent per post.
How long the  contagion in clothes and other objects remains
active, is not known; its tenacity appears, however, to be  but
moderate.
   In most  cases  contagion  is  due to association  with those
infected, and a slight exposure is often sufficient to superinduce
the disease, while in other cases a prolonged one is needed.   In
this connection we should bear in mind not merely the suscepti-
bility of the  persons infected, but also the total amount of  con-
tagion prevailing in the district of infection.  Where apartments
are insufficiently ventilated, or crowded with patients, the conta-
gious principle must  be present in greater amount than under
opposite circumstances,  and a slight contact  will then suffice to
communicate the  virus to one susceptible to its influence.  The
necessity for  suitable hygienic conditions speaks for itself.
   By far the most frequent opportunity for infection, with the
exception of  family intercourse, in which the danger is propor- 
42
THOMAS. —MEASLES.
tionate  to  the number  of occupants of the  house (Geissler)  or
dwelling-place,  is afforded  by the  "Kindergarten"  and the
schools  (Spiess,  Gruel, Yeit).   Here large numbers of children
from the most different parts of the city are  brought into close
contact, furnishing the most advantageous field for infection, by
the propagation of which, from a limited number of foci, through-
out the  entire district, they serve as the actual cause of a rapid
spread of an epidemic.  The children infected at school introduce
the disease into the entire home  circle down  to  the youngest
infant.
   Susceptibility to the contagion of measles is almost universal,
except where one attack has  already occurred.   Second attacks
of measles are, according to the experience  of most observers,
exceedingly rare, as much so as second attacks of variola, scarlet
fever, varicella,  etc.   Third  attacks  are even less  frequent,
though  their occurrence,  as in  cases  of  variola,  cannot  be
doubted.  Thus Yan  Dieren reports the case of a girl, three years
of age, who was  attacked by measles in the beginning of Feb-
ruary, 1848,  and recovered; but was again attacked on March
4th, most characteristically, with the preliminary stage and the
exanthem; and  the whole process,  accompanied in the pre-
cursory  stage by vomiting and convulsions,  began again on the
12th of  April, each  of these three attacks being succeeded by a
branny desquamation.   The cases,  however, reported by Dyrsen,
Bierbaum,  Spiess, and Home, do not exclude the possibility  of
deception.  Nor  can  we  regard  as  incontestable all the cases of
second attacks which are recorded.  In regard  to these it is  at
all events  suspicious that the report is frequently made only
with reference to single epidemics, or even to the circle of observa-
tion of single physicians during an epidemic, that a more or less
frequent occurrence  of  second  attacks  of measles has existed;
nay, at  times it is only one and the same observer who relates
that he has seen  recurrences in the one epidemic of his dwelling-
place, but not in others. So, for example, Spiess reports that the
Frankfort  epidemic  of 1866-67 was characterized  by unusually
frequent recurrences, individual physicians having testified that
the half, at least, of  their cases had been relapses from this or a
previous epidemic.  This excites   the  well-grounded suspicion 
ETIOLOGY.
43
that rubeola,—since there is no doubt of its existence as an inde-
pendent disease,—on account of its resemblance to measles, may
have been frequently confounded with true measles; and this is
all the more likely if the defenders of the frequency of relapses in
measles deny the specific nature of rubeola. Apart from rubeola,
the simple non-specific roseola may have often given rise to con-
fusion.  Against the frequent  and even customary recurrence of
measles, especially espoused  in  recent times by Trojanowsky,
we possess the strongest evidence of good authorities ;  I mention
only the names of Berndt, Thuessink,  Schonlein, Mayr, also
Schott, and Bartscher, with whose experience my own thoroughly
coincides.  Even Panum, from his immense number of observa-
tions  upon people  of every age,  has not been able  to report a
single case of a second attack of  measles.  The experienced Ro-
senstein testifies that he has for forty-four years, and Willan,
that he has for more than twenty  years, devoted the closest atten-
tion to eruptive diseases, without ever meeting with any one who
had had for the second time measles accompanied by fever ; and
that there are therefore good grounds for fearing that some error
has  occurred in the cases apparently contradicting  such  an
experience.   Stiebel alone asserts that  according- to his experi-
ence many, nay, most persons,  are susceptible to a second attack
of measles; we  seek  in  vain, however, for more definite  state-
ments in his accounts.
   Cases of a second attack of measles may be divided into such
as appear a  long time after the first attack,—that is,  at  least a
quarter  or  half  a year, or  generally much later,  even from
twelve to eighteen  years afterwards,—and  into such as occur as
early even  as a few days after the first attack, or, at most, from
three  to four weeks afterwards.  Cases  of  the first  sort  are
reported by Battersey, Roberdiere, Rayer,  Flemming, Kassowitz,
Haartman,   Webster,   de  Haen, Stiebel,  Brunzlow,  Luithlen,
Mauthner, Kierulf, Trojanowsky, Home, Baillie, Lewin, Gauster,
Karg, Behier, Tresling,  Spiess;  here, if  the diagnosis was cor-
rect, there is no doubt of a second infection.   Bierbaum relates a
case in  which measles appeared three times before the thirteenth
year.   On the other hand, a subsequent infection in cases of the
second  sort is less certain;  they should rather be  regarded as 
44                   THOMAS.—MEASLES.
mere relapses, and be  estimated in the  same way as  the well-
known relapses of typhoid fever.   It seems to me improbable
that these  typhoid relapses  owe their  origin  to  a subsequent
infection from without, and Gerhardt calls attention in this con-
nection to  the duration of the sweUing  of the  spleen  after  the
conclusion  of the  fever;  the  supposition seems  to  me more
credible, therefore, for  measles also, that some internal cause for
the new disease is in very rare cases produced by the first attack.
In favor of this is the circumstance that the free interval is usu-
ally of a tolerably definite duration.  Loschner reports observa-
tions, according to which, after the conclusion of the measles and
a perfect recovery, the disease began again, and once  more  ran
through all its stages.   Such cases are also related by Spiess,
Mettenheimer, Gauster, Yezien, Wilson, Koch, Barbillier, Graves,
Eiselt, Schuz, Kostlin, Chinnock,  Riecke (?),  Bruckmann, Bot-
tiger, Behr, Schultze, Abelin, Faye, Bidenkap, Nicola, Kierulf,
Ruttel, Thaulow.   According to v. Diiben and Malmsten,  the
interval can  amount to only a few days.  Spiess, on the other
hand, reports an interval of from  one to two months; so also
Stilling and Wendt (according to S. G. Yogel), one of six weeks ;
Steiner and  Wunderlich, one  of eight  weeks; so also Stiebel,
Bresseler, and others.  Lippe, who, in the course  of three  epi-
demics, has  seen  fifteen  cases  of this  sort,  remarks that the
children concerned were newly attacked,  three  or four weeks
after the first disease, by coming into close contact with a child
lying ill with its first attack of measles; these second attacks
were, as a rule, more severe the milder the course  of the former
had been.  The same  was observed by Seidl, who three times
saw a  violent and malignant recurrence  from four to six weeks
after a first mild attack, and in two of the cases death followed.
If future observations should prove the free interval as in fact of
a  nearly definite duration, it  can then be  assumed as  in the
highest degree probable that a definite relation exists between
the original  disease and the relapse, and not  the casual one of
reinfection.  Thus  Rufz reports cases where, in the first attack,
the exanthem did not break out, and, as in morbilli sine morbillis,
only catarrhal symptoms existed, while the eruption was perfect
in the  second attack,  which appeared two or  three weeks later. 
ETIOLOGY.
45
Whenever the exanthem of measles,  in the first attack, is not
universal, or is  merely  rudimentary in  development,  relapses
seem  to be more frequent than when there has been an intense
eruption.
   There may also  be some justification, in the  explanation of
single cases of true recurrence of measles, for Meissner's suppo-
sition, that it depends upon a temporary suppression (metasta-
sis) and a subsequent reappearance of the morbid process.   Thus
Briickmann observed a boy who, after a  normal course of mea-
sles, was attacked  by quite a violent suffocative catarrh, which
lasted over four weeks, and only disappeared after a second out-
break of measles, which  ran a normal course.   Rosenstein  attri-
buted such cases to a swollen  gland remaining from  the first
eruption, and engendering somewhat  later a fresh  outbreak.
Trojanowsky believes that subsequent attacks, occurring  after
 the lapse of years, may often be explained by geographical differ-
 ences in the contagious principles causing the attacks.
    The so-called "recurrent form"  described by Trojanowsky
 occupies a different position,  both  as  regards  its course and
 its prognosis.   The most typical factor of this is not  the  exan-
 them, but  the  fever, which  closely resembles relapsing  fever,
 though not in every respect identical with it.  It appears in the
 form of two, generally  pretty  violent, paroxysms, which, as in
 the case of relapsing fever,  rapidly  supervene and  tolerably
 quickly disappear again, possess an average duration of from six
 to eight days,  and are separated by an interval of normal tem-
 perature lasting about eight days.   The highest  elevation of
 temperature (105.5° Fahr., and even higher) shows itself on the
 second and third days  of the  disease, simultaneously with the
 highest development of the exanthem, which closely resembles
 that of measles, but whether  identical with  it I am unable to
 state, at least from  personal experience ; at all events an affection
 of the conjunctiva, and of the mucous membrane of the air-pas-
 sages, of the nature of measles,  certainly does  exist.  The dis-
 tinctive factors of such  an attack are the  violent  fever, the
 premature eruption and florescence  of the exanthem,  as well as
 the  speedy and very considerable enlargement of  the spleen,
 which is probably the cause of a coincident, very acute leucsemic 
46                   THOMAS.—MEASLES.

character of the blood ; both of these conditions, however, dis-
appear  again during the intercurrent stage of  freedom  from
fever.  If this  disease, noticed as yet only in Livonia, a district
in which relapsing fever prevails, belongs truly to measles, it yet
appears to me  as a peculiar combination of this with relapsing
fever, which thus defines the time of the appearance of the symp-
toms of measles  and may also  possess the power of modifying
them.  As Trojanowsky, the only observer of  the derangement,
does not  represent this view, I mention it together  with the
relapses of measles.
   All races of men are equally visited by measles, provided that
the contagion reaches them.  Thus, from Drake's communica-
tions (1854), whites, negroes, and Indians were indiscriminately
attacked,  after the disease had once spread  throughout the
southern parts of the United States, where previously only scat-
tered cases had occurred.
   Pregnancy is no defence against measles, and delivery may
be hastened by this as by other  diseases.   Seidl even attributes
to young  pregnant women, toward the normal end of  the  preg-
nancy, an increased susceptibility to measles.  Abortion in con-
sequence of measles has been noticed, even with a  fatal result
(Rosch).   Weisse  observed menstruation  appear for the first
time in a girl of fourteen years, during the desquamative period
of measles ; but as there is no statement of the subsequent  regu-
lar appearance of the same, the  possibility is not excluded of a
simple exanthematic  hemorrhage from  the genitals.  The sus-
ceptibility to measles is said to be somewhat diminished by  some
chronic  diseases,  for instance, according  to Mayr, by epilepsy,
chorea, paralysis; and acute diseases appear often  to exert an
influence in deferring  the outbreak of measles, so that  the  latter
does not  appear  until  convalescence fom the  former.   Thus
Weisse observed that the measles appeared, in a  boy of sixteen
years, immediately after erysipelas of the face, and only on  those
places where no exfoliation had occurred; in a typhoid patient
of thirteen years, it immediately succeeded the typhus, and ran
its regular course during  coincident suppuration of  the parotid
glands; others  have seen it immediately follow other  acute ex-
anthems.   Acute diseases may also give rise  to  changes  in its 
ETIOLOGY.
47
appearance, since it  is by no means .rare for measles to occur
in the course of these, during even  the  stage  of florescence of
an acute exanthem, or immediately before or after this, and to
mingle its symptoms with those of the coincident affection, or to
exercise a  modifying influence upon  them.   Thus the develop-
ment of vaccinia is at one time uninfluenced by measles (Panum),
at another decidedly protracted (van Halen,  Cramer), and Fou-
quier observed this last even in regard  to variola; whooping-cough
is said to disappear entirely when  symptoms of measles appear,
and  only to reappear after their complete  expiration  (Mayr).
Mumps, on the other hand, according to Liverani,  attacked by
preference  patients with  measles, and increased the intensity of
the disease; Mayr noticed the same  in measles which attacked
children  immediately  after cholera.  Kesteven  saw a  girl who
was  suffering from typhus,1 with from thirty to forty roseolse,
attacked during this disease  by measles, which ran  a typical
course in the presence of  the typhus.  That  measles can appear
during the course of variola, scarlet fever, and varicella, and vice
versa, is  shown by  numerous  observers, though  unjustifiably
denied by Hebra.  Bierbaum observed measles during the course
of a meningitis tuberculosa ; Guersent, with  a pustula maligna.
Habisreutinger  saw it in a boy during the  period of  greatest
intensity of an erysipelas serpens, which began  on the  right
foot,  and attacked first the right, then the left half of the body ;
here  it appeared partly where the erysipelas had disappeared,
and partly upon the unaffected places.  Barthez and Rilliet saw
measles three times with  erysipelas of the face, though here the
former did not  affect  the face.  Finally, the  susceptibility to
measles is  said  to be  increased by many  diseases,  especially by
affections of the organs of respiration, an  assertion which is hard
to prove, since the susceptibility to measles of  those previously
unaffected  is in every case so marked.
   Measles, from the universal predisposition to it among those

   1 As this word is used in the German without the adjective " abdominalis "  (typhoid
fever) or " exanthematicus " (typhus fever), it is impossible to designate which of the
two diseases is referred to, though it is probable that typhoid fever is meant. The
same remark applies to all other places in the text where the  simple word " typhus" is
used.— Thanslatok's Note. 
48                   THOMAS.—MEASLES.
who have not had the disease, and the subsequent almost  total
elimination of such a tendency after passing through an attack,
is particularly a disease of childhood, and preferably of younger
children.   The more children there are in one house, the greater,
according to Geissler, is the probability of the infection of those
exposed and thus far unaffected.  Most adults have already had
measles as children, and therefore escape subsequent epidemics,
an apparent proof that a second attack is  at least improbable.
Adults never affected are attacked as frequently as little children
are,  many cases occurring  even during senility.  Thus Drake
(1844) saw upon a plantation  several cases in aged negroes, one
of them at least eighty years old ; Heim, in  a woman of seventy-
six ; Michaelsen in one of eighty-three; Schultze in an "old"
lady, together with her "old" servants.  The most striking evi-
dence is afforded by the  epidemic, described by Panum, of the
Faroe Islands.  There, namely, after the non-occurrence of  mea-
sles since 1781, it was introduced from outside by a single person
in 1846,  and gave rise to such  an epidemic that of 7,782 inhabit-
ants only about 1,500 escaped  the disease, owing to their perfect
seclusion from the islands and districts infected, while over 6,000
were within a short space of time attacked.  The resulting distress
was  of  a  perfectly exceptional nature, since almost  every one,
without regard to age, lay ill at the same time, and consequently
no  systematic nursing  was possible.   Those old people  alone
escaped who had been affected as children  during the  epidemic
of 1781; while, as Panum reports, not one old person, previously
unaffected, exposed  to infection, escaped,  although with  some
younger individuals  this was  the case.  In Hagelloch, where for
fourteen years there had been no epidemic, there were  attacked
by measles, according to Pfeilsticker, 185  out  of 197 children
under fourteen years of age, and of older persons only those who
had escaped infection during the previous epidemic.  In the light
of such facts, the worthlessness is seen of all statements in regard
to the susceptibility of different  periods of life, where, in the
preparation of statistical tables, no regard is paid to the fact of
previous or non-previous infection.
   With children under one year, and especially those under six
months  of age, measles, in spite of all denial, is decidedly less fre- 
ETIOLOGY.
49
 quent, as  I also can testify on the ground of my own observa-
 tions.   Single epidemics may vary in regard to this point, and in
 many  of them  the  infection of  little children occurs more fre-
 quently, yet in general the fact of the frequent immunity of suck-
 lings is established.   This admits of a twofold explanation; it
 may depend upon diminished susceptibility, it can,  however,  also
 be the result of less opportunity for the reception of the contagion.
 This last  is especially the  case when the  suckling is  the only
 child in the family, but by no means explains the increase of the
 frequency of attack in the  separate stages of the first year of life.
 This is rather to be  explained by an increase of  susceptibility to
 measles towards the conclusion of the first year.   Sucklings then
 possess no immunity from measles, as is stated in many reports  ;
 their susceptibility is, however, indubitably less.   The following
 figures may serve as proof :


   Le Barbillier observed an epidemic of measles in the Foundling Hospital at Bor-
 deaux ; of 33 children between one and seven years of age, 24 were attacked, while
 out of 40 children under one year of age only 7 were attacked.  According to Bart-
 scher, attacks of sucklings under six months of  age were of very rare occurrence in
 Osnabriick.   According to Mayr, only one fell ill in 10 among the new-born and nurs-
 lings. Bartels saw (1860) at the same time 274 patients, between one and five years of
 age, but only 31 under one year; nurslings  often escaped altogether.  Brown saw in
 an epidemic at Leith, among 170 cases, of which 129 were less than five years of age,
 only 12 patients under one year; 24, from  one to two years; 49, from two to three
 years ; 22, from three to four years; 22, from four to five years; 18, from five to six
 years of  age.  In Pfeilsticker's epidemic, except 3 totally secluded children, only 8
 escaped,  of whom 7 were one-half year old or less.   Spiess recorded only 15 cases in
 the first  year, and 52, 68, 62, 81, 71, 82 in each of the following years of life; Trr
 ling, 72 in the first year, and 147, 142,151,  139,189,198 in each of the later ye
 Kellner,  18 in the first year, and 61, 84, etc., in the following ; Gummers, 11
 first year, and 30, 33, 25, 25, 24, 22 in those  following, out of  251 patients ur
 teen  years of age.  According to Geissler there fell ill in  Meerane, in 18r
 2,926 not previously affected children, 1,754, = 59.6 per cent.; the pr
 children under three months was 12,7 per cent.;  from  the third to the
 of age, 18.5 per cent. ; from six months to one year, 35.6 per cent.;  fro
 years, 56.5 per cent; from two to three years,  61.2 per cent; fron
years, 67.9  per cent; from four  to five years, 70.9  per cent;  fr<
years, 72.5  per cent ; from six to seven years, 77.0 per cent; from
years, 81.3 per cent. ;  from eight to nine years, 78.0 per cent. ; fromni
68.0 per cent. ; from ten to eleven years, 55.0 per cent ; from eleven 1
            Vol. II.—4 
50
THOMAS.—3IEASLES.
30.1 per cent. ; from twelve to thirteen years, 20.8 per cent.; from thirteen to fourteen
years, 63.6 per cent.  (The figures of the latter years are based upon small numbers,
since most children of these years had  previously had the disease ; the figures, con-
sequently, are of little value, partly for this reason and partly because at this age
of the children the parents might have forgotten an attack that had occurred a long
time before.

   Accordingly, no further doubt can exist with  reference to the
diminished susceptibility  of nurslings, to which,  according  to
Rilliet, Ackermann  had already called attention at the end of
the eighteenth century, and which near the first year of age rap-
idly disappears.
   Individual observations,  however,  inform us that even  the
youngest  children are not entirely without any predisposition.
Heim reports measles in a child of four days ; it was born during
the severe sickness of one of the  other children, began sneezing
and  coughing on the fourth day, and  a  common mild form of
measles showed itself on the eighth day.  Kunze saw a woman
with measles,  in the  stage of florescence, give birth to a child,
which on  the fifth day of its life took the  disease ;  both died.
Oesterlen  saw a remarkably  mild  course in patients of  from
eight to fourteen days; Mayr relates a case of  an infant  eight
days old ; Geissler also a mild case at the same age ; Monti,  one
at twelve days and  one at four weeks  of  age, in the years 1861
and 1862,  one at twelve days and one at three weeks, in 1863, six
cases between the ages of one and two  months, between  1861
and  1865,—in all  ten children under two months of age.   The
youngest case must  therefore have been infected at birth, Heim's
case even  earlier ;  consequently children can be  born possessing
at once a decided  susceptibility for the contagion  of measles.
Yerson holds that he has very frequently seen measles in new-
born children.
 .  There are  also single rare observations—with my best efforts
   we been able to  discover but  six accounts of such, in which
     f, does not exist as  to the  correctness  of  the diagnosis—
      :ng to which children have been  born with fully developed
       , characterized by the exanthem, after the mother shortly
       tad been ill of the disease.   Other observations are  so far
       loubtful, that the exanthem was no longer visible at birth 
ETIOLOGY.
51
but merely an exfoliation,  which  possibly  was nothing more
than the usual desquamation of a new-born child.  In still other
cases the disease of the fcrtus has been presumed, simply from
its uneasiness during the disease of the mother.  Most writers
report, it is true, the occurrence of congenital measles, but with-
out ever having met with examples, e.g., Willan,  Rosenstein,
Burserius,  Girtanner, Reil, etc,  On the other hand,  S. G. Yogel
has himself  seen such  a case, and  believes them to be,  as a
rule, a cause of premature labor ; Guersent holds the same view.
Two cases of older date are related with sufficient accuracy by
Hildanus and Ledelius.   Clarus stated, in the Medical Society at
Leipzig,  that he had observed the exanthem of measles quite
plainly on a foetus, the mother of which had died during the
exfoliative stage.   Michaelsen relates two cases of measles in
new-born children,  one  of  which  he himself observed:  in  this
case the woman, manifesting at the time the eruption, bore a
child which showed an unmistakable  exanthem of measles.
Seidl appears to have observed the same several times ;  he writes
that the eruption can  appear on the mother  and child imme-
diately after the birth  of the latter, or the  infant can be born
already  affected, from  which it  is  to  be  assumed  that  the
beginning  of the  disease dates from the final period of the
pregnancy.   He makes  no statement, unfortunately, with regard
to the number of his cases.   Hedrich reports that a woman with
measles was on the  fourth  day of the  disease delivered of a
girl, who  was  covered with  spots of measles  and manifested
several catarrhal symptoms,  sneezing, coughing, and moderately
inflamed edges of the eyelids.  The disease here ran a  favorable
course for both parties, as  in the cases of Hildanus and Ledel.
According to Eisenmann and others, J. Frank and Girtanner (?)
have also observed cases of  this kind.  It would be interesting
to ascertain  in  such cases  if the "morbilli neonatorum," as
might  be expected, and as appears deducible in Hildanus's case
from his  report, have  effectively destroyed the susceptibility.
In regard to this I can adduce a case in which the measles of the
mother, who was then five months advanced in pregnancy, did
not affect the susceptibility of the foetus; the child had a mild
attack at the age of nine years, at the same time with its brothers 
52
THOMAS.—MEASLES.
and sisters.  Horing mentions  a case where a woman  at  term,
together with four children, fell ill  of  measles, but forgets en-
tirely to refer to the new-born  child ; presumably it remained
healthy.
   It was  formerly often asserted that boys were more predis-
posed  than girls ; more extended observations,  however,  have
shown that the predisposition varies,  it being equal at one time in
both sexes, while at other times it may be stronger in one or the
other sex.  Sex, therefore, does not influence the susceptibility.
   That  the susceptibility to measles is far  more diffused than
that to scarlet fever, is proved  by general statistics of  diseases,
which everywhere show far more cases of measles  than of scarlet
fever.  This fact is well illustrated by observations like  those of
Faber and Heyfelder, which showed that during  a simultaneous
epidemic of both exanthems, those convalescent from scarlet
fever were frequently  attacked by measles,  while the  converse
was far less frequent.   From this it is also evident that the ten-
dency to the two diseases depends  upon different conditions.
Precisely the same  has been noticed in regard to  measles and
rubeola (Rotheln) (Thomas and Gruel).
   Single cases in all epidemics prove,  moreover, that  the sus-
ceptibility to measles may be absent temporarily, or perhaps even
permanently.   I observed during an  epidemic, among about 130
cases, five children, two of whom, boys of two  and  three years,
evinced an immunity during this epidemic,  while two boys of
eight and twelve years, and a girl of nine years, had evinced it as
well during previous ones.  Spiess also reports such cases in chil-
dren of from four to seventeen years.  Some few children appear,
without any known cause, to be free from  susceptibility  for a
while, but  to have  acquired it after a longer or  shorter period.
Thus Spiess alleges that such children, after having been previ-
ously exposed to the contagion with no result,  fell ill, in two
cases after seven weeks, once after two months, four times after
two and a half, once after three,  twice after four,  and once after
five  months.  That these later attacks were, however true mea-
sles, is shown by  the fact that in several cases further  infection
took its rise from these patients.  Moore relates a triple  invasion
by measles of a numerous family : a son, who had passed safely 
ETIOLOGY.
53
through two epidemics, fell ill during the third, and infected  a
younger brother, who at the time  of the first invasion was not
born, but who had successfully resisted the second one.  Accord-
ing to Stilling, a woman of thirty-three, whose children suffered
from measles at the beginning of  January, escaped at that time,
but fell ill in the middle of February, at which time a daughter
six years old was seized by a relapse.
   Single cases of measles are partly sporadic and partly united
in epidemics.  A sporadic appearance occurs preferably in large
cities, where the disease has become more or less endemic; yet
even  here  at times, and then in a tolerably regular manner,
it takes on the extent of an epidemic. Definite epidemics of mea-
sles appear upon low lands  and in  small districts removed from
the great highways of commerce,  and, according to the smallness
and the isolated situation of these, decades and more can elapse
between the separate epidemics, and in these intervals cases are
absolutely lacking.  For this reason, furthermore, single epidem-
ics, when they do occur, are relatively much more considerable in
small places than  in larger ones,  where,  to a certain extent, sev-
eral  epidemics  must be divided among those of the population
who are predisposed to it.  The larger a place becomes  in the
lapse of time, and the more considerable the  commerce in  it and
with it, the more frequently epidemics  of measles appear, and
the more numerous become the  intermediate sporadic cases, so
that eventually in very large places the disease is always present.
This condition of things is explicable by the great contagiousness
of the disease, and by the universal susceptibility of individuals
not as yet attacked.   The number of these increases after a time
by births to such  an extent that it  evidently often  requires
merely the  introduction of the contagion by a single person to
infect quite rapidly the larger number of those belonging to the
new generation, after which, from lack of material susceptible to
infection,  the epidemic fades out, to appear again after  years
under similar conditions.  In large  places with much commerce
the number of those susceptible can never be very considerable,
since it is continually diminished by the constant introduction
of the contagion from all  directions, and. by the more or less
sporadic prevalence of the diseases thus produced. 
54
THOMAS.—MEASLES.
   For  these reasons epidemics of measles occur with  a certain
 periodicity in medium-sized and  large places, so that  in  many
 of them now and then  the outbreak of such an epidemic may be
 prophesied  for  a certain time with considerable certainty.   The
 intervals usually vary  from  two to four years ; the shorter the
 interval, the milder will  the ensuing epidemic usually  be ;  and
 the longer, the more intense.  A mild epidemic is followed, as a
 rule, soon, and  also out  of its regular turn, by a  more severe
 one, which  compensates for the  omissions  of the former.   We
 possess reports,  for instance, from various places in regard to the
 succession of these  epidemics  during long periods,  and from
 these it appears that in  certain  years the disease is universally
 prevalent, so that epidemics of measles will be found prevailing
 simultaneously in different cities  ; while, however, on  the other
 hand, exceptions and irregularities are frequent.  Sometimes the
 epidemics are not  coincident in neighboring localities connected
 by constant intercourse,  a proof that in this question local con-
 ditions play an important part and are frequently of determining
influence.   Thus we see  that no universally applicable law with
regard  to  the periodicity of  epidemics of measles can be estab-
lished,  and the most that  can be asserted is, that with  the
increase of  intercourse and the growth of large cities they have
 become, in these especially,  by degrees somewhat more frequent.
A few examples may suffice :

   According to Geissler the population of Meerane was in 1837  4,638; in 1843,
5,550; in 1850, 7,337; in 1856, 9,530; in 1861, 12,747;  in 1867, 16,511; epidemics
occurred in 1837, 1850, 1853, 1857, 1861, 1865, 1867, 1869 ; they became therefore
with the increase of population correspondingly more frequent.  In Leipzig measles
prevailed in 1844, 1847, 1849, 1851, 1852, 1856 (1858), 1860-1, 1864, 1866-7, 1868,
1869-70,  and 1872.   In Dresden, according to Forster, in  1835, 1838,1840, 1844,
1846, 1848, 1852 (1853), 1856 (1858), 1860,  1864 (1865),  1867.  In Danzig, ace. to
Lievin, during the years 1863-1869 : 1863-64, 1865, 1868.  In Konigsberg, ace. to
Schiefferdecker, in 1857  (1860-61), 1862-63, 1868.  In Halle there were, in 1782,
24,149 inhab.; in 1852, 36,076 ; in 1871, 52,400 ; ace.  to Barensprung and Weineck,
epidemics occurred here  in 1784-85, 1790, 1795, 1801, 1804, 1806,  1808, 1810,
1812, 1815, 1818-19, 1823,1828, 1831, 1833, 1836,1838-39, 1841-42, 1843, 1845^
1848, 1850,  1852-53, 1855,  1857,  1860.  1861, 1864,  1867, 1869,  1871-72.  In
Zurich, ace.  to Meyer-Hoffmeister: 1827,  1833,  1837,  1843,1849.  In Erlangen,
ace. to Kuttlinger:  1819-20, 1825,  1831-32, 1839, 1847, 1852-53, 1856.  In Stutt- 
ETIOLOGY.
55
ga,rt, ace. to Kostlin: 1849-50, 1852-53, 1855-56, 1858,1861,  1864-65.  In Wiirz-
burg, ace. to Voit: 1846, 1849, 1854 (1855),  1860,1863,  1866, 1868, 1871.  In
Frankfurt a. M., ace. to Kellner and Spiess: 1842, 1846-47, 1850, 1854-55,  1858,
1860-61, 1863-64, 1866-67.  In Munich, ace. toRanke: 1859-60, 1861-62,  1864,
1866.  In Vienna, ace.  to Mayr and Fleischmann: 1842, 1845-46, 1848, 1850-51,
1853, 1855, 1857,  1859, 1862, 1864, 1867, 1869.  In  Prague,  ace. to Loschner:
1843-44, 1847-48,  1850 (1851), 1853,  1855-56, 1857-58  (1859-61 a  large num-
ber of. sporadic cases).  The case  seems to be similar in Berlin of  late years:
ace. to Romberg and Engel measles prevailed in 1843-44, 1844-46, 1848, 1851, 1853
-55, 1857, 1859-60 ; ace. to Passow epidemics occurred 1862-63,  1864-65, 1866-67;
in Formey's book, on the other hand, the periods are not of two but of three years:
1786, 1789-90, 1793.  In Geneva, ace. to Rilliet: 1832, 1838, 1842, 1846-47.  In
London, on the other hand, the annual mortality from measles was from 1856-1866
between 17.54 and 36.96 per thousand; it prevailed therefore with slight variations
continuously.   In contrast  with these short intervals, we may again refer to that of
Hagelloch (fourteen years) and that of the Faroe Islands (sixty-five years); on the
Cape of Good Hope, also, measles reappeared, after a pause of thirty years, in conse-
quence of a fresh introduction.  In Iceland epidemics occurred only in 1644, 1694,
1846 ; at Madeira they were unknown until 1808.

    Like all acute infectious  diseases, and  especially variola,
measles may also  appear at times with a general,  almost pande-
mic spread, to then disappear again more or less  completely for
a longer or  shorter time.   According to Hirsch,  such universal
outbreaks have been  observed already several times during  the
current century;  so for instance in 1796-1801 in a large part of
France and England, in 1823-24  in Germany, in 1826-28  in  the
Netherlands and   Germany, in  1834-36 and again in 1842-43 in
the larger  part of northern and middle Europe,  and finally in
1846-47 in  almost universal extension over  northern and western
Europe and in North America.
    Apart from their  frequency  and  their tolerably regular  suc-
cession, the form also of  single  epidemics of measles is extraor-
dinarily characteristic.   They have mostly  a short duration, and
increase, when once under way, very rapidly to quite a marked
extent, at which acme they tarry with slight variations for but a
short  time,  then  just  as speedily diminish, and either vanish
entirely, or, as is  the case in large cities,  make room for more or
less numerous sporadic cases.  These abrupt increases are, by the
way,  not exceptional,  but present  in all great  epidemics; in
smaller epidemics,  resembling rather numerous sporadic cases, 
56
THOMAS.—MEASLES.
 the type is more or less irregular, with several maxima, and the
 duration of  the epidemic is then, as a  rule, also  more  pro-
 tracted.
    Epidemics of measles can arise at any season of the year, yet
 statistical tables show that they occur more frequently during
 the cold season.

   According to Hirsch, of 309 epidemics of moderate extent, 96 began in winter
 (28 in December, 54 in January, 14 in February), 94 in spring (43 in March,  28 in
 April, 23 in May), 43 in summer (19 in June, 16 in July, 8 in August), 76 in the
 autumn (16 in September, 34 in October, 26 in November).

    Although conditions of temperature, which favor the occur-
 rence of  catarrhal forms  of  disease, would seem  from this to
 exert an essential influence upon the rise and spread of measles,
 yet a series of facts goes to show that this  disease can also arise
 entirely independently of the cause cited, and that the spread of
 an epidemic once started certainly ensues at any time and under
 all meteorological conditions.   Perhaps  the better ventilation of
 sick-chambers during  mild weather,  and the consequent dimin-
 ished concentration of the contagion, with the apparently slight
 vitality of the  same,  may be the reason why the  introduction
 of the poison often produces no effect; while the inferior hygienic
 conditions pertaining to the cold  season may be far more favora-
 ble to the development and spread of  an epidemic of measles.
 It is  certainly a fact,  that  in thickly  peopled, and badly ven-
 tilated localities, by far fewer individuals with moderate suscep-
 tibility (such as nurslings,  and a few older children) escape than
 under the opposite conditions.
   The seasons seem to exert, however, some influence upon the
 course of epidemics  of  measles in  respect to  their character,
 their  mildness or malignancy,  and  the mortality  from them!
 This must not be understood as meaning that the weather affects
 the mildness or  severity of the contagion, which is not the case.
 The influence exerted is rather upon the occurrence of  complica-
 tions  and sequelae, and the nature  of the  convalescence.   The
cold season, and still more the changeable weather of sprino- and
autumn,  decidedly favor the  production of, and interfere%vith
the recovery from, affections  of the lungs,  which may also pos- 
                          ETIOLOGY.                       57

sibly be  influenced  unfavorably by the existence of a catarrh
of the air-passages acquired before the attack of measles ; while
the hot  season, though to a much less degree,  occasions the
development of catarrh of the intestines, thus modifying the nor-
mal course of  the measles.  There are no definite statistics with
regard to this, partly because they are in most instances based
upon  old cases,  while  in  this  important  question  the  more
rational mode  of  treatment of modern times exercises a decided
influence, and must consequently be taken into consideration.
   The question of the time at which measles are most infectious
and the contagion most widely diffused, stands in intimate rela-
tion with the question of the duration of the stage of incubation
in those who have been infected.
   Since the precursory stage of measles begins, as a rule, with
marked fever,  it is  generally easy to  determine the point at
which the stage of incubation terminates; for by incubation is
understood that period only which elapses between the infection
and the evident commencement of the symptoms of  the disease,
that is, of the fever.  The  entire prodromal stage was formerly
often comprehended  under  this name, and the period of  incuba-
tion was thus  understood  to extend up to  the eruption of the
exanthem, a view which has occasioned much confusion.
   It  is  quite  difficult, usually  impossible,  to determine in a
single case the moment or even the day of infection.  It takes
place, as a rule, in the family circle or at school, that is, under
conditions which involve frequent or continuous contact with the
contagion.  Single observations,  however, exist in which a single
exposure, or that of only  a single day  is reported, and which
therefore permit us to regard a fixed time as that of the infection.
The persons  who in these cases occasioned the infection  were
partly  in the  precursory, partly in the  eruptive stage; at  some
time, therefore, during these two stages, the infecting material
must have been effectively generated and thrown out.   If,  how-
ever, the fact   is regarded  that  the  contagion may adhere to
material  objects,  those for  example of the sick-room, and pre-
serve its activity for a time  as yet undetermined, the possibility
certainly cannot be excluded that a material thrown off during
the prodromal stage may  occasion  infection  some  days  later 
58
THOMAS.—MEASLES.
 during the stage of eruption, at a time even when it is conceivable
 that the elimination of contagion from  the diseased organism no
 longer takes place.  The symptoms on the part  of the mucous
 membranes are, however, similar in the prodromal and eruptive
 stages, with the addition merely of the  exanthem  in the latter
 stage, and there is no ground for doubting the possibility of their
 giving rise to an effective contagion, but in no case as yet has
 proof been furnished that that substance, which during the erup-
 tive stage occasioned the infection, had been just before  elimi-
 nated and worked contagiously therefore in a perfectly fresh con-
 dition.  Such proof could only be furnished if  a child, at the
 commencement or height of  the eruption, should be washed, in-
 vested with clean and not-to-be-suspected clothes, transported,
 without the accompaniment of any infected object, to a healthy
 locality, and there produce infection.  Since the disease in those
 infected begins only at the expiration of  a stage of incubation,
 consequently at a time when the infecting patients are convales-
 cent and their skin exfoliating, it was formerly held that the
 infection occurred especially or solely during this period, and not
 at any earlier one.  That this opinion is completely erroneous is
 shown by  those numerous observations  in which  contact  has
 occurred only during the first period of the disease, the exposed
 person, however,  becoming infected ; this opinion,  therefore, is
 at present given up entirely.
   On the other hand, it is clearly proved that effective contagion
 is produced at the beginning of and during the prodromal stage,
 and it is precisely at this period that the greatest spread of the
 contagion takes place.  Evidence of this is afforded by the only
 slightly varying duration of the incubative stage ascertained in
 the few cases mentioned above, where the  contact of  the infected
person with the source of contagion was but for a moment or for
 one day.   If we reckon, in common cases where a  family is
infected, fourteen days back from the outbreak  of the  exanthem
in the second child attacked, we come noticeably often upon the
first or second day of the prodromal stage, or the last day of the
incubative  stage in the original case.  It is especially desirable
and would  not prove  a thankless task, for country physicians
in secluded districts to increase the small number of standard 
ETIOLOGY.
59
   observations by  further cases accurately  reported after careful
   investigation.
      The majority of these few cases have been reported by Panum,
   who made his observations upon the Faroe Islands under, it must
   be confessed,  the most extraordinarily favorable  circumstances.
   In all cases thirteen or fourteen days elapsed from the day of
   infection  to the  commencement  of  the eruption,  and  that  too
   whether the infection had taken place during the prodromal or
   the eruptive stage, upon which latter  circumstance Panum lays
   needless stress.   The cases in question concerned only: the ten
   men from Tjornevig (exanthem at end of fourteen days), a woman
   in Welberstad (fourteen days), the two young men from Hatter-
   wig (thirteen days), the first young man from Selletrad (fourteen
   days), his brother and other people in  the village (thirteen days),
   nine people in Fuglefjord (fourteen  days), the crew from Dimon
   (fourteen days),  the two men from Skaalevig who fetched the
   physician (fourteen and thirteen days).  As compared with these,
   in all nearly forty cases, the remaining literature furnishes but  a
   scant return,  since, for the most part, a contact of several days
   between the person infected and the first patient had taken place,
   and the exact estimation, to a day, of the duration of the incuba-
   tive stage is  therefore impossible.   I have been able to find only
   very few serviceable reports ; among these are : the first case by
   Gregory (fourteen days),  a child  by Mayr (fourteen days), two
   children by Dumas (from ten to twelve days, according to Simon's
   report), a girl of  eighteen years by Kiittner (ten days to the time
   of the "eruptive fever"), and two boys by Spiess (fourteen days).
   In addition to these cases many others exist  where, on the first
   outbreak of measles in families or hospitals, children were at once
   removed,  but  fell ill nevertheless and manifested the exanthem
«»  about fourteen days later ; cases which, however, do not preclude
   the possibility that the stage of incubation may have been abnor-
   mally protracted, inasmuch as the infection may have taken place
   in the prodromal stage before the outbreak of  the measles.
      If we bear  in mind the fact that the duration of  the prodromal
   stage of measles lasts three or four days, the stage of incubation,
   as shown by Panum's observations, must be considered as extend-
   ing over ten days. This period represents the  normal duration of 
60
THOMAS.—MEASLES.
the same.  With this corresponds very well the experience, unac-
companied by special instances, of Abelin, who noticed that when
a case of measles was brought into the hospital the disease began
among the other children in nine days.
   Others have endeavored to establish the duration of the incu-
bation of measles in this way:  in families, where a child had
introduced the disease, they noted the number of days from that
of the illness or eruption of  the first child to that of the same in
the others.  It is evident that this manner of reckoning does not
afford any trustworthy estimation of the duration of the incuba-
tive stage,  since the beginning of the illness and the eruption are
not always equally widely separated as to time, and the infection
of the subsequent cases can  clearly have ensued at very varying
periods,  namely : 1, before the illness of the first child, from the
same or  another source,  and particularly from the  contagion in
the clothes of the first child  ; 2, during the course of the disease
of the first child,  from the infectious material  produced-by it,
and this either at  any time of the prodromal or of the eruptive
stage ; 3, after the  disease of the first child,—or at least at a time
when the child no longer diffused any infectious material,—from
contagion which it had produced during its illness and which was
communicated to the second child by means of inanimate objects
or otherwise at second hand.  Since, however, it may be taken
for granted, from the great contagiousness of measles even  during
the prodromal stage, and from the great susceptibility to measles
in those never attacked, that the infection will occur as  soon
as possible, we may expect,  in such estimations as the above, to
meet  no very varying numbers,  and in  the majority of  cases to
observe nearly the  normal duration of the incubative period.

   In this connection I note the following results:  Pfeilsticker, proceeding on the
assumption that the infection of those subsequently attacked took place on the first
day of the prodromal stage, found an interval of from thirteen to fifteen days between
the infection and the exanthem; Girard, with the exception of three cases where it
lasted sixteen days, one of thirteen  or fourteen days. In the six cases of Harnier,
where the infection could only have occurred during the prodromal stage, the inter-
vals between the eruptions were from eleven to thirteen days.  In a carefully con-
trolled case by Rilliet, the interval between the first signs in two children was twelve,
that between the eruptions ten days, and the exanthem of the second child  appeared 
ETIOLOGY.
61
fifteen days after the commencement of the prodromal stage in the first.  Spiess, on
the other hand, observed only the time of the outbreak of the two exanthems, and
found the interval to be, in one hundred and forty-seven cases, one hundred and
seventeen times between ten and fourteen  days, eight times in nine days, and
twenty-two times  between fifteen and eighteen days;  Salzmann found, reckoning
in the same way, in twenty-five cases infected from a single source, three times in
nine, eight times in ten, thirteen times in eleven, and once in twelve days ;  accord-
ing  to Kerschensteiner, the exanthem  of the second series in thirty-seven  families
appeared thirty-four times between the tenth and twelfth days after the outbreak
of the first eruption, and once each on the eighth, fourteenth, and fifteenth days.
I frequently observed in the two series the beginnings of the prodromal stages and
the maxima of the exanthems, and found for  the first  an interval of  ten, for the
latter one of nine or ten days; these numbers, therefore, coincide exactly,—or at
least this is true of the majority of them,—with the more accurate duration of the
incubation given by Panum.

    Observations even so ambiguous  as these may serve to  con-
firm the rule  that the  incubative  stage of measles possesses a
definite duration of about ten days ;  it is not allowable to infer
from them  the opposite.
    An interval  between the maxima  of the exanthems of  the
infecting and affected  children,  which far exceeds the normal
standard,  may  be explained by the  at first  slight and  subse-
quently increasing susceptibility of  the  second  child,  so that it
becomes infected by the contagion which still adheres to objects;
it might, however, also  be explained by an unusually long dura-
tion of the incubation.   Against this  last is the fact that such
a one  was  never yet confirmed  by undoubted observations ;—a
further reason for laboring for the greatest possible augmentation
of their number.  Furthermore, it is to be remembered that Pan-
urn's figures are derived from measles in adults, not in children.
    How certain  unusual observations  are to be explained must
for  the  present be  left undecided ;  it is probable that the con-
tagion adhered  to objects which did not at once come into con-
tact with the person subsequently  affected.   Thus Roux  ob-
served  an  epidemic of  measles, which broke  out among  the
healthy occupants of a vessel seventeen clays  after leaving the
harbor ; Tuffnell, the isolated affection of a soldier who  for forty-
five days had been in prison.   In both cases the diagnosis  is said
to be indisputable.  Possibly existing chronic diseases sometimes 
62
THOMAS.—MEASLES.
influence the extent of the incubative  stage : thus, according to
Mayr, the rickets.  Emmert reports a case where a boy of ten
years, just recovered from an acute rheumatism,  fell very  ill
after an incubation of two and a half weeks.

                         PATHOLOGY.

                   Anatomical Changes.

   Measles are characterized by an eruption upon the skin of red
spots, accompanied  by catarrh of the mucous membrane of the
upper air-passages and by a brisk fever.
   In normal cases  perfectly developed measle-spots have a dia-
meter  varying  from  one-twentieth  to two-fifths of an inch;
their  form is roundish, long, half circular, or like a half moon.
Their margins are rarely rounded off, generally  variously  in-
dented, and frequently even provided with offshoots, not fading
off into surrounding parts, but sharply defined.  Their color is
more  or less rosy red, sometimes with  a  light shade of blue, at
times dark red.  They are usually discrete and  separated  by
healthy, pale tracts of skin; but where closely contiguous their
margins can in various ways become confluent, and thus produce
at one time a more or  less uniform redness over a large  extent of
skin, on which can still be recognized, however, the original spot-
ted character by clearer and darker streaks, as well as by single
pale points remaining  free ; at another, a marbled injection of the
skin  in irregular configurations, separated by numerous pale
streaks and spots.  At times, in confluent measles, moderate tur-
gescence of the skin  takes place.   In  no case does the redness
occupy the entire superficial area of the  body  uninterruptedly,
only single tracts are at most confluent,  the others show the usual
spots.  A certain resemblance to scarlet fever can at all events be
occasioned in severe cases by an extended and almost universal
confluence. The single spots are  very  slightly  raised, and very
often  have in  the centre  of  each a miliary papule, which fre-
quently occupies the place of a hair, and  rises almost impercep-
tibly above the spot.  The spot disappears on pressure, but when
this is removed  returns  immediately with the same form  and 
AX ATOMIC AL CHAXGES.
63
similar  characteristics.   Many spots  contain  several papules.
With an intense exanthem these fine papules are also more evi-
dent,  but  rarely  so strongly developed as to mislead a person
into confusing them with forming variola papules.  They charac-
terize to a marked degree the eruption of measles, and distinguish
a confluent exanthem resembling scarlet fever from a true case of
the latter.  As a rule, the hyperaemia around the papule is some-
what darker than at the margin of the spot itself.
   Mayr and Hebra seek for the anatomical basis of the measles
papule in an inflammation of the sebaceous follicle of the skin,
which excites a superficial capillary injection of the contiguous
parts, which is generally limited by the furrows of the skin, thus
losing the form of a circular inflammatory  areola.   The hairs
which are present in  the inflammatory tract are merely inciden-
tally so ; if the hair-follicles specially participated in this inflam-
matory process, the scalp would necessarily be the proper focus
of the exanthem,  and the palms of the hands and the soles of the
feet would remain free, neither of which is the case.   This opin-
ion, not based otherwise upon  anatomical investigations, is not
shared by G. Simon.  He examined a papule cut, together with
a small portion of the subjacent cutis,  from  a boy with measles.
It appeared that  the epidermis was  unaltered, and not separated
from  the cutis ; this latter bulged  somewhat at the site of the
papule ; why, was not ascertained.   Abnormal elements were not
present, with the exception of  very small, roundish molecules,
unaffected by acetic acid, between the cutis fibres ; these them-
selves showed no change, the papillae were not enlarged, and it
was presumed therefore that the papule resulted merely from a
collection  of  fluid.   On the upper portion  of  the hair sac no
change was found, nor any swelling of the sebaceous glands.
Neighboring  papules seemed  often  to  unite in a group, which
was then, as  a rule, surrounded by  a more extended hyperaemia
than where single papules only had been developed.   The exan-
them  acquires a somewhat abnormal  appearance when  the
papules are not grouped but discrete, and  the roseola of measles
is  formed  around each separate papule.   This  is especially the
case in young children and nurslings.  When the roseolae are
here  so large as to be almost confluent, the appearance of the 
64
THOMAS.—MEASLES.
eruption is rather suggestive of scarlet fever.  On the other hand,
an unusually marked development of the papules often occurs
in anaemic, scrofulous children, and in such cases very considera-
ble, entirely or nearly pale, papules frequently appear near and
between the usual hyperaemic ones. The sight of the hyperaemia
appears to be in the deeper strata of the  rete Malpighii.
   The  spots  of measles  are  developed upon all parts of  the
body, on  the  face and trunk  more than upon the  extremities,
especially the lower, where in light cases they are very scattered,
and somewhat smaller.  The confluence  of separate spots is usu-
ally confined to the face,  where also, as the most vascular part
of the skin, they are usually most  developed ; and their redness,
which is tolerably uniform throughout other parts of the body,
is here often somewhat brighter.  They have no regular  arrange-
ment, and are scattered about, the  smaller and larger ones alter-
nating in various ways.   It is rare that other parts are  more
affected than the face.  Now and  then no difference can be per-
ceived between this  and the whole or single parts of the trunk,
and in this case there may be a more or less universal confluence,
as in  scarlet fever,  even  at times upon the  scalp  also.   This
occurs only in  very severe cases.  The eruption upon the gluteal
region is often of a darker  color, and its appearance modified by
an erythema arising  in consequence of pressure.   The buccal
region, palms,  and soles are covered with spots like the rest of
the body, the  genitals of boys and girls to a less extent.   The
exanthem varies but little as to quality and quantity upon  the
flexor and extensor  aspects of the  extremities ; any existing  dif-
ference is accidental.  I have often seen  in anaemic patients, with
a delicate skin, an eruption which was in all parts of the body of
a light shade of rose color, the extent and swelling of the spots,
nevertheless, leaving nothing to be  desired.
   If  the exanthem  is specially scanty, the single spots are  never
equally diffused over the whole  body,  but grouped upon  a
smaller  or larger surface, generally discrete, sometimes slightly
confluent.  Neighboring surfaces of equal extent may be free or
slightly spotted.
   The  diversity of form in individual cases  depends upon vari-
ous deviations of the same in regard  to the size,  height  and 
ANATOMICAL  CHANGES.
65
grouping of the papules, to the extent and intensity of the con-
secutive hyperaemia, to the swelling of the hyperaemic spots, to
the manner of mutual  position on the part of the spots, and can
also be due to variations in the spread of the exanthem upon
single parts of the body,  or to the occurrence of bruises and the
development of vesicles upon the site of single  spots.   Mayr
and Hebra distinguish: Morbilli Imves, smooth, simple measles,
without especial elevation of the follicle, all the spots clearly iso-
lated ;  M. papulosi, with a more evident papular formation, so
that this feature specially defines the character of  the eruption ;
M. vesiculosi seu miliares,  when the eliminating ducts  of the
follicles, filled by fluid exudation, protrude in the form of fine,
transparent miliary vesicles, giving to the eruption  an appearance
resembling miliaria;  this is especially the case when  perspira-
tion is profuse ; M. conjiuentes, due, according to these authors,
to the outbreak of such  a number of spots or papules that the
free interspaces are reduced  to a minimum ; If. TiamorrTiagici,
where the efflorescences represent spots or papules  of  a dark red
color, not disappearing on pressure; these  result from  capillary
hemorrhages.
   The outbreak of the exanthem does not  always take place at
a similar period of the  fever, while the point of its highest devel-
opment, the maximum of the exanthem, is  a  nearly fixed one.
Thus, the earliest signs of the  eruption, at first in a  thoroughly
undeveloped condition,  appear not  infrequently upon the first
day of the febrile period, more often on the second or third; in
the larger half of the cases, however, they appear late, from one-
half to one and a half days before its maximum. As the point of
origin of this single manifestation, I recognized in most cases a
faintly hyperaemic  swelling  around the orifice of a sebaceous
gland,  the papular character of the exanthem thus being pro-
nounced at the outset.  A faint hyperaemia, without  swelling,
existed only rarely at first,  more often a pale papule without
hyperaemia.  Variations  of this kind appeared usually, not iso-
lated upon single parts of the body or extended areas, but near
to and between the hyperaemic papules.  When the development
of the exanthem is  rapid, these abnormal  appearances speedily
develop into the usual  spots of measles, and yet I have also seen
          Vol. II.—5 
66                   THOMAS.—MEASLES.

in several cases  the  disappearance, during convalescence,  of a
considerable number  of papules which had remained pale.  On
the other hand, the spots, even in the lightest cases, never remain
in their original purely hyperaemic condition.
   The papules  show themselves first of all  upon the  face,
especially on the chin, cheeks, forehead,  and temples,  further-
more over the processus  mastoideus,  and very commonly also
upon the scalp, at times upon the occipital region.   Somewhat
later, but still at an  early period, they also often appear upon
the throat, neck, and the  upper parts of  the breast and back;
only very rarely, and then faintly, they appear upon the last-
named or other parts at first.
   When it appears quite early the exanthem at first  changes
but slowly, and extends just as slowly to other parts of the body.
Thus it may develop and remain for days  in a moderately devel-
oped condition upon the  face alone.   A  quicker  increase then
takes place at or soon after the beginning of the marked increase
of temperature  which characterizes the  acme  of  the  disease.
While  previously a slight hyperaemia had begun  to form very
slowly  around the swollen follicular orifices, it now spreads very
rapidly;  the red areolae around contiguous papules run together,
and  swelling of the  hyperaemic  spots occurs over  regions of
varied extent.  The previously unaffected parts are now attacked
in rapid succession.  While roseolae appear upon the face around
the original papules, there arises on  the trunk, and soon also
upon the extremities, a formation of fresh papules, the further
development of which progresses speedily.   In this way it  is
very common for the maximum of the exanthem  in  the face to
exist in  a state  of perfection at a time when its  most marked
development has been also reached upon the other parts of the
body.
   When, however, the eruption  first appears at a late period,
namely,  during the  acme, its  extension over the body is  more
rapid.  In a premature outbreak the development and extension
of the single spots can be followed step by step.   Where this is
delayed,  there appears at once, and almost over the whole body
at the same time, an exanthem, developing speedily, especially
in regard to the formation  of  roseolae, where half a day before 
ANATOMICAL CHANGES.
67
 only traces could be observed, or not even these.   Its increase in
 intensity and  extension is rapid,  and  its maximum  is soon
 attained.
    The  duration  of  this  maximum, that is, of  the greatest
 development of the eruption on all parts of the body at once, is
 about half a day, more  or less.  It is usually observed only at
 evening, and is then of shorter duration, since by the next morn-
 ing retrograde metamorphosis of the exanthem  has, as a rule,
 already begun ; while, if it appears in the morning hours, it usu-
 ally, under the influence of the evening increase of fever, remains
 until night, or even perhaps  increases  somewhat at evening.  I
 have never observed the  duration for twenty-four hours of a true
 maximal-development.  I find,  furthermore, that  others also
 describe the duration  of  the maximum as  being very rarely
 longer than this.
    The retrocession of the exanthem takes place usually some-
 what disproportionately on the different  parts of the body.  In
 general it is the rule that the parts first attacked are also the first
 to become normal again.  Twenty-four hours after the ebb of the
 maximum of the exanthem, we find usually that the head and
 trunk, also the upper halves  of the extremities,  are pale, while
 hyperaemic spots still remain upon only the lower legs and feet,
 forearms and hands.   As a rule, however, the redness of these
 parts will  be found also to have diminished long  before.  If the
 maximum is rather protracted, the spots upon the extremities are
 often still slowly progressing, while  the  face has already begun
 to fade out; one sees, then, only a scanty pale red exanthem  on
 the face,  while on  the lower  part of the body the spots are
 larger, redder,  more elevated  than  a few hours before.  Such
 slight  deviations take place  especially when the eruption  of
 measles is intense.  If during the decline of the fever a considera-
 ble exacerbation should abnormally recur, one  often sees the
 faded redness return upon those parts of the body recently and
 severely attacked ; and that, too, to a marked degree, even if not
perfectly in its former strength.   This is likely to be the case on
the trunk,  and  on the upper  parts  of the arms  and legs, espe-
cially the hinder parts of these which are kept pressed and warm
by lying in bed.  This new and less marked redness always lasts 
68
THOMAS.—MEASLES.
but a short time; the influence of the increased  activity of the
heart's action produced by the fever is  soon overcome  by the
tendency to contraction of the vessels of the spots  of measles,
and the retrocession of the exanthem again proceeds.   When the
duration of the defervescence  lasts for  a day and  a half, the
usual inconsiderable exacerbation exerts  either very little influ-
ence or none at all, upon the color of the exanthem, nor does
one notice, as a rule, any striking return  of the redness upon the
occurrence of  feverish complications  at  a still later time; the
eruption rarely, under  such circumstances,  appears with any
degree of distinctness, or at most the spots are  faded and not
clearly defined.  A rapidly progressing fading of  the exanthem,
after  the ebb of its short maximum, may be considered as the
rule, and a renewed redness of spots which had faded,  as the
exception.
   I have never had an opportunity to convince myself of the
connection of  a speedy fading of  the spots with the  sudden
occurrence of a complication.  A simple,  rapidly  progressing
paleness of these can certainly not be considered anomalous.
   When the exanthem is not excessively crowded together, and
has become confluent only at the height  of the maximum, from
the great spread  of the roseolae, this confluence usually disap-
pears during the fading  stage, and  the centres of  the spots,
which before were  the  most deeply red,  alone retain any color.
The very slight swelling of the spots, and that especially of the
nodular protuberances, disappears simultaneously with their loss
of color.
   It is only in rare cases,  and where the  hyperaemia  is very
slight and of  short duration, that the roseolae disappear without
leaving some traces ; they usually  leave behind  a yellowish or
brownish stain, signs of which are also often quite evident upon
pressure, even  at the time of the  maximum of  the exanthem.
These stains last—according to the intensity of their color, occa-
sioned by the presence of red blood-corpuscles, or at least of the
coloring  matter of the  blood—for  a  varying number of days;
and  from them, sometimes even after  from eight to fourteen
days, the previous  existence of  the exanthem  may be deter-
mined.  Their color becomes less by degrees, and vanishes imper- 
ANATOMICAL  CHANGES.
69
ceptibly,—to a certain extent, undoubtedly, with the epidermal
layers, which  at the time of the exanthem were still deeply situ-
ated.   The pigmentation is generally deeper the redder the pre-
vious exanthem was ;  and from it alone is the latter still recog-
nizable upon the dead body.
   More noteworthy  are  the colorations  produced  by  actual
extravasation  of blood on  the site of the spots that  frequently
appear during the  retrograding stage of an attack of measles,
which otherwise runs a perfectly normal course.  Such  hemor-
rhagic stains  can  appear upon  individual  parts, or upon the
whole body, and then more or less upon all or the majority of
the places previously simply hyperaemic.   Their color varies
between wine-red and clear to dark violet, in the most  various
shades, and is not,  as a rule, of the same depth upon different
parts of the body.   They appear to be composed, at one time,
chiefly of  single, larger or  smaller points of  blood; at another,
they  represent more  uniformly  colored areas, with well-defined
margins, as in the previously existing spots; if these were con-
fluent, the same can  be the case here.   The hemorrhages  fre-
quently appear even  during the maximum of the exanthem, so
that this  shows at that time an unusually dark tint, and does
not disappear entirely on  pressure; the hemorrhagic nature of
the spots becomes perfectly evident only upon the fading of the
roseolae, and it can,  then, in spite of the disappearance of the
hyperaemia of their sites,  be still visible, just as in the florescent
stage of the eruption.   Through  the customary transformation of
the coloring matter of the blood, they assume by degrees a paler
bluish, and dirty  yellowish tinge,  and  disappear like common
measles, more or less quickly, according to the depth of their
hue.   Extravasations of blood depend doubtless upon  the fact
that under the influence of the contagion of measles the walls of
the vessels become  temporarily,  and usually only locally, more
fragile, or permit at  least  a more profuse escape of  red blood-
cells ;  any permanent injury from this I have never seen, nor
have  Veit, Hochmuth,  and  other observers.   A dissolution of
the blood, as the cause of these benignant hemorrhagic effusions,
is at all events entirely out of the question.
   When the exanthem is strongly developed, a  little vesicle 
70
THOMAS. —MEASLES.
appears now and then upon the summit of the papule, especially
upon the trunk and under the influence of profuse perspiration.
Heidenreich states that the contents of these miliary vesicles of
measles have an  acid reaction, but this has not been found by
others  to  be the case.  The inoculability of these contents has
been asserted on several sides.  I have never seen in any patient
the entire  eruption marked by a vesicular conformation.
   Exfoliation of the epidermis takes place generally only to a
moderate  extent on the face, but here tolerably regularly,  espe-
cially on the forehead, cheeks, and nose; a by  no means incon-
siderable  exfoliation occurs,  however,  at times even upon the
whole  body.    Profuse perspiration,  frequent  cleaning of the
body, and baths generally interfere with the  occurrence of a per-
ceptible desquamation, while  the nature  of the eruption has  a
less influence upon its development; yet, as a rule, an intense
exanthem and  marked desquamation coincide; exceptionally,
with an equally severe exanthem there may be no exfoliation, or
with a mild exanthem, on the other hand, some exfoliation may
take place.  The  exfoliation, according to my experience, takes
place only upon the sites of the spots, and is, therefore, always
branny or in fine  scales; larger scales occur only with confluent
exanthems, but yet never to the same degree as in scarlet fever.
In measles the  skin does not peel off in large lamellae from the
fingers, palms, toes, and soles.  Desquamation may be apparent
very early, a few days  after  the maximum of the exanthem,
while the redness of the spots still exists ; at  another time it only
appears after complete fading.  As a rule,  it lasts some days,
rarely protracting itself into the second week, or disappearing as
early as in one or  two days.   Thus its appearance and duration
are both undetermined.  According to my experience with scar-
let  fever,  I hold  it as probable that, in  the oft-cited  cases or
epidemics  with  quite anomalous symptoms  or groups of symp-
toms, the  coincidently observed desquamation  in large lamellae
and  of long duration is  to be explained  by the confounding of
measles with scarlet fever, or by the combination of  the two
diseases.
   As  a rule, the mucous membranes of the nose,  the throat,
the upper air-passages,  and the conjunctiva  are attacked, in 
ANATOMICAL CHANGES.                 71
measles,  and  often much sooner than  the outer skin.  The
catarrh of the upper air-passages  in particular is, in all parts of
the earth where measles has as  yet been observed, a  so  con-
stant manifestation, that it  justly merits  the  attribute of a
pathognomonic symptom, a fact especially to be considered in
the diagnosis of measles  in  the colored races.   How  far the
hyperaemia of the mucous membranes in measles can extend in
normal cases  towards the lungs and  the oesophagus,  and in
what form  it exists  upon  more  remote  and less accessible
mucous  surfaces,  is  unknown ;  on the visible mucous mem-
branes the following condition may be seen :—
   Sometimes, at the  end of the stage of incubation, and cer-
tainly in the beginning of the prodromal stage,  or soon after,
there is found, corresponding to the symptoms which appear at
this  time (sneezing,  coughing,  and running  from eyes), a  con-
gested condition  of the  mucous  membrane of the eyes,  nose,
throat, and  larynx ; this steadily increases,  and becomes most
intense just before the outbreak  of the exanthem, and in  the
beginning of the  period  of eruption.   During the maximum of
the exanthem, or, where the outbreak is intense, at the latest
with  the close of this  maximum, this hyperaemia begins to fade
out,  generally disappears rapidly, and is entirely gone at  the
end of a few days.  Earlier or  later,—frequently by the second
or even by the end of the first day of the disease, but rarely as
late  as on  the third day,—this hyperaemia has  commonly
extended from the back nasal passages to the neighboring  por-
tions  of the soft and hard palates and  the buccal cavity gene-
rally.  When the palatal  mucous  membrane is first attacked,
there may often be seen,  together with single, somewhat dilated
vascular  twigs,  a  larger or smaller number of  very  minute
hyperaemic points, which spread rapidly.  This process affords
a peculiar appearance during its highest development at  the
beginning of or just before the  eruption.  The mucous mem-
brane is reddened, especially toward the uvula and the palatal
arch,  and upon it may be found, to a greater  or less  extent,
dark  red spots from the  size of a pin's head to that of  a bean,
or larger, of very irregular contour, varying in  distance from
each other, and with faded margins, which,  for the  most part, 
72                   THOMAS.—MEASLES.

are connected at single points with their neighbors by faintly
colored bands ;  a nearly universal confluence  is more rare.  At
the close  of this process,  which  lasts but a few days, several
more  marked swellings, red, and of  the  size of a  millet seed,
frequently arise, especially upon the darker and more uniformly
reddened back portions, just as they also occur, in varying num-
bers, and  irregularly scattered, in an ordinary chronic catarrh.
These papules have no close relation with the faintly outlined
red spots  of  the mucous  membrane.  This spotted condition,
owing to the  deeply injected condition of the mucous membrane
far back,  is here very indistinct; it is more apparent where
the injection is less,  and  especially in the  parts  further for-
ward ; there exists, however,  no special  resemblance between
this condition of the  mucous membrane and the typical form
of the eruption upon the skin.  The retrocession of  this redness
of the mucous membrane occurs often simultaneously with, but
usually earlier  than,  that of  the exanthem ; it may be  influ-
enced, however, by the intercurrent, abnormal development,
during the process of  the measles, of some further more intense
derangement of the throat, but only by such  a one.   With the
usual normal course of the affection, we see at  one  time only a
few injected vascular trunks, more often some punctiform extra-
vasations  in addition, which quickly  disappear and seem more
numerous, though  also much  smaller, than those  hemorrhages
upon the skin, which  are merely  faint pigment stains.  On the
buccal mucous  membrane we  notice sometimes a faint injection
of single places, of the lips by preference, elsewhere often  noth-
ing at all abnormal,  while at other times an exanthematous,
blotchy formation  may be seen, but  much less distinct than on
the palate. The same condition obtains with the conjunctiva ; a
slight general injection is never absent, but more distinct spots I
have never been able to make out; the ciliary margin and lach-
rymal caruncle  are usually considerably reddened.  When the
eruption upon the face is intense, with high fever, the redness of
the conjunctiva is  also usually considerable, and  occasions a
slight  or more  marked oedema of the lids.  Nor could I detect
anywhere what might be  called a blotchy character of  the
raucous membrane of  the nose and throat, the redness of which 
ANATOMICAL CHANGES.
73
fades somewhat more slowly than that of the palate.   Obser-
vations  have  also been made  upon  the laryngeal  mucous
membrane  of  living  persons:  Rehn found at the  beginning
of the eruption a tolerably uniformly diffused, certainly  not
blotchy, redness;  Stoffella (presumably at different stages), an
equally diffused intense redness;  Gerhardt, on the other hand,
noticed in several cases  in the prodromal  stage,  simultaneously
with the blotchy redness of  the palate, a similar condition also
of the epiglottis and larynx.   In dead bodies a blotchy redness
was found  several times by  Steiner upon the larynx  and bron-
chi,  by Wilson,  Eisenmann and  Rayer  on  the  trachea and
bronchi, by Gerhardt on the hinder wall of the trachea.  I can-
not  admit, from these  contradictory and in part insufficiently
characteristic results,  as well as from the somewhat imperfect
statements, any similarity of this  affection of the mucous mem-
brane with that  of  the external  skin, and,  consequently, do
not recognize the  perfect justness of the  term  '' exanthem  of
the mucous membrane;'' but I willingly c oncede that, since the
peculiarities of  the  process upon the  mucous  membrane  are
unmistakable, one does not  need  to be so precise in one's appli-
cation of  the  conception of the  exanthem  of measles here as
upon the outer skin, since  not its form,  but its mere  appear-
ance at all, is of any significance in regard to a diagnosis.  Pos-
sibly we have to  do  with a mixed process :  together with an
undoubted simple catarrhal condition of  the  nose, throat, and
upper air-passages, there may exist, supposably, an indistinct,
blotchy, exanthematous one, especially upon the palate, the evi-
dence of which  in the  portions further back is often more  or
less obscured by the intensity of the catarrh.
   The tongue offers in contrast with scarlet fever nothing typi-
cal ;  it is usually furred, and its turgescent papillae often  stand
out somewhat more prominently.
   Of the older authorities, Heyfelder in particular mentions an
eruption like measles upon the mucous membrane of the duode-
num  and jejunum, sometimes  also, at the same  time,  of  the
stomach and ileum; Weber, Eisenmann, Fuchs,  and Lieutaud
also  mention it.  In modern times Steiner speaks of  a  blotchy
redness of  the intestinal mucous  membrane in  children dying 
74
THOMAS.—MEASLES.
during the stage of florescence, and compares it to the exanthem
of the skin, an opinion for and against which an equal  number
of grounds may, according to Volz, be adduced.   It  is not yet
established whether such affections, perhaps of a lighter nature,
can be found also in normal measles ; for this reason they may
in the meantime properly be recorded here.  Fuchs says that at
times even the genital mucous membrane is covered with numer-
ous red, somewhat puffy spots overspread with mucus.  Henoch
and Chomel also relate such cases.  These statements in regard
to an affection of the mucous membrane, visible even on the dead
body, should attract our attention all the more  from the fact
that, except where the measles have  been hemorrhagic in char-
acter, almost no  other lesion beyond the exanthem is noticed
after death.  Many authors  assert that  a general  furfuraceous
desquamation of  the  epithelium  of  the buccal  cavity and of
the kidneys is  a normal appearance in  measles, although they
admit that it is present here to a much less degree than in  scar-
let fever.  The affection of the mucous membrane is more often
erythematous than follicular; in intense cases,  however,  the
latter may  exist,  as  is shown by some reports  of  autopsies.
More severe affections of  the mucous membrane belong to the
decidedly anomalous forms of the  measles process.
   Stiebel mentions a blotchy redness of  the pleura pulmonalis.
This was covered on  both sides,  before  as well as  behind, with
round, red spots, partly discrete and  partly arranged in groups,
but never blending;  they were situated immediately beneath
the pleura, their contours were sharp, and they were not altered
by  inflation  of the lungs.  They resembled an extravasation,
and were partly surrounded  by small ramifications  of vessels ;
but were, however, plainly to be  distinguished from extravasa-
tions.  He observed them to a similar extent in four autopsies.
   The  spleen in measles is found to be  moderately swollen ; in
the same way the lymphatic glands appear frequently to become
somewhat enlarged even before the exanthem.
   The  blood is thin and fluid, dark, poor in fibrine,  and shows
in fatal  cases a great tendency  to  infiltrate  the  tissues.  The
number  of the red blood-corpuscles is  diminished, that  of the
white at times sensibly increased. 
SYMPTOMATOLOGY.                   75
                      SYMPTOMATOLOGY.

   The course of measles, as of  every other infectious disease,
possesses a definite  type,  which  is  most clearly marked in
uncomplicated  cases of medium severity.   Normal cases are
such as follow the ideal type in  all essential points, and there-
fore naturally constitute the starting-point of the description.
   There are two factors, without the normal condition of which
an  attack of measles  cannot be considered normal: the exan-
them  and the general disturbance, which  is portrayed in the
manifestations of the fever.   Inconsiderable derangements of the
course of the disease do not affect both, and should the normal
type be lost through some extraordinary influence, it is the more
sensitive fever which is first or perhaps even alone changed.
   Normally the stage of incubation is that of perfect latency of
the disease,  consequently without fever and  free from local
symptoms.   It  may be regarded as a slight and unimportant
anomaly, when  now and  then at its conclusion,  or at another
time, an inconsiderable rise of temperature occurs with or with-
out moderate symptoms  of  catarrh of the air-passages.   The
latter is not infrequent, especially at the close of this  stage,  and
it is conceivable that,  even at  this time, infection may be occa-
sioned by means of the secretion.   Somewhat more considerable
elevations of temperature may also at times occur  under the
form of an ephemeral  fever,  with various  slight feverish symp-
toms ; but its short duration prevents any effect upon the further
course of the disease.  These febrile manifestations may perhaps
arise from incidental causes in consequence of an increased  sus-
ceptibility on the part of the individual infected.
   The febrile period in measles may be divided into two princi-
pal stages, according to the absence or presence of the exanthem :
the prodromal  and  the exanthematic or  eruptive stages, from
which also a stage of florescence is sometimes distinguished.
   The  duration of  the prodromal stage is, in normal  cases,
three, at most,  four or five  days.   During its  continuance, in
many cases,  no evidence of the typical exanthem  of measles is
yet visible; in  others, indications  at least of  this appear on 
76
THOMAS.—MEASLES.
different parts of the body, principally upon the face ; this hap-
pens especially  on  the third  day, and sometimes even on  the
second, but rarely on  the first.   One notices here, for instance,
a larger or smaller  number  of  the minute nodules  mentioned
above ; these may increase slightly toward the end of the pro-
dromal stage, but the typical blotches never form around them
thus early.   The nodules are generally so small as  to escape
observation, or call  for the most minute examination.  This is
less the case with the blotchy affection of the mucous  mem-
brane,  which  has already been  described.   This usually appears
before  the exanthem,  and is even  frequently well developed on
the third, or  possibly  even on the  second day  of the prodromal
stage ;  it more rarely appears simultaneously with the spots upon
the skin, on the  fourth or  fifth day of the disease.   On the first
day it  is more common to find some slight evidence of the devel-
opment of this affection of the mucous membrane than to find
indications of the subsequent exanthem.  On the other hand,  the
anatomical changes which are the cause of the typical prodromal
symptoms—the  catarrh of the mucous membranes—is usually
present from the first.   These changes of the mucous membrane
and their sequelae are very rarely entirely absent in normal mea-
sles ; they take place, at the earliest, at  the commencement of
the prodromal stage.
   The prodromal stage begins suddenly, as a rule, during per-
fect health, or after previous slight catarrhal disturbances, with
fever,   cough,  snuffles, sneezing, photophobia  and pressure  in
the eyes, loss of appetite and  thirst.   These symptoms appear
nearly  simultaneously; but those  of fever are the ones which
define most precisely the beginning of the disease, and influence
most strongly the character and intensity of the prodromal symp-
toms.    The temperature increases rapidly,  and generally con-
tinuously to  a considerable, or at least  an appreciable degree
(102°-104° Fahr.), rarely remaining under 102°; its course there-
fore is  very different from that of the latent period, if perchance
an increase of temperature should  occur in  the  latter.   The
height  of the  maximal temperature, attained during the evening
hours of the  first day of the disease, enables us to determine in
some measure, in primary measles,  the intensity also of the later 
SYMPTOMATOLOGY.
77
symptoms of the  disease.   As a rule, on the following morning,
that is, on the second day of the prodromal stage, a considerable
remission of the fever takes place, and the temperature frequently
becomes even normal; or, exceptionally, it remains elevated for
twelve or even twenty-four hours longer, and is then followed by
the remission for the first time.   To  this febrile initial stage,
which lasts on an average one day, succeed two days of usually
very slight fever.   On the first of these—the  second  day of the
disease—the elevation of temperature is especially moderate, and
in mild cases can even be entirely absent; this absence of fever,
however, will not last beyond the morning hours of  the follow-
ing, the third day (when even a lower temperature than twenty-
four  hours  previously may be  observed), while  at evening  a
more or less marked increase is rarely wanting.  During this
interval of more or less complete absence of fever, the other gene-
ral symptoms usually subside, the natural vivacity returns, and
even  the appetite may be restored,  though  both  may  have
remained normal  from the beginning, owing  to  the mildness of
the fever on the first day.   The whole prodromal stage may thus
escape the observation of  the parents,  who then assert emphati-
cally that the disease first began with the  outbreak of the exan-
them, a  supposition based upon error,  as  can be shown by
accurate observation  in each individual  case.   The catarrhal
symptoms,  however, generally increase during these days; the
conjunctiva is reddened, the lids are swollen, the eyes shun the
light  and  smart, and there is an increased  secretion  of tears.
The  nose seems stopped  up, and begins  by degrees  to secrete
mucus ; sneezing  takes place, and epistaxis may occur, rarely to
such  an extent, however, as  to call for active interference.  If
the catarrh is severe, the face becomes cedematous; itching of
the skin appears, and  even an  urticaria.  The cough, at first
dry, manifests itself usually on the first day, and becomes subse-
quently worse, assuming frequently a peculiar, harsh  sound,
though  rarely so convulsive  as in croup  or  whooping-cough
(Weil).   According to the severity  of the catarrh the voice
becomes thick and rough, or even quite hoarse.  At times even
sore throat may occur, the usual slight redness of these parts in-
creasing to  actual inflammation, the tonsils  becoming1 swollen, and 
78                   THOMAS.—MEASLES.

angina faucium  with its sequelae taking place.  Weil observed
parotitis and  pleuritis  during the prodromal stage.   Gastric
and  intestinal symptoms, on the other hand, are  either absent
or moderate in the  prodromal stage, with the exception of some
loss of appetite;  frequent vomiting is especially rare. Slight diar-
rhoea sometimes occurs.  Frontal headache is frequent on the
first day, if  the fever is high, otherwise it is rare, and under the
same circumstances a tendency to sleep  often at first exists, but
it disappears with the remission of the fever on the second day.
Other slight nervous symptoms  may be present, but the severe
initial symptoms of  febrile diseases in children, such as convul-
sions, for instance, are almost always absent.  Edwards describes
as peculiarities of the convulsions in the prodromal stage of mea-
sles : an extraordinary  severity  of the  attack, with a  duration,
however, so short that the physician who is called  rarely has an
opportunity to observe it; the immediate return to consciousness
after the attack without tendency to coma or sleep; the appear-
ance of  the attack but once, while other forms of eclampsia, espe-
cially the bad forms of the same in  the eruptive stage, repeat
themselves ; the dilated pupils, which yet respond to the stimu-
lus of light.  Other authors do not allude to these peculiarities
in the convulsions of the early stage, but report them as of the
usual character.  Such  convulsions do not render the prognosis
less  favorable.  Tiingel saw an epileptic, aged sixteen  years,
attacked by headache, clonic cramps  in the  arms and legs, and
sopor;  the  twitchings returned on the following day to a less
degree ; three days later the eruption  appeared, and thenceforth
everything took its normal  course.   Wisshaupt noticed in  a
child of three years a  similar influence of the eruption,  upon
the appearance of which the prodromal convulsions ceased.
   The eruptive  stage begins in normal measles on the  fourth, or
at the latest on the fifth day of the febrile period of the disorder.
When this  appears  the remittent and intermittent character of
the prodromal fever ceases, and instead we have the more marked
and  continuous  elevation of temperature  characteristic of the
acme of the measles fever.
   During  the stage of eruption, and  usually about  thirty-six
hours  after its commencement, the  maximal temperature   is 
SYMPTOMATOLOGY.
79
reached; this in normal cases corresponds with the maximum
of the exanthem, or at least with the first stage of it.  It is
exceptional when the maximal temperature occurs near the begin-
ning of the eruptive stage.  The normal duration of the acme is
from one and a half to two and a half days, corresponding con-
versely with the duration of the prodromal stage, so that  the
maximal temperature occurs with considerable regularity at the
end of the fifth or sixth day of the disease.  The  period of the
maximum of the exanthem, and with it of the maximal tempera-
ture, is more constant than the duration of  either the prodromal
or the eruptive stage, each of which compensates for the other.
The time which elapses from the moment of infection to the max-
imum of the eruption (about fifteen  days) appears  to be still
more uniform, and Panum has therefore employed this interval,
or rather the shorter one, only to the  beginning of the eruption,
for the reckoning of the duration of the incubation.
   The development of the spots, in  other words  the eruption,
shows itself in milder cases at the beginning, in more severe ones
only in the second half of the fourth day of the fever.   Accord-
ingly, the morning temperature of this day is usually higher in a
mild case  than in a more severe one, for it  is the eruption which
in this stage especially influences the course of the temperature.
When the first  considerable increase of temperature (as high, for
instance, as 102.2° Fahr. and above) occurs  in the morning, there
is generally a further rise towards evening, followed by a moder-
ate remission or none at all the next morning, and on the evening
of this day (the fifth of the disease)  the maximal temperature.
When the beginning of the increase of the eruption occurs on the
evening of the fourth day, there is usually the next  morning little
or no remission, and the subsequent course is the same as in the
first case,  except that the maximal elevation of temperature will
take place on the evening of the sixth day.   Often,  however,
regular remissions with subsequent exacerbations appear on two
successive days, and the maximal temperature  of the case is only
reached in the second exacerbation. At another time the evening
maximum may be absent and appear first on the following morn-
ing,—that is, where the eruption has begun  early, on the morning
of the sixth day.  This is the state of things when the maxima of 
80                  THOMAS.—MEASLES.

eruption  and temperature coincide in cases  of  measles  with a
perfectly normal course.   In a decided minority of cases, which
are normal as regards the exanthem and the defervescence, the
maximal  temperature can appear somewhat earlier, at nearly the
same time as the eruption, if not at its commencement, and the
maximum of the exanthem may therefore be developed only after
some decrease in  the temperature, a state of things which often
marks the occurrence of some complication.  But the proposition
cannot be advanced  that the outbreak  of the exanthem, rather
than its maximal development, is the cause of the highest stage
of the fever of measles.   If this were the case, the temperature
at the commencement of  the eruption would not so often be only
moderately elevated or nearly normal, whereas, when the erup-
tion is nearly at its height, the temperature is always  elevated.
The maximal increase of  the temperature during the acme is as a
rule the  most considerable elevation observed throughout the
attack;  only once in a while is  it exceeded by the initial eleva-
tion on the first day of the disease.  It occurs, as stated, usually
toward evening.   The highest point reached is on  an average
104° (Fahr.), but often it  maybe as high as 105.8°, or even more,
without  the  intervention  of  any  cause outside of the exan-
them.
   The eruption makes its appearance at the time of  the marked
elevation of temperature on the fourth or the fifth day of the
disease, and extends, during the continuance of the fever, over
all parts  of the body.  At the maximal temperature, or  near it,
the spots are largest, reddest,  and thickest, even confluent in
places ; they sometimes cause considerable itching.  The face at
this time, often independently of the eruption, is reddened, even
somewhat  sodden, usually  only  in  consequence of the fever.
If no abnormal complications occur, the  affection of  the mucous
membrane of the mouth and throat remains at the beginning of
the eruption in nearly  the  same condition as just  previously,
while at  the time of  the maximum of  the exanthem it  is often
already somewhat  faded.  The  inflammatory symptoms of the
mucous membranes remain at the beginning of the  eruption in
about the same intensity as in the prodromal stage, but  they soon
decrease  with the elimination of a more profuse secretion.  Grad- 
SYMPTOMATOLOGY.
81
 ually the photophobia and the profuse lachrymation disappear,
 the cough becomes moister and less frequent, and is accompanied
 by a muco-purulent  expectoration;  the  irritation of the  nose,
 and, for the most part, the epistaxis, also cease.   Other symp-
 toms, however, sometimes  become more severe at this period, as
 a consequence of the supervention of slight inflammations ;  thus,
 for example, the voice becomes rough or hoarse; there is diffi-
 culty in swallowing;  dry or moist  rales may occur throughout
 the chest; the gums may swell and become partly  excoriated.
 Abdominal  symptoms often appear at this time as a sign of a
 perhaps specific congestion of the  intestinal mucous  membrane,
 and diarrhoea, if not already present, is apt  to occur, especially
 in little children and during summer epidemics, and in such cases
 the character of the stools and the intensity of the attack  often
 remind one of cholera.  Vomiting and severe colics more rarely
 ensue.  The nervous  symptoms, brought  over perhaps from  the
 prodromal period, increase with the intensity of the fever during
 the eruption, and afterwards definitely disappear when the remis-
 sion takes place.
   In the literature  scarcely any mention will be found of the
 nature of the urine in measles, yet it is evident from  even these
 scanty references that essential  anomalies have been  but rarely
 observed.  Brown  thinks, in opposition to Becquerel,—who has
 never met with albuminuria, even in cases in which the kidneys
 were congested,—that the  urine may become albuminous when
 the eruption develops rapidly,  and that this  albuminuria gener-
 ally occurs on  the third day.  It may be only a question here
 of a slight temporary amount of albumen occurring at the time
 of the highest fever,  in consequence of the excessive increase of
 temperature, more rarely of a slight desquamative nephritis, in
 favor of which is the fact that now and then a profuse exfolia-
 tion of  the  epithelium of  the  urinary apparatus is observed.
 Thus Abeille twice found albuminous urine  in measles, lasting
 for seven and eighteen days respectively.   An essential partici-
pation  of the kidneys,  as in scarlet  fever,  does not occur in
measles.   In a patient affected  a few years before with  dropsy
from scarlet fever,  but decidedly free from albuminuria before
the measles, I found  a very transient though tolerably severe
       Vol.  II.—6 
82                   THOMAS.—MEASLES.

attack of the latter, during the eruption of measles, accompanied
by a profuse separation of hyaline casts.
   After the exanthem  has reached its most  intense  develop-
ment, the temperature, which at  this time is at its maximum,)
begins also to sink, or—if it has  abnormally reached  its maxi-
mum somewhat earlier—to fall more speedily than before, with
the fading away of the exanthem.  This fall in  temperature
is more  or less rapid, so  that generally the normal condition is
attained from one to one and a half days at most after  the maxi-
mum has been passed; this frequently occurs on the morning
after the evening of  the maximum,  more rarely first after from
two to two and a half days.  The most rapid fall takes place from
evening to morning, exceptionally at some other time.  When
the course of the defervescence is rapid, the temperature sinks
without any material interruption ;  when it extends over a day
and a half or more, its course is remittent.  From  the evening
of the maximal eruption to the next morning the temperature
generally sinks considerably, frequently until  there  is hardly
any fever, to perhaps only one or two degrees above what is nor-
mal.  During the next period of exacerbation there is a new and
temporary  increase which never  attains  in normal  cases the
height of temperature of  the previous evening;  during this the
rapidly blanching redness of the  exanthem may increase again
on all, or only the lower, parts of the body to a varying extent.
Soon afterwards, in the beginning of  the night, the further fall of
the temperature commences, and by the following morning at the
latest this  is normal  and continues so subsequently, provided
no intercurrent disturbance occurs.  Subnormal  temperatures
even may be present in the first days of convalescence, at other
times the same days show trifling elevations, but only of tenths
of a degree, or vacillations may occur between these two limits.
These slight anomalies, occurring  as a  rule  only when  the
local symptoms have been well marked, are of no importance,
and give place in a few days to a  perfectly normal  temperature.
The usual slight temporary desquamation of the skin begins at
this time, if at all, and  a similar, less noticeable process  takes
place upon the mucous membranes.  The other symptoms of the
disease  abate  in normal cases after the  disappearance of  the 
ANOMALIES OF THE COURSE.
83
fever, and a slight  susceptibility to  external influences remains
for at most but a short time.  The  mucous secretion from the
nose and air-passages, the affection  of  the eyes and intestines,
all cease by degrees, the appetite returns, sleep becomes less and
less disturbed by catarrhal symptoms, the strength increases, the
children wish to leave their beds, and may—at the end of three
weeks (in simple measles), rarely after a  shorter period—be con-
sidered, except where the disease has been very severe, as recov-
ered.   Yet they need for several weeks  subsequently  unusual
care and watching.


                  Anomalies of the Course.

    The  normal course which has been described is that  of the
majority of the cases of mild epidemics.   But even in these there
is no lack' of cases with an anomalous course, and these may in
more  severe epidemics constitute a  much higher proportionate
per cent, or even the majority.
    The  anomalies may pertain in part to the course of the mea-
sles in general or to that of single stages, in part to the develop-
ment  of the individual  localizations of the process  of measles.
The last are  much influenced by complications which usually
appear  also on other parts than those normally affected by the
measles, and which are therefore capable of entirely changing the
general  appearance of this disease.
   The  abnormal forms of the course as a whole  are of two
kinds: the essentially mild and the essentially severe.
   The  two most  important mild  forms are  measles  without
catarrh and  measles without exanthem.   Cases of the first sort
occur now and then in  every epidemic  of measles, and attack
more  often the younger children, who have less individual sus-
ceptibility, than the more advanced or adults.   They are gener-
ally also accompanied by less fever.  Such cases destroy the sus-
ceptibility to  measles no less than an attack running a normal
course,  for these are genuine cases  of measles,  though of the
lightest  form  and imperfectly developed, but otherwise normal.
They must not be confounded with rubeola, which has a peculiar
course, and which certainly may occur sporadically, as also may 
84                   THOMAS.—MEASLES.

mild measles without catarrh;  generally, however,  it appears,
like  the measles,  in  epidemics.  The reports of an  epidemic
occurrence of light cases resembling measles in young, or more
particularly in older children, must be received with suspicion, it
being highly probable that  the disease was  rubeola.  Eubeola
affords no protection  against measles, and furnishes an explana-
tion of many cases of ostensibly secondary occurrence of measles
in the same person.  Moreover, it is only the mildness of the
general course which gives  to such  cases of measles  a certain
resemblance to rubeola, and not the absence of mucous mem-
brane symptoms, which, as a rule, are also present in rubeola to
a moderate degree.
   Measles without exanthem (morbilli sine  morbillis) can have
a, varied course.  This form of the disease may be diagnosticated
in persons previously unattacked, if, in a single case, during an
epidemic of measles, the characteristic mucous-membrane symp-
toms  together with fever  appear and become exactly  as much
developed as in measles  with  an exanthem, so that one  has
ground for assuming that  this symptom alone is lacking from a
normal  course.   The number of the well-established cases which
manifest the tolerably characteristic  deportment of the mucous
membranes above  described, is probably small;  it may be as-
sumed that the diagnosis  of measles without exanthem is more
often made than justified.   Cases at times occur,  likewise in per-
sons previously unaffected, where the disease runs a usual course
up to the time of the eruption of  the exanthem, but  then ceases
without manifesting the exanthem and the fever of the eruptive
stage.   Such cases are therefore distinguished from  other cases
with irregular fever by the presence of the first half of  the regu-
lar fever of measles.  Whether morbilli sine morbillis was rightly
diagnosticated in those cases, in which there occurred subse-
quently an unmistakable attack of measles, and  in which, there-
fore, it must be assumed that the susceptibility to the disease had
not been destroyed by the first  attack, is an  open question.   It
also  appears to  me rather doubtful whether, in  ostensible cases
of measles without eruption, where subsequently  well-marked
desquamation  is said to have been present, the exanthem really
was  absent.  I have never seen a convincing case of  this sort, 
ANOMALIES OF  THE COURSE.
85
and such an occurrence would also conflict with the circumstance
that the intensity of the desquamation is in general in proportion
to that of the exanthem.   And yet the occurrence of desquama-
tion without  an exanthem in the closely allied scarlet fever has
been so often asserted as to hardly admit of any doubt, and may
therefore be  also assumed in measles, especially since observers
like Seitz support it.
   Salzmann had described as a striking anomaly of the exanthem
the occurrence, during the epidemic of 1861 at Essling, of bluish,
smooth, round, elevated spots,  from the size of a nickel cent to
that of a half-dollar, which took the place of the eruption,
though accompanied  by all the other appearances of measles,
and at one time changed  to the normal exanthem subsequently,
at another remained unchanged until the end of the disease.
These spots were due in  Salzmann's opinion to an exudation in
the subcutaneous cellular tissue ;  I  should  prefer to consider
them as forms of urticaria.
   An anomalous or a rapid and virulent course of measles ap-
pears usually with, rarely wijbhout, the appearance of a hemor-
rhagic diathesis.
   True hemorrhagic measles are much rarer than the same form
in variola.   They occur even in little children, but are most com-
mon in the  sick and debilitated, and are  therefore generally
secondary or only apparently primary.   They must be especially
distinguished from  the previously described mild, hemorrhagic
form, which differs only in the character of its spots from the per-
fectly normal form, and is very  common in perfectly healthy and
robust children.  The oldest accounts of the malignant form are
of little value, though by far the most numerous, for the "black
measles " played formerly a great role.  Doubtless its ostensible
frequence is somewhat explained by the preposterous  treatment
of old times,  but more particularly by the fact that measles and
scarlet fever were included in one category, and malignant  forms
of scarlet fever were described  as measles.  Before or after the
development of the  eruption of measles, which, if present, usu-
ally fades quickly, hemorrhages ensue from vessels in  all pos-
sible regions: in the skin, where at one time they give  a  violet
coloration to many roseolae, while at another they appear, inde- 
86                   THOMAS.—MEASLES.

pendently of the exanthem, in the form of petechiae and more
extended ecchymoses ; in the mucous membranes, where they
manifest similar appearances  or  occur  in  the form of almost
uncontrollable bleedings from  the free surface (especially from
the nose and kidneys, at times from the bronchi, and in women
from the intestines and uterus); finally, in the parenchyma of
organs,  in cavities, and in the cellular tissue.  In addition, we
find as  a rule important parenchymatous  changes  of organs.
The cause of this disturbance of the normal course of  the process
must be sought  in an alteration of the blood occasioned by the
contagion, in consequence of which the blood-cells  are largely
destroyed and the normal  composition of  the blood becomes
changed.  Blood so changed is no longer capable  of supplying
sufficient nourishment to the  elementary  constituents of  the
organs;  delicate changes  in the vascular  walls ensue,  which
may be  the cause of extravasations from the intra-vascular pres-
sure.  Death generally occurs, before  any considerable anatom-
ical changes of the organs have taken place, a few days after the
appearance  of symptoms  of the hemorrhagic diathesis;  more
rarely hemorrhagic  inflammations and infarctions  of single or-
gans are present.
   Where severe acute or chronic disease is present, the infection
alone, without the production  of hemorrhagic diathesis, may so
shatter an already debilitated constitution as to cause death in a
few days, and that, too, without violent fever and without any
considerable local affection.
   The  prognosis is  somewhat more favorable if the illness is
prolonged.   The anomaly can commonly be recognized at  the
very first from the great intensity of the scarcely remitting, and
therefore untypical  fever,  which during the  outbreak  of  an
imperfectly developed, discolored, livid exanthem, goes on even
increasing.   Great weakness  soon results; the pulse becomes
small, and, for measles, uncommonly frequent, the tongue dry,
the gums and lips covered as with soot, the abdomen distended,
diarrhoea sets in, the  catarrhal affection attacks even  the finest
bronchi, and broncho-pneumonia appears.   The debility in-
creases, frequent collapses  occur, and death takes place  in the
second week, unless within a very few days the fever  moderates; 
ANOMALIES OF THE COURSE.
87
 recovery  is  only to  be expected when, in a very  moderately
 developed pneumonia, the remissions increase, the exacerbations
 by degrees diminish, the intensity of the fever lessens, and the
 nutrition and strength improve.  The appearance  of  patients
 during the fever  resembles  in  some measure  that  of  typhoid
 patients,  especially  when  the  respiratory symptoms  are not
 prominent, and this modification  of  the course of  measles is
 therefore also called typhoid measles.
    While the different stages, especially in malignant forms of
 measles, can be essentially altered or entirely obliterated, in other
 cases they may retain their  general character and change  only
 their form.   The  variations  concern  particularly the course of
 the fever and the deportment of the eruption.
    Whether  in anomalous cases the duration of the stage of
 incubation can vary, as has at times been asserted, is very doubt-
 ful.  Most observations of this sort are ambiguous,  and afford
 no opportunity for any positive decision.  It may, however, in
 exceptional cases, be accompanied a part of the  time by fever.
 An ephemeral fever during the stage of incubation has no signi-
 ficance, if it  lasts but a short time, appears early, and towards
 the end either disappears altogether  or moderates essentially.
 Should it, however, make its first appearance at the close of the
 stage of incubation, it obliterates, if intense, the commencement
 of  the prodromal  stage, and permits us to prognosticate subse-
 quent anomalies in  this stage  also.  Henoch relates a case of
 measles in which fever was present ten  days before the normal
 eruption.   It is possible, however, that a febrile incubative stage
 may  not  result  from the infection of  measles, but  from some
 casual affection.
    Essentially abnormal variations in the prodromal stage are
 often the  results of the development of unusually intense local
 disturbances.  Especially ominous is  every  marked  access  of
 fever at this  period, with the exception of that on the first day,
 which is to be considered  normal unless the increase is very con-
 siderable.   Such  unusual accessions of  fever  can immediately
 succeed the initial stage, with no interval, but can also, after a
brief remission, characterize the end of  the  second day and the
days  following.   The eruption, under  these circumstances,  is 
88                   THOMAS.—MEASLES.

often accompanied by even more marked and sometimes extraor-
dinary fever, but sometimes also by an unusual and anomalous
diminution of it; both give rise to complications.  Thus Politzer
observed a prodromal stage lasting eight days, with  typhoid
symptoms and great  depression, without high fever; the symp-
toms of prostration disappeared with the outbreak of a profuse
exanthem.  In another case the fever lasted four days with great
prostration, but without any local  manifestation; on the fifth
day symptoms like cholera appeared, with great collapse ; on the
sixth, remission of these and the eruption, and with this the end
of the previously anomalous course.  Most complications origi-
nate, at least in previously healthy children, in an eruptive stage
with fever, which succeeds a prodromal stage  either normal, or
from its fever and long  duration abnormal.   Again, the eruptive
stage may be normal,  and the period of defervescence be the first
to manifest the existence of any disturbance, in that it is either
unusually protracted by repeated  exacerbations, or is imme-
diately interrupted by  a new and  continued  elevation of  tem-
perature.  Such  disturbances  in temperature occur  less  fre-
quently during the desquamative stage or  convalescence, after
the normal expiration of the fever of measles.   The great value
of measuring the temperature in the study of measles consists in
this, that by it better than by any  other means, and especially
much better  than  by merely regarding the exanthem, normal
cases can be distinguished from  abnormal ones, the occurrence of
anomalies and  complications can be defined, and their signifi-
cance determined.  The prognosis is favorable when  the course
is but moderately abnormal, and especially if the first  appear-
ance  of a slight disturbance of the characteristic course of the
fever does not occur till late.
   The already mentioned  anomalies  in the  character of  the
exanthem are of  less importance, for  even in very  anomalous
cases the eruption can be of such a character as to justify us in
considering it normal.  The exanthem is anomalous in that it
may be absent altogether, or may appear  in  varying  manner
upon different parts of  the body; the  spots may appear at first
on the abdomen or the extremities and spread from here to the
other parts, or they may develop only on individual parts of the 
ANOMALIES OF  THE COURSE.
89
body (Niemeyer), e.g., only on the face and trunk, etc. ;  again,
they may be absent  on certain parts which usually are severely
attacked,  as for instance the arms or the neck (Neisser); or they
may only appear upon  one  side (for example,  after hemidrosis,
only upon the perspiring side);  finally, they may not appear on
paralyzed parts (as, according to Hebra, in paralysis of the lower
limbs from  spondylitis), or they may appear  here  to either a
very slight or a very marked degree.  The same variations may
also be observed in regard to the size of the single spots, which
may be very small or so large as to  be universally confluent; or
in regard to their color, which may be unusually dark, hemor-
rhagic, or pale, and very different on different parts of the body ;
or finally in regard  to their duration,  which is exceptionally
unusually long, or may be quite  short.   The short duration of
the eruption was formerly thought to exercise  a  great influence
upon the character and course  of the disease, especially when
complications were developed, since it was held that the retroces-
sion of the former must be regarded as  the cause of the  latter;
careful investigations have now shown that the  complication is
usually present before the  exanthem disappears, and therefore
cannot be occasioned by the disappearance of the latter.
   The eruption in  secondary attacks of the disease is usually
anomalous.
   Mention  must also be made of the rare cases of a  relapse of
the eruption, which occurs after the commencement of retroces-
sion, and is  associated with a return of  the fever; in these cases
the spots appear on parts of the skin, which up to that time had
preserved their normal appearance.   As these  relapses are usu-
ally of short duration, we  are justified  in including  them under
the anomalies.
   Lewin, while describing  a similar occurrence in scarlet fever,
mentions  incidentally a singular kind of anomalous course in mea-
sles, in two boys sick with the disease.  The  eruption appears
to have suddenly ceased without  causing any perceptible detri-
ment, and after two weeks to have returned ; furthermore, while
in one case the disease ran a normal course, in the  other this only
occurred  after a second equally harmless  interruption of  several
days.  Such a course is perhaps a parallel one  to many of those 
90
THOMAS.—MEASLES.
relapses appearing after the first eruption, also to Trojanowsky's
recurrent form of measles.

                       Complications.

   Measles may be said to be complicated when the usual con-
comitant manifestations or other  morbid processes are so in-
tensely  developed that they constitute  the most prominent
feature of the disease. The more important complications always
essentially retard the recovery and thus acquire, in proportion as
the characteristic symptoms of measles recede, more and more
the significance of independent lesions.  The frequency of their
occurrence varies in different epidemics, and the form which they
assume is due partly to  the character of the epidemic, partly to
individual peculiarities,—whether these consist of individal mor-
bid predispositions, or of unfavorable external circumstances.
   The skin becomes at times  not only the seat  of exceptionally
numerous miliary vesicles, developing upon the customary pap-
ules of measles, but may even show a well-marked  and profuse
formation of pustules.   Coincident chronic cutaneous eruptions
are said to cause frequently an unusually intense desquamation.
Single bullae and eruptions of urticaria, particularly in intense
exanthems, are no rarities. Erythema occurs at one time at the
beginning of the disease with  the initial fever, at another at the
height of the eruption, especially if the exanthem is marked or
the patient kept too warm.   Meyer-Hoffmeister observed a scar-
latinous erythema even during convalescence ; Hauner frequently
saw one resembling an acute lichen.  It may be more or  less
intense  and diffused over the whole  body, or limited to a single
region.  Thus, for example, Gerhardt mentions having seen upon
the femoral triangle a prodromal exanthem which preceded by a
day the general eruption.  In the eruptive stage  herpes facialis
is not rare.  I have observed at  this period zoster femoralis;
Krieg and Loschner pemphigus bullae; Thore, pustules of ecthy-
ma ; Salzmann,  impetigo  and urticaria (?);  others  later, furun-
culosis.  Lafaye describes two cases of sphacelus which ended in
recovery after the fall of the superficial slough, and  were perhaps
caused by the irritating and profuse conjunctival and nasal secre- 
COMPLICATIONS.
91
tion;  in one of these  cases small, dark gray sloughs with red
borders appeared on the sixth day after the eruption of measles,
on the right ala of  the nose and on the upper lip, and soon after-
wards also upon the oedematous cheeks and eyelids.   In connec-
tion with  severe affections  of  the  skin, abscesses and phlegmo-
nous suppuration in the subcutaneous cellular tissue  have been
described, and Heslop has even seen emphysema of the skin after
gangrene of the mouth.
   More  important are the complications involving the mucous
membranes, the conjunctiva,  the nasal mucous membrane, that
of the throat and  of  the upper air-passages.  Special mention
must  be  made  of the  intense phlyctenular  inflammations of
the conjunctiva, with their consequences: profuse blennorrhoea,
abscesses, keratitis, and iritis, as they occur in scrofulous chil-
dren,  especially those whose eyes have been previously diseased ;
also rapid keratomalacia. Furthermore, under similar conditions,
occur severe inflammations of the nasal  membranes and exces-
sively  profuse epistaxis, the latter, more especially in the pro-
dromal stage and during the commencement of the eruption, in
which case extensive bleeding produces fading of  the exanthem,
while moderate bleeding acts rather favorably. Abnormally se-
vere affections of the mucous membrane of the throat also occur.
Thus Blanckaert found a grayish-black coloration of the mucous
membrane of the  throat and upper part of the larynx, without
softening, in the case of a child which was attacked by measles
during a whooping-cough, and exhaled  a foul breath for  some
days before it finally died from pneumonia.  The  larynx is often
especially severely affected.   The tone of the cough in measles is
usually, at least at the beginning of the disease, rough and bark-
ing, and somewhat spasmodic; the attacks are  frequent, with
only short intervals, often interfering seriously with sleep ;  later
on, the cough becomes less frequent, looser, and more moist; the
voice, however, usually remains clear, and the respiration undis-
turbed.  The case is different in  more severe affections of the
larynx, such as have been found more particularly in cases that
have proved fatal from any cause, but also in those terminating
in recovery.  Barthez and  Eilliet  found, in nearly half of their
autopsies of patients who had had measles,  ulcerations and ero- 
92
THOMAS.—MEASLES.
 sions of the mucous membrane of the larynx, especially upon the
 vocal cords; Hauner also found  the same thing.  These ulcers,
 according to Gerhardt, who observed them during life, occur pre-
 ferably upon the posterior wall of the larynx, and are due partly
 to the follicular swelling characteristic of the catarrh of  measles,
 partly to the mechanical irritation of the loosened mucous mem-
 brane produced by the frequent  motion from coughing.  They
 appear at times even in the prodromal stage,  more  frequently
 however, during the eruption, and  occasion quite severe laryn-
 geal symptoms, which are often designated as pseudo-croup.  The
 cough is  here dry and rough,  exceedingly frequent  and spas-
 modic, almost  incessant; the voice is often very hoarse; the
 larynx is painful in coughing, speaking, or swallowing, and is the
 seat of a burning sensation ; a rough, whistling, respiratory mur-
 mur is audible on auscultation, and often even at some distance;
 at times, especially with violent, incessant, irritating coughing or
 when drinking, there occur suffocative spasms and a painful sense
 of oppression (Mertens).  Such attacks are specially induced by
 the presence of inspissated and very irritating deposits of mucus
 upon the laryngeal mucous membrane.   The more violent symp-
 toms usually moderate when the eruption reaches its full  develop-
 ment, though the hoarseness and the  barking spasmodic cough
 may remain for  some time before the latter gradually  becomes
 looser.  These consecutive manifestations of intense  laryngitis
 are distinguished from true croup by the absence of the pseudo-
membranes  and  the lack of signs indicating stenosis  of the lar-
ynx.  The catarrhal affection of the larynx spreads usually also
to the trachea, and even the larger bronchi may be moderately
affected.
   Capillary bronchitis, especially when affecting  a large portion
of the lung, is far  more dangerous than the simple, though  per-
haps severe forms  of laryngitis and tracheo-bronchitis; for not
only does  the swelling of the mucous membrane of  the small-
est  bronchi in  connection  with  the profuse secretion,  produce
severe disturbance of respiration, but these processes lead  also
very frequently  to further affections of the parenchyma of the
lungs.  Marked  bronchitis is not so apt to appear  in  the  pro-
dromal stage as affections of the  larynx and trachea ; it is more 
COMPLICATIONS.
93
 likely to occur  during the eruption,  or even  not before  the
 fading of the exanthem, and then regularly delays the deferves-
 cence, or may even postpone it until after the varying duration
 of a more or less severe feverish condition; its course is then
 usually  very  irregular.  Like pneumonia, it  attacks by prefer-
 ence the very young,  poorly nourished, atrophic, and scrofulous
 children, and like it also proves to be in such  cases an extremely
 dangerous complication.  The sputa accompanying it are more or
 less thick, muco-purulent, and may contain streaks of  blood of
 varying aspects (Karg).
   Among all the  dangerous  complications  of  measles,  pneu-
 monia is the most frequent, although in different epidemics great
 differences exist.  It appears, like capillary bronchitis, especially
 in and just after the eruptive stage, and  increases the fever of
 this,  where it was  relatively  moderate,  in  proportion  to  the
 extent of lung involved.   With the exacerbation of the  fever  the
 intensity of   the eruption can likewise  at  first increase, but
 usually it disappears sooner than its wont, and leaves no trace;
 this formerly  was the main ground for the opinion that the cause
 of the complicating  pneumonia was the "striking in" of  the
 exanthem.  For  the  most  part  the  pneumonia of  measles is
 catarrhal, more rarely croupous in its nature. Croupous pneu-
 monia is marked by rather high fever, with few  remissions and
 interrupted at times by pseudo-crises, further by its complete or
 essential limitation to one, usually a lower lobe of the lung, and
 by the absence or slight development of the  signs of bronchial
 catarrh.  The frequency of the pulse  and of the respiration is
 usually much greater  than it had been before with the simple
 measles ; pain in  the  chest is a common symptom ; the cough,
 however, is often  not increased, though usually it occurs in spas-
 modic  attacks, and  its violence  corresponds to the  stage  of
 measles in which the pneumonia appeared.   After the pneu-
 monia has run on for a week or ten days, the fever is wont, as  in
genuine primary  pneumonia, to decline speedily, convalescence
taking place in the usual, undisturbed manner.   Broncho-pneu-
monia acts otherwise.   This never occurs without intense catarrh
or other inflammation of the bronchi, and is therefore marked by
numerous rales at the  points affected.  As in the usual catarrhal 
94
THOMAS.—MEASLES.
pneumonia,  so here do we find at the autopsy an intense redness
of the mucous membrane of the bronchioles,  cylindrical dilata-
tion and filling of the same by  a tough, muco-purulent exuda-
tion, more or less extensive collapse  Of the lungs, especially at
the lower border of the lower lobe and throughout the poste-
rior  portions of  the  lungs, where these  lesions are sometimes
found symmetrically  situated on both sides, emphysema of  the
front upper  parts, subpleural ecchymoses, and finally inflamma-
tory thickenings,  which exist either as solitary, smaller or larger
nodules,  or  as uniformly  diffused infiltrations.  While the col-
lapsed places are perfectly re-expanded by inflation, and then, in
consequence of the resulting injection with blood, show a bright,
almost cinnabar-red color, in the infiltrated parts this is only  the
case with single small lobules ; these parts, if the lesion is recent,
appear of a  dark brownish-red color, void of air, as a rule irregu-
larly shaped, and uniformly tough and resistant.  Some weeks
later these masses are  often of a  pale gray color,  poorly supplied
with blood, without air, rotten and crumbling,  and give off  when
cut a large  amount of thin fluid resembling pus.   A character-
istic of broncho-pneumonia is the unsymmetrical progress of  the
infiltration,  the result of which is that, where the disease  has
existed for some time, a cut surface shows parts infiltrated with
pus  alternating in motley confusion with  others infiltrated with
blood and serum, or simply collapsed, or finally even containing
air.   Catarrhal pneumonia attacks, as a rule, both lower lobes at
the same time, especially their dorsal aspects ;  while in the upper
only a few smaller foci are usually present.  The final extent of
the trouble  is such that, together with numerous more or  less
clear rales,  an  at least moderate dulness and  slight bronchial
respiration  are rarely absent.  The fever varies in intensity with
the severity of the disease.   In  light cases  the  pneumonia may
cause a moderate increase of temperature immediately succeed-
ing the acme of  the measles, or soon following it, and of short
duration, its course  strongly resembling the defervescence by
lysis.  In severe  cases,  however, the course, in regard  to its
intensity, often manifests a great resemblance to that of croup-
ous  pneumonia, and is distinguished from  this only by its long
duration and its slow, frequently interrupted  defervescence,  cor- 
COMPLICATIONS.                     95
responding with the varying and  irregular course  of  the local
affection.  The pulse is apt to be unusually frequent, but the
other symptoms present no special contrast to those of a com-
mon broncho-pneumonia.  Death  occurs—especially with  very
young children, and then usually  in the first week of the pneu-
monia—partly from the intensity  of the fever, partly  from the
carbonic-acid poisoning, due to the rapid spread of the process
and the absence of expectoration.   The children become somno-
lent and pale, the extremities cool, the pulse constantly smaller
and more rapid; the face and mucous membranes soon become
markedly livid, the cough becomes less frequent, loud  rales are
heard in the trachea, and finally,  after protracted agony,  fre-
quently interrupted by very distressing paroxysms, death takes
place; or recovery  may slowly ensue,  and then often  only  sev-
eral weeks after the beginning of the pneumonia.
   Steiner and Neureutter observed gangrene of the lungs  with
measles in two instances.  Both cases ended fatally.
   Noteworthy disturbances of the auditory apparatus,  often
overlooked, owing to the fact that the  symptoms  may not be
strongly marked, very frequently occur during the eruption,  and
immediately afterwards, as a result of the more intense  affections
of the naso-pharyngeal fossa.  They  are,  according to Wendt
(personally communicated), seldom purulent, usually simple ca-
tarrhal processes, limited to the Eustachian tube (swelling  and
obstruction of it  by secretion), or  also extending to the deeper
portions  (mucous secretion  into the tympanic cavity, with or
without swelling of its lining membrane).   Hearing can thus be
diminished by the mere accumulation  of secretion, or  it may be
more  markedly so  from swelling  of the mucous membrane in
different ways, while in other cases, in which the affection of the
tubes is  more prominent, the  hearing  will vary at times.   The
exudation and swelling are sometimes preceded by pain ; severe
pain usually also precedes the mechanically produced perforation
of the membrana tympani, this lesion  being due to  the pressure
of the profuse secretion accumulated in the middle ear, and being
followed  by immediate abatement  of the suffering.  A more or
less perfect recovery is tolerably frequent, and is due  in favor-
able cases to the drainage of the  secretion by means of ciliary 
96
THOMAS.—MEASLES.
motion through the gradually increasing  calibre of the Eusta-
chian  tubes, to the retrogression of the swollen mucous mem-
brane, and to the closure of any existing  aperture in the mem-
brana  tympani.
   The mucous membrane of the digestive canal can also become
the seat of important complications of measles.  Simple stomatitis
(Weil, Dusevel, Thore), also the aphthous (Hartmann) and ulcer-
ative (Pank) forms, and glossitis  are rare  complications, though
gingivitis is somewhat more  frequent  (Dusevel).   Mertens ob-
served  upon the lips, gums, and  tongue a thrush-like pseudo-
membranous affection, which spread rapidly  and occasioned in
very young  children such rigidity of the tongue that they could
not nurse.  Erichson saw in  the prodromal stage, and also during
the eruption, marked increase of the  saliva; Weil, stomatitis ; he
and He_yfelder, also parotitis.  Angina morbillosa is by no means
rare, various authors to the contrary  notwithstanding.  Consider-
able parenchymatous tonsillitis, clearly  recognizable by the diffi-
culty in swallowing, may occur before the eruption, as an adjunct
to the affection of the  pharyngeal mucous membrane, already
well developed in the prodromal stage or during the existence of
the exanthem.  Severe  gastric  affections are rare, but intestinal
catarrhs of varying severity are quite frequent, and it is not pos-
sible to  specify exactly where a light diarrhoea ceases  to be
merely that  and becomes a  complication ; for it is probable that
in measles the intestinal mucous membrane participates normally
in the  general congestion of the  skin  and superficial mucous
membranes.   Thus, the diarrhoea  begins very frequently in the
prodromal stage, or on the first  day of the  eruption, not so often
during  the same, and least frequently during  the stage of  retro-
gression, though these last cases  are apt to be the most severe.
The  diarrhoea begins with  or  without  previous indigestion, is
painless  or  at times  associated with colic, and  passes rapidly
and harmlessly away;  or, especially after laxatives have been
used for preceding constipation, it may last with great violence
for even a week or more. In the case of little children, in whom,
moreover, these intestinal complications  are most frequent,  death
may ensue even  in mild epidemics, and this occurs  especially
under  the influence of the heat of summer, with gradual disap- 
COMPLICATIONS.
97
 pearance of bile from the stools and the appearance of even true
 choleraic  symptoms.   Or  again, if  the large intestine is more
 especially attacked, a dysenteric, bloody, mucous character mani-
 fests itself  in  the dejections,  with tenesmus.  Now and then,
 however, we hear reports also  of malignant epidemics, in which
 even in winter (Kapff),  and in adults, a fatal result was due
 chiefly to the affection of the intestines, or where the same caused
 at least great danger  to  the life of the patient.  As a rule the
 affection of the intestines, since it rarely depends upon marked
 anatomical changes, heals soon  after the fading of the exanthem,
 upon the duration and course of which, as upon the similar con-
 ditions of the fever, it exerts no influence except when it appears
 unusually early and produces by its great intensity a cholera-like
 collapse.  The unfavorable  influence exerted by the diarrhoea of
 measles appears to depend especially upon the fact that it dimin-
 ishes the energy of the body, and renders it less able to resist the
 invasion of further complications.  Besides the epistaxis, hemor-
 rhages also occur  in the prodromal stage  and later from the
 anus and even from  the  kidneys and genitals, the last of  which
 possess, however,  of themselves no unfavorable prognostic signifi-
 cance ; they appear  during the menstrual period  or at other
 times.
   Measles differ from scarlet  fever  in this,  that affections  of
 other organs not  essentially implicated  in the process of measles,
 especially inflammations of important internal organs, so also of
 the serous membranes and of the joints, are tolerably rare.  Yet
 now and then affections of various kinds occur, especially inflam-
 mations during the eruptive  stage ; they are mostly without influ-
 ence upon the exanthem, but effect alterations  in the course  of
 the fever and prevent the rapid  defervescence of the measles.

   Conspicuous among the affections of the nervous system are: Meningitis (Spiess,
 Voit, Mcyer-Hoffmeister. Kellner, Constant, Loschner, Thore, Bufalini, Krug) ; men-
 ingitis with tetanic and cataleptic rigidity of the limbs (Mettenheimer) ; spinal men-
 ingitis (Franque, Rilliet) ; hyperaemia of the brain  (Geissler) ;  meningoencephalitis
 (Hannon) ; encephalitis (Rilliet) ; fatal " cerebro-spinal affections " (Barbieri, Mayo) ;
 apoplexy of the brain  (Spiess) ; hemiplegia sinistra and paralysis of the left foot
alone  (Reichard) ; meningitis tuberculosa (Monti, Mayr);  hydrocephalus acutus
(Kroncnbers, Ilivden, Weil,  Pfeilsticker, Heyfelder, Schallenmuller); hydroce-
     •  Vol.  II. _7 
98
THOMAS.—MEASLES.
phalus chronicus,  augmented by the outbreak of measles, and consequently fatal
(Heinecke); thrombosis of the cerebral sinuses (Faye, Routh); muscular paralysis
resulting from an affection of the spinal marrow (Holmes Coote) ;  universal paral-
ysis  (after gangrene:  Bourdillat);  paralyses and contractions (Hennig);  mental
disorder  (immediately after the eruption: Mugnier) ;  transitory  mania  and paral-
yses  (Christian);  delusions  about persecution in the  delirium of  the  collapse
(Weber);  severe cephalic symptoms of varying nature (Neureutter, Lippe); great
sopor (Hauner);  coma (cured:  Schepers; with  ischuria vesicalis: Mettenheimer,
Brown);  various  cases of disturbances of sensation, paralyses, contractions of the
muscles of neck, spasms of the glottis (Zavizianos) ; chorea (Sibergundi, Boning);
tetanus (with tubercles of the brain as also with ischuria: Simpson) ;  tonic«spasms
(especially in the flexors of the extremities, rolling spasms of the head, two days after
the eruption, accompanied by its disappearance: Pinkham); convulsions and eclamp-
sia, usually with a similar effect upon the exanthem, at  different periods of the same
(Bartels, Posner, Bierbaum, Adet de Roseville, Trousseau, Carroll, Edwards, Kauf-
rnann, Liverani, Weil,  Brown, Bartscher, Jutting, Brachet, Espinouse,  Fichtbauer);
neuralgias of the  face (Imbert-Grourbeyre),  and  elsewhere (intercostal neuralgia,
with convulsions: Rilliet; neuralgic arthralgia of a lower limb, with immobility
of the knee, as an  abnormal prodromal  symptom:   Kostlin);  strabismus  (Bier-
baum)  immediately  after the period of eruption.
   Among the affections of  the thoracic viscera are to be mentioned :  " Inflamma-
tions of the heart" (Hennig); endocarditis (Martineau, West,  Kohler); pericarditis
(Berndt, Majer, Espinouse,  Braun,  Siegel, Mettenheimer, Heyfelder;  according to
Autenrieth this is frequent); furthermore,  gangrene of the lungs (Bartels,  Mayr);
tuberculosis (Ziemssen) ;  pneumothorax from abscesses of the lungs  (Barthez and
Rilliet); pleuritis  (Giinzburg,  Simpson,  Salzmann, Monti, Voit,  Rilliet, Bemdt,
Kellner, Spiess, Abelin, Trousseau); all these disturbances with or without the most
usual complications : capillary bronchitis and broncho-pneumonia.
   Nicola saw aphthae spread from the buccal cavity over the whole oesophagus to
the stomach.  Further complicating affections of the  abdominal viscera are,  apart
from those  already mentioned, for the most part only  catarrhal affections of the
intestinal  mucous membrane producing  moderate diarrhoea:   enteritis (Espinouse,
Kellner, Luithlen, Lees, Rosch, Thore, Abelin) ; dysentery (Carroll,  Kapff during  a
winter  epidemic, with retrocession from the respiratory organs,  Daniell,  Rufz);
intense neuralgic  colic  (Kapff, Meyer-Hoffmeister, Fricker) ;  intestinal bleeding
(Rilliet) ;  ascites, without anasarca,  with albuminuria (Zehnder);  ascites (Pfaff);
peritonitis  (Simpson, Lees);  tuberculous peritonitis (Spiess);  " affections of denti-
tion " (Bartscher).  A  moderate swelling of  the  spleen was proved by Clemens; a
greater byLoschner, Lehmann, Huguenin; by the last, as also by E. Wagner, a swell-
ing of the liver.   Meyer-Hoffmeister  several times observed  icterus; Clemens the
same on the cadaver, the liver being fatty and full of blood, and  pneumonia also
existing;  Mettenheimer, icterus in the prodromal stage; Hennig records  granular
formation in the liver,  and calls the bile diminished, yellowish-brown,  viscid.
   Of  the affections of  the genito-urinary apparatus  and their consequences, are 
COMPLICATIONS.
99
 worthy of mention: Simple albuminuria, which, according to  Mettenheimer, who
saw it in a girl of seven months, is frequent  in many epidemics (Vallon, Espinouse,
Abeille, with anasarca; Kaurin) ; anasarca, without albuminuria, from obstruction
in consequence of capillary bronchitis (Trousseau); anasarca without regard to albu-
minuria (Dubini, Hannon, Jutting, Seidl [especially with chronic diarrhoea], Siber-
gundi,  Nicola, Billard, Rilliet,  Liverani, Loschner, Hauner, Schott, Capuron, Bec-
querel,  Barbillier); anasarca with intermittent albuminuria (Denizet); hydrops with
and without albuminuria (Lombard, according to Rilliet, Kennedy, Flechner, Pfaff,
Zehnder, Weil, Bictt, Duchek) ; congestion of the kidneys (Becquerel); parenchy-
matous  nephritis (G-eissler,  Roser, J. Frank, Rilliet, West, Kjellberg, Lehmann,
Muller  [fatal from  uraemia], Bouchut, Malmsten [three to four  days before the
eruption], Spiess, Hauner, Thomas) ; morbus  Brightii  (Steiner  and Neureutter,
Zehnder); bleeding from the kidneys (on the second day of the eruption:  Malm-
sten) ; anuria (Rilliet, Kolb) ; dysuria (Henoch, Rilliet) ; retention of urine (lasting
forty-eight hours: Pfeilsticker,  Kohler); profuse  menstruation  (Rilliet); abortion
(Rosch); mild oedema of the genitals and extremities (Masarei).
   Furthermore should be mentioned: Marked swellings of the lymphatic  glands
(Salzmann, Coley, Meyer-Hoffmeister,  Mettenheimer);  glandular inflammation and
suppuration (Gregory, Rilliet);  parotitis (Fichtbauer, Thore, Eisenmann, Bufalini,
Battersey) ;  abscesses in  the subcutaneous  cellular  tissue  (Barthez  and  Rilliet,
Ottoni); sclerosis of the cellular tissue, fatal in a three-months' child (Salzmann);
inflammation of  the ankle (Meyer-Hoffmeister);  synovitis of the knee (Kohler);
coxitis  (E. Wagner).
   Finally, of constitutional diseases there immediately followed measles: intermit-
tent  fever (Zicmsson,  Meyer-Hoffmeister); acute rheumatism (Salzmann); hemor-
rhagic diathesis (Trousseau);  morbus maculosus Werlhofii (Mettenheimer, Masarei) ;
rachitis (Mettenheimer).

    More important  complications  of measles are the  following
general diseases : Acute  miliary tuberculosis ;  the tubercles ap-
pearing specially in the  lungs  and the membranes of  the brain.
The disease  at  times  immediately  follows  the exanthem, and
runs  a fatal  course in a few days  or  weeks, appearing under
the  form  of an  intense bronchitis  and with cerebral  symptoms
like those of acute hydrocephalus, but with a high  fever and
frequent pulse;  the  very sensitive  skin  is in  such  cases fre-
quently the seat  of erythematous  processes.   Diphtheria is far
more  rarely associated with measles than with scarlet  fever; it
affects, by  preference,  the organs  of the   throat: at  times  the
pharyngeal portions  (Fichtbauer,  Steinthal, Forster,  Bartels,
Hauner,  Voit),  including the back  nasal  passages  (Steudel);
at times the  larynx and trachea (Abelin, Spiess),  and  its course 
100                  THOMAS.—MEASLES.

is  that  of simple primary diphtheria. The disease can remain
confined to the tonsils and  other pharyngeal parts,  or spread
from  here  to the air-passages and even into the bronchi, or
begin at the larynx and extend  upwards and downwards, or
affect this alone,  and so on; it can, if of moderate extent, lead
to slower or more speedy (Rothe) recovery,  while it usually
proves rapidly fatal if the  air-passages  are early implicated.
Diphtheria generally appears at  the acme  of  the eruption of
measles,  or soon after; is in the light forms, as, e.g., croup of
the tonsils, without influence upon  the character of  the exan-
them, while in severe cases,  when the air-passages are greatly
affected and  the  appearance  of the  diphtheria is temporarily
coincident  with  that  of  the  exanthem,  the latter becomes
changed as with broncho-pneumonia, which then, moreover, gen-
erally sets in  as a further complication.  The normal type of the
course of the  fever is affected by every severe complication,  and
so, when diphtheria complicates the disease, the fever is usually
heightened and protracted.  The  diagnostic symptoms of  the
diphtheria are furnished, as in the common form, by the inspec-
tion  of  the  pharynx, by the cough and  hoarseness, and by
the consequences of the stenosis of the air-passages ;  and these
pseudo-membranous affections of the organs of the throat must
be clearly distinguished from the already-mentioned  severe in-
flammations which are not pseudo-membranous, although about
equally  dangerous.  Diphtheria of other organs  than those of
the throat is very  rare in measles.  Diphtheria is recorded of
the eyelids (Mason), of the conjunctiva (Hauner),  of the prepuce
(Schreiber), and of the female genitals.  Pavn and  Aarestrup
saw a fatal case of secondary diphtheria of the nose, oesophagus,
and eye-lids,  in consequence of which parenchymatous nephri-
tis had  also resulted.  In  debilitated, scrofulous, and rachitic
children, rarely also in those previously healthy, measles  can
give  rise to  ulcerous and  gangrenous affections. The ulcers
manifest from the first a discolored base, whether they have pro-
ceeded from a catarrhal and apparently simple affection, or from
an originally  suspicious one  (gangrenous bullae, branny infiltra-
tion).  They occur  especially in the buccal cavity and  on  the
genitals of boys and girls (noma).   In the former case they take 
COMPLICATIONS.                     101
their origin from the gums, the lips, the  mucous membrane of
the cheeks, the cavity of a tooth, etc., and can go on uninterrup-
tedly in their course while they destroy very considerable  por-
tions of the skin of the face and of the base of the  tongue,  even
of the muscles of the tongue as far as to its extremity ;  or  they
may cause at least  a partial  separation of  the attachment  of
the tongue and consequent  difficulty in swallowing (Bartels),  or
even partial exfoliation of the nasal bones (Huxham), and of the
jaws (Huxham, Sadler, Bartels, Bresseler), or at  least loss of the
teeth (Bresseler).  This noma  arises for  the most part only after
the  fading of the exanthem,  and therefore does not influence
its course; it, however, generally occasions more or less violent
fever with its consequences, loss of appetite  and diarrhoea, and
respiratory symptoms.  Death does not  always occur; where
the course  is relatively mild, the patients can recover with dis-
figuring losses of tissue (Bentley described a case where such a
stenosis of  the mouth was formed that only one  finger could
be introduced, and then only with difficulty).   At  the frequent
autopsies one finds the extremest anaemia, atony  and emaciation,
gangrene of the lungs, and broncho-pneumonia, while the vessels
of the  gangrenous  mass remain unchanged.  Apart from the
above-named  anomalies of constitution, and  residence in badly
ventilated, overcrowded rooms,  the misuse of  many  drugs, as for
instance calomel, is spoken of  as a special cause.  Noma (gan-
grenous ulcer) of the genitals is more common  with girls than
with boys,  in whom  it may begin  at the  prepuce and progress
as far as the navel (Bartels).   Gangrene of the vulva is developed
in the same way as that of the buccal cavity, and can destroy
the labia, the vaginal entrance, the soft parts at the mons  ven-
eris,  even  the perinaeum  as far as the  anus.  The secondary
results are the same as those already mentioned.

  Gangrene may also occur after  measles upon other ulcerating or eczematous
portions of the skin, especially on the nasal  alae and the external ear (Mayr, Tri-
boulet, Causit). Mayr observed gangrene of the forearm in caries of the radius;
Faye describes a case in which gangrene spread from the finger upon the forearm;
Battersey a similar one, also a case of gangrene  on the lower lip;  Faye still
another, where some pustules which had arisen during the eruption produced gan-
grene  and extensive destruction of tissue upon the loins;  Thomas (of Paris) men- 
102
THOMAS.— MEASLES.
tions the case of a child of two years, on whose nates extensive gangrene was
developed.   Carroll selects from a  severe epidemic of measles at Sydney several
cases of special malignancy, where on the face and thorax only a few dark blotches
appeared, while upon the extremities single vesicles were formed, which rapidly
increased to  a large size, burst, and became gangrenous; the  affection extended
with such rapidity that sometimes within  twenty-four hours the  whole epidermis
would be lost.  Masarei observed upon the soles of the feet and the palms of the
hands, during the desquamation, large bullae, which burst, leaving obstinate, pain-
ful ulcers. Iu rare cases gangrene of the lung occurs.

    Finally, in measles,  appearances  of scurvy occur now and
then, especially in the buccal cavity, without giving rise to gan-
grene, and either with or without  further symptoms of the hem-
orrhagic diathesis already referred to.

                            Sequelm.

    The sequelae of measles are those maladies which arise in con-
sequence of it, and  remain after  its termination as independent
diseases,  or which  appear for the first time after the measles
without being immediately due to any complications of the same.
As co-operating toward this end in these cases may  be mentioned
all unfavorable influences present in the constitution of the indi-
vidual (scrof ulosis, rachitis, chlorosis, tuberculosis,  and impover-
ished nutrition in general), or which have acted upon the patient
from  without  (bad  nourishment,  damp, badly ventilated dwell-
ings, bad treatment and  nursing).  Especially important are the
following: chronic  diseases  of the skin, pustular eruptions over
the whole body (Braun),  gangrene  of the skin  (on the neck:
Gruel), furunculosis, abscesses;  ozaena, sometimes with, some-
times without the elimination of  a thin, offensive,  more or less
profuse secretion, in consequence of  which eczema of the face
usually ensues ;  chronic  ophthalmia : sometimes blepharitis and
the frequent  formation  of  hordeoli,  sometimes  conjunctivitis,
with especially annoying photophobia, keratitis, etc., in various
forms, and at times with the worst results {e.g.,  keratomalacia,
according to Beger ; paralysis of accommodation and consequent
strabismus convergens, according to Coley; even capsular cata-
ract) ;  chronic affections  of the auditory apparatus : according to 
SEQUELAE.
103
Wendt  (personally communicated),  formation  of  adhesions
(immediate or  from new-formed  duplications of  the mucosa)
between the ossicles or membrana tympani and the walls of the
tympanum, taking place while the parts are swollen and inflamed,
and resulting  in  more or less diminution in the hearing;  transi-
tion to the chronic form of  catarrh of the middle ear, with ten-
dency to hypertrophy and other alterations modifying unfavora-
bly the  physical  properties of the mucous membrane ; also sup-
puration with  its consequences (otorrhoea).   Gummers saw very
frequently chronic enlargement of the tonsils after measles.  Still
further sequelae are chronic  catarrh of the mucous membrane of
the respiratory organs, both  of the  larynx  and trachea, and of
the bronchi, of the most variable nature and intensity,  sometimes
with  a character  like whooping-cough (Bartels);  asthmatic
attacks (Eisenmann) ; chronic lung affections ; pericarditis (Kell-
ner) ;  affections of the heart (Testa and others, according to Eis-
enmann) ; affections of the parotids (Eisenmann, Seidl, Schultze,
Kellner);  chronic inflammations of the periosteum and  of the
joints (Niemeyer) ;  caries (Seidl).   It is not uncommon for chil-
dren, apparently  recovered from measles, or convalescent,  to be
seized  anew with  difficult respiration,  and  after  a  longer or
shorter  duration  of the new disturbance to even die,  sometimes
of cheesy pneumonia,  with or without tubercles, sometimes from
general miliary tuberculosis or tubercular meningitis, the causes
of which, as it appears, must be especially sought in the cheesy
degeneration of the swellings of  the lymphatic glands occurring
in the course  of  measles.  The tuberculous bronchial glands in
particular afford a frequent point of origin for  tuberculosis of
the lungs after measles ; Pank observed tuberculosis of the mes-
enteric glands.  The diphtheritic and  gangrenous processes dur-
ing and immediately following measles can induce a great variety
of sequelae : ichorous suppuration in the throat and subcutane-
ous cellular tissue,  diphtheritic paralyses, affections of the lym-
phatic glands  with their consequences, diseases of the kidneys,
disfiguring cicatrices.   Severe  chronic  intestinal diseases can
result from intense affections of the small and large intestines in
measles: chronic entero-colitis with wearisome diarrhoea,  intes-
tinal ulcers and  stenoses, with ascites,  icterus, and  cardialgia 
104
THOMAS.—MEASLES.
 (Seitz), and their unfavorable influence upon the nutrition of the
 entire organism, whereby scrofulosis, rachitis, habitual anaemia,
 and other constitutional diseases can be induced.   Stone in the
 bladder, according to Coulson, is also to be enumerated among the
 sequelae of measles, in the case of children.  Masarei describes a
 very acute febrile dropsy without albuminuria, which caused in
 eight cases, within a few days, the death of patients decidedly
 convalescent; in such  cases he observed also " scurvy mostly, in
 the  form of purpura."   Seidl reckons  pleuritis  and hydrops
 among the  sequelae of  measles.   Gley  observed  very intense
 "purpura haemorrhagica" some  days after the disappearance of
 the exanthem, together with scorbutic appearances in the mouth.
   It is a very common experience that after epidemics of measles
 the  children who have been  affected  are  more prone to all sorts
 of attacks than  at other times; they are anaemic, out of humor,
 dull, without appetite,  etc.  Among the severe acute diseases we
 should mention more  especially the strikingly frequent appear-
 ance of croupous pneumonia for a period  of several months after
 the conclusion of the epidemic, especially  in winter and spring.
   Secondary  measles can  exert various  influences upon the
 primary disturbances.  When the latter belong  to the common
 complications  of measles, they usually  grow  worse upon the
 appearance  of secondary measles.  Should these,  for example,
 occur in the course of, or during convalescence from a pneumo-
 nia,  this becomes worse  or reappears,  and in all cases recovery
 is delayed;  so, too, a bronchitis is likely to become aggravated
 to a capillary bronchitis and broncho-pneumonia.   Phthisical
 processes become speedily  worse,  and lead more  quickly  to
 death.  Walz  lost by  suffocation a girl of. five  years, suffering
from aneurism of the aorta.   Children with chronic diarrhoea
 are usually made much worse by measles, and in general a pre-
 vious gastro-intestinal  affection predisposes remarkably to the
 diarrhoea of measles, e.g., in teething children (Walz).  The same
explanation is undoubtedly to  be given of the report of Polak,
Mayr, and Weisse, viz., that children with measles are very  often
attacked by cholera, and usually in a very marked degree.  The
cause of diphtheritic and  gangrenous affections, especially  of the
buccal cavity and of the genitals, must be especially sought in 
SEQUELAE.
105
slight primary disturbances of these parts  (hollow teeth, slight
gingivitis,  scrofulous  leucorrhoea),  and  decidedly  gangrenous
affections of  other parts have  also  a  similar origin.   Should
measles, on the other hand, appear during a disease to which they
do not usually give rise,  they may favorably influence the course
of the latter.   Thus  they have  frequently  exercised  a cura-
tive effect, according to  Rilliet, Taupin, Guersent, Rayer, upon
chronic diseases of the  skin; according to  Behrend, not only in
children, but also  in the case of a woman of  forty years, whose
eczema of  the scalp of three years'  duration he saw disappear
permanently after measles.  Barthez and Rilliet saw chorea, epi-
lepsy, and incontinence of  urine of several months'  duration
healed by measles ;  furthermore, they observed that an anasarca
after  scarlet fever disappeared coincidently with the eruption of
measles.   Rilliet found  that a  chronic coxitis improved notice-
ably after measles.  Weisse  reports that measles, in the case of
a girl suffering from convulsions, entirely removed this  disease ;
Mettenheimer, that a boy suffering from nervous winking of both
eyes lost this evil entirely during measles,  though after several
weeks it  by degrees returned; measles, moreover, put a stop
to a  peculiar sort of nervous cough of three months' duration.
Guersent noticed, with the beginning  of the fever of  measles.
permanent relief from epileptiform attacks, which had appeared
in consequence of a fit  of anger,  and of which the patient had
had several daily for quite a length of time.  Schmidt saw a girl
of six years, who for a year had suffered from frequent daily con-
vulsive attacks,  which had so reduced her strength that death
was expected, recover entirely owing to measles; he also treated
a boy of five  years, with a contraction of the lower extremities
lasting for six months, in whom this disappeared as if magically
with  an  attack  of measles.  Feith  and Schroder van der Kolk
report the case  of a woman who for five years had been in an
insane asylum  with violent  attacks of mania, which  did not
return after recovery from  measles, and the woman was soon
so well as to be discharged.  Mombert and Michele mention the
passing  of lumbricoid worms,  in consequence of measles,  as a
frequent occurrence.  Hildenbrand  saw an obstinate disease  of
the joints, which had  been treated for three years in vain, heal 
106
THOMAS.—MEASLES.
 after measles, of itself, in a short time;  so also obstinate glandu-
 lar tumors dispersed by it in the same way.   Mettenheimer saw
 a  caries of  the tibia strikingly improve immediately after mea-
 sles ; Roser, a caries of the hand of a year's duration, in the case
 of a boy three years old, heal speedily after measles.  According
 to Levy, an  old gonorrhoea of the penis disappeared with the out-
 break of an  eruption of measles, which was immediately followed
 by varicella;  after the  expiration of this the gonorrhoea imme-
 diately returned ; in another case after measles it did not return.
 Pank  saw an obstinate  ophthalmia disappear for  a short time
 under  the influence of measles.

                         Diagnosis.

   The diagnosis of measles is based, first,  upon the exanthem,
 secondly, upon the character of the mucous-membrane symptoms
 and of the fever, attention being also paid,  in doubtful cases,  to
 other attacks of this malady at the same place and time, espe-
 cially such as may stand, as regards contagion, in direct relation
 to the case  in question.  The following should be remembered
 as diseases which, at definite periods of their  development, fre-
 quently possess a striking resemblance to measles : rubeola, scar-
 let fever, variola,  varicella, the different roseolae,  and typhus
 fever.
   The eruption  of rubeola can closely resemble that  of mea-
 sles ; the points of difference are the indented character of the
 blotches of measles, the  slight papular prominences upon them,
 the casual confluence upon  the face, the  more intense  and pro-
 tracted fever at the time of the eruption,—preceded, as stated, by
 a  prodromal  stage,  while  rubeola can  run its course  without
fever—and the more violent symptoms  upon the mucous mem-
branes  in measles.    Many  of  the light epidemics of  measles
observed in  former times may have been in reality epidemics  of
rubeola.
   The eruption of scarlet fever occurs often in small spots, bear-
ing some resemblance therefore to the similar  form of measles,
and eruptions of scarlet fever can even occur in  the form of large
spots, thus  increasing the  possibility of  error.  On the other 
DIAGNOSIS.
107
hand, an  almost universally confluent  eruption  of measles  can
exceptionally take  on an appearance resembling scarlet fever.
Points of  distinction  are afforded by the early eruption of  the
exanthem in scarlet fever, also by other concomitant appearances,
especially the absence of coughing and sneezing in scarlet fever ;
the absence of  early  angina, of the scarlet-fever tongue, and of
the marked swellings  of the lymph glands in measles.  The char-
acter of the fever aids  our decision if  it runs a normal course,
since in measles it possesses a very characteristic curve.   The so-
called relapse of scarlet fever (pseudo-relapse) often  possesses,
according to my experience, great resemblance to measles.  It  is
to be distinguished by the character of the fever, by the form
and extent of the blotches, the difference from measles as to the
character  and site  of confluence,  the absence of the papules of
measles upon the individual spots, as well as of the characteristic
mucous-membrane  symptoms,  finally by the  casual (coincident,
but to be referred to  the first outbreak of scarlet fever) affection
of  the kidneys, which is decidedly typical of scarlet fever.  This
resemblance of the relapse of  scarlet fever  to measles may have
given rise to the common  opinion  that measles  often  immedi-
ately succeed scarlet fever.
    Typhus fever often  causes well-founded doubts in coincident
epidemics of the two diseases.   Its exanthem is by no means
rarely papular and even hemorrhagic,  like that  of measles,  and
a catarrhal affection of the air-passages, especially of the trachea,
is one of  its usual concomitant symptoms  (Pastau).  In two of
Rautenberg's children  with typhus, the papular roseola was so
 thick that one  could hardly help confounding it with measles ; as
a rule, apart from the  fact that  the fever and the course of the
disease are different,  the deciding symptoms against measles are
 the absence of  or  sparse  eruption upon the  face,  the absence
 of  catarrh of the nose  and conjunctiva, and  lastly, the marked
 swelling  of the  spleen.  According to Naunyn, children with
 tvphus may be attacked  by  nasal  catarrh,  conjunctivitis, and
 cough, and an exanthem perfectly  resembling measles  may ap-
 pear after three  days; while Kierski observed these  mucous-
 membrane symptoms for  the  first time at the  end of  the  first
 week of the fever.  A correct decision may perhaps be  reached 
108
THOMAS.—MEASLES.
by  observing  the  condition of the  palatal mucous  membrane
before the outbreak of the exanthem.
   In variola  the  blotchy prodromal exanthem presents diffi-
culties, though only for a short time, since by the next day the
protruding papules remove  all doubt.   Moreover, there  is the
peculiar limitation of the spots in variola to certain parts  of the
body, the absence of the fine papules of measles, also  of the
mucous-membrane symptoms typical of measles.
   The same is true of the spots  at  the commencement of vari-
cella, at  which time fever is  also frequently lacking.  Measles
with large miliary vesicles may cause suspicion of varicella, and
the latter,  if  the single  vesicles are unusually small, and inter-
spersed with  profuse well-developed roseolae,  be mistaken for
measles ; the next day, however, will be sure to furnish typical
proruptions.
   The symptomatic roseola of other diseases,  such as typhoid
fever and cholera, is clearly defined by the rest of the course of
the disease.
   Measles and  simple roseolar eruptions are  distinguished by
the partial confluences of the spots in certain regions of the body
in the former  disease ; by the  absence, in roseola, of injection of
the palatal and  pharyngeal mucous membranes, and especially
by the absence of the concomitant symptoms of measles ; finally,
by the characteristic course of the fever in measles.  It is very
true that one  is not likely to  commit an error, if able to  follow
the entire course of the disease ; but  it is quite possible to err if,
as is  usual,  one  is called upon to make the diagnosis of a more
or less rudimentarily developed exanthem, or of one which has
only half run  its course. In  such cases measles are to  be ex-
cluded, if the  temperature is  normal, if there  is a vivid colora-
tion of the eruption on  the trunk, if the separate spots have a
very  smooth character,   and if there are no symptoms on the
part of the  mucous membranes.   If doubt  still remains,  it  is
often entirely removed by the absence  of contagiousness.   Epi-
demic, measles-like  eruptions  in southern lands (dengue,  Malta
fever, etc.) are sufficiently characterized by their  peculiar symp-
toms.  Roseolar exanthems produced by decaying straw are said
to resemble  measles very closely (Salisbury), but the statement 
PROGNOSIS.
109
that they afford protection against measles is not to be believed
for a moment.
   The darker complexion  of  the non-Caucasian races presents
especial difficulty for the diagnosis of measles, as of other hyper-
aemiae.  We learn from the communications made by Pruner in
regard to this point,  that the exanthem in the brown-colored
Abyssinians, Nubians and Fellahs  appears in the form of irre-
gularly indented,  coppery blotches,  and  occasions a marbled
appearance, while that of the negroes is distinguished by little
vesicles, like lichen  papules or miliary vesicles, or, according to
Manger and Rigler, by papules appreciable to the touch,  which
last fact, together with the symptoms from the mucous  mem-
branes and the furfuraceous white  desquamation, was  made
use of by  Roux in diagnosticating the disease in  the case of
Indians.
   The diagnosis of measles without exanthem can be made with
some degree of certainty only during an epidemic, and in cases
where, the patients having been previously  unaffected, the  symp-
toms on the part of the mucous membranes are perfectly typical;
one must regard the  same factors in  the  diagnosis of measles
in the prodromal stage, and must also especially notice in such a
case whether some signs of the future exanthem are  not present
on the face and on the neck.

                        Prognosis.

   The prognosis of primary and uncomplicated measles is thor-
oughly favorable, death from the severity of the infection alone
being extremely rare.   It is  only owing to diseases during the
course of which it is developed, or to the complications which are
induced by it, that it becomes  a disease the mortality of which is
not insignificant, and in rare  cases can even become excessive.
With a typical course of the individual stages of the disease the
result is always favorable ; therefore all such deviations from the
type as signify an aggravation of the trouble are unfavorable.  In
severe cases such deviations may begin  even in the prodromal
stage, though more frequently they first  appear in the stage of
eruption, and most commonly  only when  the  exanthem has 
HO                 THOMAS.—MEASLES.

passed its acme.  The anomalies most important to a prognosis
are:  unusually high fever and delay of its crisis; very profuse
and vividly colored or anomalous exanthem ; unusually intense
affections of the mucous membranes ; finally,  complicating affec-
tions  of internal organs,  or  some complicating general  malady.
Specially ominous  are: high or increasing fever on the second
and third days of the prodromal stage, also  protraction  of the
same  beyond the normal duration,  therefore retardation of the
eruption when the fever is high; intense exacerbations of temper-
ature at the beginning of the eruption, with normal or anomalous
prodromal  stage,—generally  forerunners of further anomalies;
exceptional elevations of temperature (105° Fahr. and more in the
axilla) at any period of the disease, even at the time of the maxi-
mum of  the  exanthem ;  finally, duration  of the fever after the
stage of eruption, in place of the crisis.   This  last behavior of
the temperature indicates with great certainty in most cases the
occurrence of complications of the  most varying nature.  Fur-
thermore, the prognosis is modified when  the eruption is anom-
alous : unusual sparseness and paleness of the  same, with high
fever; universal confluence or a hemorrhagic character of the
spots; partial eruptions ; beginning  of the same elsewhere than
upon the face, or anomalous diffusion over the body ; premature
and sudden fading or abnormally protracted duration of the erup-
tion in the condition of most marked development.  All severe
complications can affect the favorable prognosis of measles, espe-
cially broncho-pneumonia, croup and diphtheria,  intense diar-
rhoea, convulsions,  particularly in the eruptive stage, also severe
cerebral attacks in general,  inflammations  of  internal  organs,
gangrenous affections, keratomalacia;  many epidemics have be-
come fatal from these disturbing influences.   Profuse perspira-
tion  and severe hemorrhages  are  also unfavorable  symptoms.
The prognosis of  secondary measles is unfavorable, especially if
this,  as is often the case, is  at the same  time complicated; but
even without any complication the result of secondary measles is
 often fatal.   Much naturally depends upon the nature of the
original affection ; patients are especially endangered who suffer
from chronic thoracic affections ; the same is true of the  anaemic
 and poorly nourished, those who have intestinal catarrh or who 
PROGNOSIS.
Ill
are predisposed to disturbances of the brain (hydrocephalus and
convulsions).
   Healthy children between the ages of four and five have mea-
sles most lightly; younger ones, with the exception of the young-
est sucklings,  are  often severely attacked.  Teething children
appear often to be attacked with special severity.   I have several
times seen them die with uncontrollable fever and severe nervous
symptoms, and have discovered on the cadaver tooth-points just
broken through. Measles is also a severe disease for older adults;
they are rarely, however, attacked in these days ; it is also severe
for pregnant women, who readily abort, and for those recently
delivered.
   Death occurs rarely in the first, mostly in the second week of
the disease ; also later,  according to the time of the accession of
the fatal complication.
   Those anomalies in the course of measles, which often interfere
with a good prognosis,  occur especially with patients in the first
years of life.
   According to Kellner there  were, of 18 cases during the first year of life, 8, = 44
per cent, anomalous; of 61 during the second, 32, = 52 per cent.; of 84 during the
third, 29, = 34 per cent.; of 168 during the fourth and fifth, 36, = 21 per cent.; of
204 during the sixth to tenth years, 43, = 21 per cent.; of 34 during the tenth to fif-
teenth years, 7,  = 30 per cent.; of 11 during the fifteenth to twentieth years, 2, = 18
per cent.; of twenty cases above twenty years, 2, = 10 per cent.  Spiess found the
relative per cent, for the first year = 7 per cent.; for the second, = 42 per cent.;  for
the third, = 25 per cent.; for the fourth, = 16 per cent. ; for the fifth, = 15 per cent.;
for the  fifth to tenth, and tenth to fifteenth,  = 12 per cent.; for the fifteenth to
twentieth, = 4 per cent.; anomalous cases of over twenty years gave 26  per cent.

   These figures show  plainly the diminishing tendency to com-
plications with increasing age;  it is only after  youth  is passed
that an  increase begins again.  Anomalous  cases are said  to
especially characterize the  beginning of an epidemic (Kellner)  ;
there are proofs enough, however, of the contrary.
   The age of the patients is, under all conditions, of the greatest
influence upon the mortality of measles.   Disregarding the fact
that healthy and very young children (up  to about the age  of
six months), probably  from  their  feebler  predisposition,  are
attacked  very mildly, if at all,  the  rule  may be laid down that 
112
THOMAS.—MEASLES.
 measles are essentially dangerous  only for young or very young
 children;  that its  danger  decreases rapidly with  accession  of
 years,  and in  the  late years of childhood is  already at a mini-
 mum;  in old people, who have,  however,  but little predisposition
 and are rarely attacked,  the disease is again dangerous.   Excep-
 tions to this are not often reported.

    Thus Schuz saw, in particular, children of from six to eight years die.  In the
 Paris garrison, that is to say, among people between  eighteen and thirty years of
 age, numerous  fatal  cases of measles took place in 1838, '39, '48, '49, '55, '60, due,
 according to Laveran, to the influence of vitiated hospital air.  The following
 estimates can testify to  the  correctness of the rule given above: According to
 Schiefferdecker there died  in London of measles from  1856-66:  in the first year
 of  life,  3,368; in the second,  7,606; in the third,  4,261;  in  the fourth, 2,247;
 in the fifth, 1,184 ; from  0 to five years, 18,666;  from five to ten years, 1,076 ; from
 ten to fifteen years, 84; above fifteen years, 111 ; total, 19,937.   So at Konigsberg
 in six years:  in the first  year of life, 88; in the second  and third, 157; from the
 fourth to the tenth, 115 ;  from the tenth to the twentieth, 2; of older persons, none
 at all.  According to Passow the  absolute mortality  from measles  in Berlin, in
 1863-67, increased up to the second year  of life, at which point it reached its
 greatest height: 24 per cent, of all the deaths were in the  first year, 31  per  cent, in
 the second year.  From the third year on it diminished, at first rapidly, then slowly,
 up to the thirtieth year, not constantly, however, since in the eighth and tenth years
 there was a slight increase,  while from  the twentieth  to the twenty-fifth  year no
 deaths took place.  From the thirtieth to the thirty-fifth year the mortality again
 increased slightly; above thirty-five years there died only one  person, aged sixty-
 two.  According to Ranke there died in Munich (1859-68) 70 children  under  one
 year (out of  195), 119 at the  age  of  from one  to 6ve years, 11 persons above
 fifteen years (out of 185  sick);  the  mortality of the first five years was therefore
 94.5 1 per cent.   In Wurzburg it was, according to  Voit (1842-71), for the same
 years of life about  93l per cent.  ; there  died of 88  patients under  one year,
 21, = 23.8 per cent. ;  of 367 from one to five years, 15, =  4 per cent.;  of 289 from
 five to fifteen years, 3, = 1 per cent.  In the Vienna Children's Hospital there died,
 according to Monti, 1864-67, of 372  cases of measles the monstrous number of 98,
 of which 6 (out of 16 patients) were between six months and one year  old; 70
 from one to five years (out  of  173  patients, namely,  35 patients with  21 deaths
 in the second year ; 52 with 26 deaths in the third year; 47 with 13 deaths in the
 fourth year;  39 with 10 deaths in  the  fifth year);  22 from five to eleven years
 (of  183  patients there were 43 from five to  six years, with 9 deaths; 38 between
six and seven, with 6 deaths;  33 between  seven  and eight,  with 4 deaths; 32

   1 These are probably typographical errors; 24.5 per cent, and 23 per cent, being
intended.—Translators Note. 
PROGNOSIS.
113
  between eight and nine, with  3  deaths); of persons  above this age no one died.
  According to Geissler there died in 1861 at Meerane, out of 1,754  patients, 63 •  out
  of 13 under six months, no one; out of 99 from one-half to  one year, 2; out of
  221 from one to two  years, 19; out of 264 from two to three years, 26 ;  out of  226
  between three and four years, 7;  out of 204 from four to five years, 6 ;  1 each  out
  of 187, 151, 144, of six, seven, and eight years respectively; of 227 older children
  (up to fourteen years) no one  died.  According to Spiess  (Frankfort, 1860-61) the
  mortality equalled for  the first  year 8 out of 45 cases, = 18 per cent.; for  the
  second, 15 out of  156 cases, =  10 per  cent.;  for the third,  9 out of 204 cases, = 4.4
  per cent,; for the fourth, 3 out of 186, = 1.6 per cent.;  so also for the fifth (4  out
  of 243); for the  fifth to the tenth, = 0.7 per cent. (7 out of 954).  According to
  Kellner there died at Frankfort, in 1858,  43 children of measles: 8 in the first,
* 18 in the second, 5  in the third, 4 each in the fourth and fifth, 1 in the sixth
  and seventh, 2 in the eighth year, above eight years no one.  The influence  of
  measles upon the mortality of different ages is very well shown in the epidemic
  of the Faroe Islands observed by  Panum.  During this, i.e., in the first nine months
  of 1846, far more people died than ought to have done so  in accordance with  the
  average for the year, and of these, in  the first  year of life, nearly 3 times more,
  between  one and twenty  years the normal proportion, in the third decade  1.4
  times  more, in  the fourth to the eighth decade 2.4  times,  2.6 times, 4.5 times,  3.9
  times, 2 times more, between 80 and 100 years 1.5 times more.   The chief  portion
  of this excess  of  deaths was due to  measles, which is therefore  more  dangerous
  the older the patients are; the decrease of the mortality in the oldest decades was
  due to the fact that only sixty-five years had elapsed since the last epidemic, and
  the oldest people  were therefore  for the most part no longer  liable to  attacks of
  measles, and therefore could of  course  not die from them.

     Sex has no influence upon  the  mortality of measles :  accord-
  ing  to  the reports,  the  number of deaths  among  boys at  one
  time  slightly exceeds that  among girls, while  at another it again
 falls below it.
    The mortality of  measles  in general is  as a  rule  slight,  so
 that it may justly be  reckoned among the least fatal of the infec-
 tious diseases.

    Thus, according to Faber, there died in the epidemic of 1827-28, at Schorndorf
 only 1.8 per cent,  of 2,100 cases; according to Geissler,  from 1835 to 1869,  at
 Meerane,  only 2.1 per cent, of all the deaths among children were from measles,
 the severe epidemic of 1861 causing only a mortality of 3.5 per cent.;  according
 to  Ranke, in four epidemics at  Munich, the  mortality varied from 0.7  to 2.7 per
 cent.; in  the Children's Clinic at Wiirzburg, there died, according to Voit, out  of
 851 cases  of measles, from 1842-71,  39 = 4.5 percent.; in  Stuttgart, according to
 Kostlin (1852-65),  1.8 per  cent.;  the epidemic  at Frankfort  (1858), occasioned,
         Vol.  II.—8 
114
THOMAS.—MEASLES.
according to Kostlin, a mortality of 2.4 per cent.  Occasionally an epidemic is
marked by  special malignancy,  owing to the occurrence of severe complications,
which markedly increase the number of fatal cases.  Thus, there died at the Chil-
dren's Hospital in Wurzburg, in the epidemic of 1863, 10.5 per cent.; in the Grand
Duchy of Baden, according to Meier, from 1818-24, 5.4 per cent. ;  in an  epidemic
at Sydney, according to Carroll, 6 percent.;  at Leith, according to Brown, 9.7 per
cent.; in the district  of Zolkiew (1840), according to Seidl, out of 1,519 cases 196,
i.e., almost  13 per cent.; at Nagold, according to Schiiz, nearly  10 per cent. ;  at
Altdorf, according to Kapff, 10 out of 95 cases; at Herrenberg, according to Fricker,
1 out of 11 ; according to  other physicians at Wurtemberg, in the years  1836-3',,
out of 317 cases, 47;  out of 312, 22; out of 266, 24, etc.  Under  the influence  of
specially harmful agencies, similar or still more unfavorable proportionate ratios are
exceptionally encountered.   Thus there died on the river Amazon, 1749-50, accord-
ing to d'Alves, 30,000 Indians; a similar mortality occurred in British North America,
according to Meyer-Ahrens; at Madagascar, 5,000 cases died in one month in 1806;
in the American army, according to "Woodward, out of 21,676 cases of measles, over
2.5  per cent, perished, merely from the fever,  without reckoning the numerous com-
plications ;  the mortality was very considerable during the well-known epidemic  of
the Faroe Islands, also, according to Meyer-Ahrens, during that of Iceland (1846).
There succumbed upon an Indian emigrant ship, according to Roux, out of 43 cases
of measles, 11 ; in the restricted accommodations of the Children's Hospital at Stock-
holm, of 131  cases,  36 per cent, died; under unfavorable hospital conditions,
according to Laveran, 40 died out of 125 soldiers who had contracted measles, but
who were at the same time  worn out by the campaign.

    The  causes of the malignancy of individual more or less ex-
tended  epidemics of  measles are, for the most part, unknown:
they have been,  in past  times,  unjustifiably sought only in the
geographical position, character of  the soil, special climatic  influ-
ences, etc.,  and thus, according to  Hirsch,  the unsuitable thera-
peutic and dietetic  methods of the day have been  left entirely
out of consideration.   Even this, however,  does not explain the
differences  of mortality which one and the  same physician ob-
serves during different epidemics,  or which  have been reported
from the  same region or district at different times.

    Thus Lippe, in middle Hungary, had in 1856 an epidemic so malignant through-
out that over 50 per cent, of the cases died, mostly after a normal  prodromal stage,
through complications which occurred after the fifth day, while in  1863 only 3 per
cent. died.   The epidemic  at Winschoten, beginning in May, 1865, occasioned,
 according to  Tresling, a mortality of 4.83 per cent, while that of the  middle of
September,  1871, caused one of  only 2.1 per cent.   According to Karajan, the mor-
tality of the epidemics of 1862, in lower Austria, which  occurred during the pre- 
                            PROGNOSIS.                        H5

 sumably unfavorable cool  months, reached only 2.29 per cent., while that which
 occurred  in the  summer months of 1863, in the same district, attained  to 6.29
 per cent.  If from this summer epidemics should appear more fatal, yet in otlier
 places  precisely the reverse has been the case.  Thus, according to Voit, there died
 in the Children's  Clinic at Wurzburg, within thirty years, during the winter months,
 12.7 per cent, of the measles cases; in spring, 11.5 per cent. ; in summer, only 2.5
 per cent. ; in autumn, 0.4 per cent.  According to Passow, however, of all the fatal
 cases of measles in Berlin, from 1863 to 1867, there took  place  in winter, 41.4 per
 cent.; in spring, 11.9  per cent.; in summer, 13.3 per cent. ; in autumn, 33.4 per
 cent.; the autumn was, therefore, essentially more unfavorable than in Wurzburg.

    It is therefore  clear that universally applicable rules cannot
 as yet  be laid  down, and even the rare exceptions of malignant
 epidemics must still await their explanation.
    The mortality from  measles  varies  at different  places, as
 we  learn  especially from the  compilations  of Schiefferdecker.
 According to  him there are due to measles out of 1,000 deaths in
 London, according to statistics extending over eleven years, 27.0;
 in Frankfort-on-the-Main (for  a period of twelve years), 12.0 ; in
 Konigsberg (for the same length of  time),  9.2 ; in  the Canton of
 Geneva (for thirteen years), 6.6 ; in Stuttgart (for fifteen years),
 6.3; in  Munich (for seven years),  5.8; in Berlin  (for  eighteen
 years), 3.8 cases.   In some small places the difference may partly
 depend upon  the presence or absence of severe epidemics of mea-
 sles during the years concerned,  but this cause does not at all
 explain the very  noticeable  difference between  the  two  great
 cities, London and Berlin, in  which  it may  be presumed  that
 measles continually occur,  and the  cause  must  therefore be
 sought  in local conditions,  which either increase  the mortality
 from measles  in London, or that  from other causes at Berlin :
 the former is probably the most important  cause of the marked
 difference.
   The influence of the mortality of measles upon the mortality
 of children generally, has been especially studied  by Schieffer-
 decker.

  Thus at Konigsberg,  according to the statistics of six years, among 1,000 deaths
4.2 were due  to measles during the first  year of life ; 23.3 during the  second year,
16.8 during the third, 17 during the fourth, 21.6 during the fifth year.   Statistics of
eighteen years give for Berlin, at the corresponding ages, 3.2, 13.7, 15.4, 17.3, 12.7; 
116
THOMAS.—MEASLES.
of eleven years for London, 20.0, 100.9, 111.3, 96.5, 78.0.  According to Gregory,
there died of measles in England and Wales in 1838, 6,514; in 1839, 10,937; in
1840, 9,326 persons.

   In hospitals and barracks, in a word, in too crowded localities,
the prognosis of  measles is often less favorable, partly owing to
the deteriorated  air prevailing in such places, partly from  the
possibility of  other attacks  of different infectious  diseases,  the
contagious principles of  which are often, so  to speak, domiciled
in badly arranged hospitals  (separate buildings for special dis-
eases exist only in very few  places), and are more easily propa-
gated amongst a closely packed population with  its excessive
intercourse than under ordinary circumstances.
   Poor  people  who  are usually  badly nourished and often
cachectic, scrofulous and anaemic, die  to  a  greater  extent than
those in better circumstances.  Lievin  proved this  by extensive
estimates for Dantzic, while he was unable to show that a similar
influence was exerted by a too dense population.

                         TREATMENT.

   The most effective  prophylactic measure is the  isolation of
those  affected by measles.   If this could  be strictly carried  out
under existing circumstances, it would doubtless  prevent  the
spread of  epidemics, for the poison of measles is reproduced by
infected organisms  alone,  and is communicated  only by inter-
course.  Such isolation cannot, however, be reasonably demanded
at present, and we must  therefore give our minds to opposing, in
the interest of individuals, the evils brought about by an essen-
tially unimpeded spread of  the contagion.   To  this end it is
demanded, not unjustly from a purely medical stand-point, that
the brothers and sisters  of affected children should be forbidden
access to all schools and institutions for a certain time,  in order
that the disease may not be transmitted by means of  objects
which have come in contact  with the  contagion, such as, espe-
cially, the  clothes of  the healthy members of the family.  Such
measures thoroughly enforced would certainly remove an impor-
tant source of infection, thus guarding those disposed  to the dis-
ease from an attack of it at a period of  life when the prognosis is 
TREATMENT.
117
more unfavorable.   Such a prohibition, however, is often enough
evaded because it seriously interferes with the education of the
children, nor can  it be extended to the usual domestic  inter-
course, especially that between families ; and  thus ample oppor-   i
tunity for infection is always afforded.  Nor is even the  above
measure of itself sufficient,  for it does not prevent the possibility
of infection from a person in the stage of incubation or even in
the prodromal  stage, if this has been overlooked.  The closing
of schools  and  similar institutions entirely upon the appearance
of an epidemic would doubtless interfere materially with its
extension, but would not  permanently prevent its development;
moreover, the measure would be superfluous in  the usual mild
epidemics,  and  at  most only to be made use of when these were
malignant.  In private houses isolation is usually without  effect,
contagion  occurring during the unrecognized prodromal stage;
the measure is  therefore superfluous.  But when it  is necessary
to protect very young people, or those already ill with some
other disease, from a secondary and oftentimes dangerous attack
of measles, the physician  must represent clearly  to the friends
the importance of  isolation, and insist upon its being carried out
with great strictness.  It is generally Considered unnecessary to
seclude healthy children  of more advanced age during a mild
epidemic, but, as the prognosis is not absolutely favorable, the
physician should  not advise  against such  a  measure.   In chil-
dren's hospitals, measles should in  all cases  be  treated in sep-
arate wards, though in hospitals for adults this  measure  would
be superfluous, as all the inmates of the ward would probably be
no longer  susceptible.  Finally,  care should  be  taken that the
clothes and other  effects of patients who have recovered be sub-
mitted to thorough disinfection before they come again into con-
tact with healthy  individuals, and this involves complete  purifi-
cation in an apparatus set apart for the purpose, by  means of
effective washing,  and not  through simple exposure to the  air.
   The greatest cleanliness and frequent  change of the  air in the
sick-chambers  of  patients with  measles,—where, if possible,  a
window should be continually  open—benefit not only the pa-
tients themselves,  but also those in their neighborhood who may
perhaps  be dispo sed to an attack, by preventing the infectious 
118
THOMAS.—MEASLES.
material from working in a too concentrated condition upon the
latter.  Even if this axiom cannot be positively proved in every
individual instance, yet experience shows that an anomalous and
complicated course of  the disease, with its previously described
evil consequences, is rather to be expected in  badly ventilated
and crowded rooms than a normal and mild course.   The conta-
giousness is also probably diminished by frequent bathing of the
patients.   Other prophylactic measures and methods which have
been employed are, as experience shows,  of no use, or at  least
uncertain;  the latter  is especially true of inoculation, which,
however,  under suitable  circumstances,  might be empirically
employed to procure further experience.
   In the treatment of measles, as of the acute exanthems in gen-
eral, the axiom must be borne in mind that the disease in its nat-
ural typical development cannot be interrupted,  and leads to
recovery, provided the fever and the local disturbances remain
within  their normal boundaries, and no dangerous Complications
intervene.   The  physician has therefore nothing more  to do than
to watch the course of the disease, to oppose injurious  influences,
and  to place the  patient under  those  circumstances in which
interferences with  the  normal course are as far as possible obvi-
ated.  All  this is accomplished if the patient is enjoined to take
to his bed, his diet suitably regulated, his thirst quenched with
water, his chamber ventilated and kept at a temperature of about
63° to 67° Fahr., and somewhat darkened in his immediate neigh-
borhood.   During the  preliminary  stage,  children with perhaps
considerable fever at  evening must be prevented  from running
about or going out of doors.   In simple measles the normal
development of the  eruption upon the skin should  be neither
retarded  nor promoted with useless  zeal, i.e.,  patients should
neither be  kept too  cool  nor foolishly heated  with heavy bed-
clothes, warm drink, etc. ; the former course is especially to be
avoided, if fever is lacking, and the latter should certainly not be
followed where the fever is severe.   Simple paleness of the erup-
tion, with slight fever  and anaemia, demands no interference, at
most some slight additional warmth ; too marked a redness, usu-
ally accompanied by severe fever, may, on the  other hand, need
rool applications.   The physician  must prevent as far as  pos- 
TREATMENT.
119
sible any irritation of the mucous membranes affected, partly to
get rid of annoying symptoms, partly to guard against more or
less threatening dangers.  If the eyes are congested, light should
be excluded, the secretion  frequently removed with lukewarm
water, and, if necessary, cold applications employed.   For severe
coryza, water of an agreeable temperature or moderately warm
vapor should be drawn into the nose.  If the cough is violent, the
air of the  room should be  of a moderate  temperature and fre-
quently changed, the  patient of  course being protected from any
draught. If more is needed, and severe nervous irritation is pres-
ent, the neck may be slightly protected with flannel, and mucila-
ginous, sweet, warm drinks  administered, if  thirst and heat per-
mit ; if marked though simple laryngitis  is the cause of the
cough, cold compresses about  the neck are indicated.  At times
cold packings succeed in removing  an immoderate tendency to
cough.  Narcotics  should  be employed for this purpose  very
carefully, in doses corresponding to the  age of the  child, and
when a tormenting  cough, preventing sleep, cannot be otherwise
relieved.   The cough may also  be  checked by  an emetic  given
early, but care must be taken not to give too large a dose, espe-
cially if  tartar emetic is employed,  for fear of  exciting a  diar-
rhoea.  Irritation of the gastric and intestinal mucous membranes
is most easily prevented and treated by prescribing a suitable
diet devoid of substances difficult of digestion, flatulent, fatty, or
laxative.  If constipation is present, which is rare, laxatives may
be employed,  but  only the lightest forms (calomel  excepted) ;
usually simple injections are enough, while purgatives should
only be employed after the expiration of the disease.  Diarrhoea,
which is often present and frequently severe, should be treated by
cold compresses frequently  renewed, or even by bladders of ice
upon the abdomen;  if less severe, by moist heat and by the
limitation and still more  careful  selection of  the food taken.
Narcotics are  only to be used in extreme cases; emulsions and
astringents  are preferable ;  revulsion to  the skin by packings,
with or without subsequent hip-baths, may succeed, and can  at
all events be tried  if the application of a more intense cold to
the abdomen is  contra-indicated or  refused.  The usually slight
angina accompanying measles, and the hyperaemia of the buccal 
120                  THOMAS.—MEASLES.
cavity demand no special  treatment beyond cleanliness of the
parts.
   The most important thing is the suppression of immoderate
fever  in  the prodromal  and especially in  the  eruptive  stage.
Even  in  the  last century a few physicians employed cold for
this purpose in the form of douches, baths, and spongings (Hahn,
Currie), and Frolich and Thaer at the  beginning of the present
century drew up tables in regard to the warmth of the water to
be used, which presupposed the thermometrical measurement of
the temperature of the measles patients.   At present cool baths,
packings, and extensive  cold  compresses are the  usual means
employed ; spongings are also admissible, though wiping must be
omitted on account of its unavoidable irritation of the skin.   The
advantages of a judiciously administered cold-water treatment in
measles are, that it  usually affords to the patient more speedily
and  safely than any other antifebrile  method a  certain sense
of comfort; that it is not apt to weaken or otherwise act unfav-
orably,  and that it shortens  convalescence by permitting the
patient to expose himself  to the fresh air  sooner than  under
any other treatment (Mettenheimer).   Moreover,  it favors the
cleanliness of  the body, a thing of the greatest importance for
the prevention of certain complications.   While it is indispen-
sable to combat, by means of cold,  a high and dangerous fever,
it is no less  advantageous to  moderate  betimes a fever which
tends  repeatedly to exceed definite limitations.  Compresses and
packings should therefore be employed as soon  as the tempera-
ture of the axillae approaches or exceeds 102° Fahr., and baths
once or twice  daily as soon as it remains at 103°  Fahr. ;  with
higher temperatures, especially  in  young children, both these
means should be united.  The physician  should proceed  syste-
matically, and not leave it to the relatives to determine the time
and method of reducing the temperature, except where it is abso-
lutely necessary; for  the  friends  of the patient usually  feel
called upon to act only when severe nervous symptoms and the
unmistakable  signs  of excessive heat are  present.   From the
prudent  application  of cold one need not fear in  the least any
unfavorable influence upon the intensity and duration of the
eruption upon the skin.   The sensitive nervous system of chil- 
TREATMENT.
121
dren forbids, of course, the use of very cold baths, especially
when the skin is very much overheated; here we should rather
employ exclusively the gradually cooled baths of Ziemssen from
about 90° to 77° Fahr.   Cough and diarrhoea afford no contra-
indications ; on  the contrary, they are frequently  quickly and
decidedly improved, especially by packings ; even the congestion
of the skin, evidenced  by the frequent sweating, is  a very good
means, according to Hofmann, of furthering the development of
the eruption and also of hastening the expulsion of the conta-
gious matter from the body.  In general, cold water may be em-
ployed more boldly in the prodromal and  eruptive  than in the
desquamative stage.  If, however, cold water has been employed
from the beginning, there is nothing to fear  from its contin-
uance ;  otherwise it is better to begin with lukewarm baths,
or with somewhat cooler  ones containing  salt (artificial  brine
baths, according to Schwalbe), and proceed by slow degrees to
cold washings  and frictions, in order to harden the  skin and not
to increase the catarrhal symptoms.  Moreover, the patient must
under all circumstances, as long as fever  is present, and  espe-
cially with severe  cough and objective signs of a bronchitis of
the finer bronchial tubes,  keep to  his  bed, and only  leave his
room in favorable weather, when the cough and other important
symptoms of disease have essentially disappeared.  Hauner says,
and  not without reason,  "in no disease is careful  nursing and
attention so necessary as  in measles, since with improper treat-
ment and neglect the frequent and disastrous  sequelae will not
fail to appear."  " It would be well as a sanitary measure if the
masses could be instructed in some suitable manner as to how
they should treat their children when attacked by measles."
   If the family refuse to allow these hydro-therapeutical meas-
ures,  in the severe cases inunctions  of  lard  or oil  may be em-
ployed from two to four times daily, till the end of the eruptive
stage.  These, according  to Schneemann, Walz (who out of 343
cases had but  three fatal  ones), Scoutetten, Mauthner, and Cor-
naz, alleviate the febrile symptoms and prevent sequelae, and also
exercise a favorable influence upon the bronchitis,  etc. If the
fever is very high, one may use in such cases quinine, which Binz
wannly recommends for children, and which plays so important 
122
THOMAS. —MEASLES.
 a role in the treatment of typhoid fever, but not in too small
 doses.  I have often enough given children twenty grains a day,
 divided  into  two doses, without any evident result,  certainly
 without injury.   Smaller doses are of no value.   Roncati and
 others, especially Italian physicians, recommend  the daily  ad-
 ministration of two drachms or so of sulphate of magnesia, until
 the end of the eruption, as a febrifuge  and to  prevent severe
 brain  symptoms.  Brown  had the  whole skin rubbed several
 times daily with diluted oil of turpentine, with the best results,
 especially as regards the bronchitis.  These are harmless meth-
 ods and require,  in addition, merely the thorough ventilation of
 the sick-chamber.
    A rational treatment during the  normal course of measles is
 the best prophylaxis of complications  and sequelae.  Deviations
 from  the  normal course  of  the temperature, and especially
 immoderate exacerbations of the fever, are usually the first mani-
 festations of the development of complications and  anomalies in
 the course of measles, or point at least more definitely than any
 moderate local symptoms to the danger which threatens the
 patient;  a careful examination of the state of the temperature
 throughout, by means of the thermometer, is, therefore, the first
 condition of the proper treatment  of  measles.  Not less to be
 regarded, however, are  the abnormal  local signs of  disease:
 particularly severe nervous symptoms, usually the result of the
 increase of fever ;  thoracic symptoms with broncho-pneumonia  ;
 also intense diarrhoea with violent and extensive disease of the
 intestinal tract.  Already in earlier decades a distinction was
 made from this practical stand-point between  typhoid,  inflam-
 matory, and gastric measles, according to the  special predomi-
 nance in the course of the disease of nervous, thoracic, or abdom-
 inal symptoms.
   Moderate deviation of the fever  from the  normal type  re-
 quires  only the usual treatment, with  greater care; premature
fever, violent in the prodromal and lasting strongly during the
eruptive stage,  calls for  immediate and most energetic treatment
by  means of frequently renewed compresses and  packings,  or
cool baths, in order to oppose  at their very first appearance the
graver  anomalies  and to calm the nervous system, the irritation 
TREATMENT.
123
of which can be manifested by delirium, sopor, jactation,  and
even convulsions;  good results from this method as a rule are
easily perceived.   If this cannot be done, the milder anti-febrile
measures above mentioned are to be employed.    De Keghel em-
ployed with good results, as  a revulsive in cerebral congestion,
woollen stockings dipped in cold water.  He employed the same
means for feeble development of the exanthem, with severe brain
symptoms and high fever, with the effect usually of causing  per-
spiration and a normal eruption.   For  the violent and long-con-
tinued convulsions of a child of four months sick with measles,
Pinkham  gave  chloral hydrate in two-grain doses every twenty
to sixty minutes, with the best results, a proof that even convul-
sions, which as here cause the disappearance of the exanthem,
admit of  treatment;  initial convulsions in  measles are usually
not dangerous, if not too  intense or  frequently  repeated,  and
require, therefore, no special treatment.   If  after the longer or
shorter  duration  of  severe brain  symptoms the energy of the
heart begins to  sink, an unfavorable result may often be averted,
or deferred at least, by the immediate administration in large
doses of stimulants (wine, benzoic  acid, camphor; if the  surface
is cold, warm baths and cool douches upon the head, irritants
of the skin,  etc.).
   Severe capillary bronchitis,  the precursory stage of broncho-
pneumonia,  may at first be treated by  one or more emetics, the
preparations of antimony  being  avoided on account of their
action upon  the intestine.   Emetics,  however,  are usually only
of service when the larger bronchi are  crowded with mucus ; the
violent affection of the smaller and smallest bronchi must be met
by calling forth prolonged and deep inspirations, and by revul-
sion to the skin.  As regards the genesis of  broncho-pneumonia,
Bartels  has  especially alluded to the great importance of thor-
ough  ventilation  of  the sick-chamber, for  he  has shown  that
this complication appears preferably in the small, low,  tightly
closed, foul-smelling,  crowded  dwelling  and sleeping chambers
of the poorer  population.  The deleterious influence  of such
dwelling-places upon  the  bronchitis  of  measles he  ascribes
largely to the  circumstance  that  they contain an excess of  car-
bonic acid, which  prevents the elimination  of this element from 
124
THOMAS.—MEASLES.
the blood, and also causes the energy of  the  respiratory move-
ments  to  become  so weakened that collapse  of the lungs  and
pneumonia must almost necessarily follow.  The resulting mor-
tality of the epidemics which he observed lasted until the popu-
lation  became frightened at the high death-rate, and then at last
followed the directions of physicians in regard to ventilating the
sick-chambers.  In summer, patients may be carried with  cer-
tain precautions into the open air.  It  is just as important to
pay heed to the skin as to the organs of respiration, if  we wish
to avert or cure the complicating pneumonia of  measles or to
cure the disease itself.   Though the old sudorific  treatment, the
purpose of which was to occasion  a more marked development
of the exanthem, under the idea  of thus relieving the  internal
organs, has been  given up by  physicians in the treatment of
measles, nevertheless prejudices are still entertained by many
against the use of baths, even warm, on account of the supposed
possibility of their exerting an unfavorable influence upon the
cough  and catarrh of  the air-passages  in general.  It  is to be
hoped  that the favorable results of hydrotherapeutics may over-
come these prejudices,  and that ventilation and cleanliness may,
in future  epidemics, gradually cause pneumonia  and the other
dangerous complications of measles, and with them their mor-
tality,  to  sink to an unavoidable minimum.  The most advan-
tageous method of treating  the high fever of the broncho-pneu-
monia  of measles, according to Bartels, Ziemssen and others, is
the following: several  thicknesses of cloths wrung out in cold
water are  laid upon  a  piece of flannel of sufficient width to pro-
tect the bed-clothes  from becoming wet;  the naked patient is
then placed upon these and  enveloped in them.  Lively kicking
and screaming  ensue, giving depth and force to  the previously
superficial inspiration;  by  degrees  the  children  become more
quiet,  and soon  fall  asleep.   The cold wrappings  are to be
renewed every half hour, or less,  until  the temperature, pulse,
and frequency of  respiration  are  markedly  diminished,  which
is usually the case in  a couple of hours.  The wrappings are
then removed,  the skin dried,  the children  clothed in clean,
warmed garments, moderately covered up, and left to  lie until
a new  exacerbation of  the fever and of  the dyspnoea, or  of the 
TREATMENT.
125
pains in the chest, renders necessary the repetition of the wrap-
pings.  This point is to be especially impressed  upon the atten-
dants.  It is only in exceptional cases  that the wrappings  must
be continued uninterruptedly for several days and nights, or
that we are obliged to resort  to the use of baths and cold douches
upon the head and back.  This mode of treatment may have to
be repeated daily for weeks, according  to the duration of the
pneumonia.  Wrappings  are usually  preferable  to the use of
more energetic antifebrile methods, since the cooling of the body
is  more gradual, and therefore  irregularities in the circulation
and  distribution of the  blood  are probably  better  guarded
against.  They obviate also  any necessity for the use of medi-
cine.  The  cough is generally relieved  by the easier expectora-
tion of the mucus, and the pains in the chest and the febrile
symptoms,  as manifested in the peripheral organs, are usually
diminished in proportion to  the effect  produced.  It  is not
necessary, according to my experience,  to employ other febri-
fuges,  such as digitalis, or quinine in large doses ; I  strongly
recommend, however,  the use of stimulants, especially wine.
Now and then,  when  the  bronchi  are filled with mucus, an
emetic  may be of use  (apomorphine, ipecacuanha).  Trousseau
especially recommended, when the chest symptoms were severe,
as a revulsive to the skin, urtication, i.e., whipping  the  whole
skin with nettles, while Brown  advised inunctions with oil of
turpentine.  A diet as nourishing as possible  under the circum-
stances will essentially aid the therapeutical  measures, which, if
a certain  temperature is kept up, under the control of the ther-
mometer, can  hardly  exercise any  injurious effect  upon the
exanthem, especially in the beginning.
   Carefully  wrapped  packings  are  especially  to be recom-
mended, if, apart from  the  antifebrile removal of heat, a revul-
sion to the skin in a marked degree appears desirable.  This is
the case with diarrhoea, which is often quite violent, and does
not always exercise a favorable  influence upon  the chest symp-
toms.  With remission of the fever, and after continued diar-
rhoea,  a moist abdominal bandage generally suffices; this acts
like a  moist compress   of the  same temperature  as the  body,
and causes by degrees the relaxation of the  vessels of the skin, 
126
THOMAS.—MEASLES.
and thus a favorable determination from the intestines ; it must
be allowed  to remain until nearly  dry.    With dysenteric,
muco-sanguineous discharges, it is  at times  advisable, accord-
ing to Mosler, to wash out the large intestine with  a large
amount of water; so  also to employ ice  clysters liberally for
severe hemorrhages.   On the other hand, moderate injections of
cold water, repeated several times daily, are especially advisable
if  the upper  intestinal tract is alone concerned.  A moderate
amount of fresh water is the best drink to appease the torment-
ing thirst.  With adults and older children appropriate doses of
opium in  a mucilaginous vehicle are of benefit;  with  smaller
children these should be avoided or  only very cautiously  em-
ployed.  Astringents,  as possessing no toxic action,  are better
suited to these cases, though their taste often causes a sufficient
dose to be refused.
   The treatment of the other local  affections is modified by the
presence of measles only in  so far as the avoidance of debilitat-
ing influences of all kinds,  especially losses of blood, is con-
cerned ; in the case  of gangrenous complications and affections
of the intestinal canal, mercurials and strong purgatives should
be avoided to the utmost.  The following affections alone require
special mention.
   Slight epistaxis in the prodromal  stage demands  no special
treatment, is even often of benefit; profuse epistaxis requires the
head  to be raised, the arm  of the  side affected to be held up,
a  cooled  head, antifebrile  remedies,  local  cold  applications,
astringent  injections,  compression of  the nasal apertures if the
bleeding is  from the front portions, and ergot in case of need.
These will generally suffice, and render unnecessary the trouble-
some application of mechanical contrivances.   Trousseau especi-
ally recommends injections of water as warm as possible. Ozaena
is to be treated as usual, that is, by  frequent cleansing and the
use of disinfecting and deodorizing injections.
   Marked affection of the eyes requires the energetic application
of cold and  frequent  cleaning of the parts, and at a later stage
somewhat astringent compresses and eye-waters.
   Light  cases of aural affections often recover  of  themselves,
but may, according to Wendt, demand at times a special treat- 
TREATMENT.
127
ment.  The object of this is the alleviation of existing pain (local
bleedings, frequent  filling of  the auditory passage with  warm
water,  poultices); restoration of the normal  atmospheric pres-
sure in the middle ear (forcing the air in by the so-called Pol-
itzer's  method); removal  of the secretion from the nose and
pharynx (nasal douches, not too often within twenty-four hours;
gargles), and also from the external auditory canal, when per-
foration of the membrana tympani is present (injections).
   The more intense laryngeal affections demand  special con-
sideration.  Cold wrappings or Priessnitz's compresses over the
region of the larynx answer the purpose at first, especially with
otherwise high fever.  If pseudo-croup appears (hoarse cough,
whistling inspiration,  protracted expiration), diaphoretics are
needed, and the neck is to be sponged lightly with pretty hot
water,  but not so as to burn the skin;  the resulting determina-
tion of blood to the surface occasions the remission of the threat-
ening  symptoms.   Should  these,  however,  continue,  emetics
must be given until they act; if no benefit ensues, and symp-
toms appear of  oedema of the glottis, warm compresses should
be tried before having recourse to the last means of saving life,
tracheotomy.   The  same treatment is  adapted to true  croup.
In paroxysms like those of whooping-cough, narcotics may be of
service, if the age of the child renders them admissible.  Where
the laryngeal trouble is subacute and tends to become chronic,
blisters may be  applied to the neck ; the surest result is guaran-
teed by  the inhalation of atomized fluids, or by cauterization
for ulcerations, and here with adults the laryngeal mirror should
be employed.  West was  in  the habit, in croup, of cauterizing
with a little sponge fastened to a piece of whalebone and dipped
in a strong solution of nitrate of silver.  Leeches should not be
employed for fear of too great loss of  blood from subsequent
bleeding, and consequent weakness.  The diet should be a very
nutritious one to prevent chronic respiratory troubles and tuber-
culous affections.
   Gangrene is to be prevented by careful cleanliness of all parts
of the body, especially of  those which manifest slight acute or
chronic affections, excoriations or wounds, and in hospitals by
isolation from patients already attacked by it.  If it is  already 
128
THOMAS.—MEASLES.
present it needs very energetic treatment.  If we wish to restrict
the gangrenous ulcer to a small tract, the parts attacked must
be  cauterized with  concentrated  hydrochloric acid and other
caustics, even with the actual cautery, and then bandaged with
disinfectants.  Bathing  must  be  zealously kept  up,  and the
diet made as strengthening as possible.
   Complicating  diphtheria of the pharynx is to  be treated in
the usual manner, with frequent purifications of the mouth, and
by  gargles  containing suitable  disinfectants  (chloric, acetic, or
carbolic  acids),  or by antiphlogistics (cold  bandages   around
the neck, ice  in  the  mouth),  but not by cauterizations,  If in
this way the progress of the affection  to  the  trachea  cannot be
prevented, there is here nevertheless a much  better prospect of
saving the patient's life by  tracheotomy than  in the diphtheria
of scarlet fever;  under Abelin, at least two out of  six who had
been thus operated upon, recovered.
   In  the treatment  of the diphtheria of other mucous mem-
branes, the same therapeutical principles are to be observed. 
RUBEOLA.
              (EOETHELN,  GERMAN MEASLES.)

Writings which do not regard rubeola under the acceptation of the present day, or
    do  not decidedly advocate this  acceptation: Orlow, De rub. et morbill. dis-
    crim. Progr.  Konigsb., 1758.— Willan, Hautkrk. fibers, v. Friese 1798-1816.—
    Heim,  Hufel. Journ.  Bd. 34. p. 76.  1812.— Wolf, Hufel. Journ. 1812. Bd. 34. 4
    St.  p. 69.— Henke, Hdb. d. Kndrkkh.  1818.— Meier, Badische Ann. 1828. HI. 2.
    Heft. p.  129.—Jahn, Anal. iib.  Kinderkkh. 4. Heft. p. 150.  1835.— Fuchs, D.
    kkhft. Verand. d. Haut. p. 1063.  1841.—Bchonlein's Path. 5. Aufl. H p. 272.
    1841.—Meissner,  Kndrkkh. 3. Aufl. II. p. 582.  1844.—Canstatt, Hdb. H. p. 278.
    1847.—Kronenberg, Journ. f. Kndrkkh. 4 p. 244.—Simon, Hautkrk.  1848.—
    Naumann, Pathogenie  1841. p.  292.—v.  d. Busch, Oppenh. Zeitschr.  p. 289.
    1851.—Paasch, Journ. f. Kind.  Bd. 24. p. 74.  1855.— Bednar, Lehrb. d. Kin-
    derk. 1856.— Wunderlich, Path. 2. Aufl.  1856.—Kuttner, Journ. f. Kind.   Bd.
    30.   p. 180.  1858.—Gelmo, Jahrb. f.  Kindhk.   I. Ser.  I.  p.  152.  1858.—
    Lebert, Hdb.  d.  pr. Med.  1859.—Th.  0. Heusinger, Diss, inaug. 1860.__Gin-
    trac, Canst. Jahresb. 1858.  Journ. de Bord.  p. 545.  1862.—Cless, Wurtemb.
    Corr. 1862.  Nr. 16.   Bd. 32.—Bericht etc.   Ibid.  Nr. 20.—Niemeyer, Path.
    5. Aufl.  1863.— Kunze,  Compend.   2.  Aufl.  1865.—Kostlin, Arch. d. V. f.
    wiss. Heilk.  II. p. 338.  1866.— Henoch, Beitr. z. Kindhk. 18G8.—West-Henoch,
    Kindkkh. 5. Aufl.   p. 476.  1872.—Foss, Edinb. Journ.   p. 280.  1872.—
    Seitz, Bay. Intell.  1873.  Nr. 51.
The following advocate a specific rubeola :  Wagner, Heck. Ann. 1829. XIII. p. 420.
    Hufel. Journ. 1834.   79. Bd.   2. St. p. 55.—Collin, Hygiea  12, p. 347.  Schm.
    Jb.  Bd. 76.   p.  66.  1852.—Salzmann, Wurt. Corr.   1862.   p. 153.— Faber,
    Ibid.  1861.   p.  32G.—Thierfelder,  Greifsw.  med.  Beitr.  Bd. II. Ber. p. 14
    1864.— Hennig, Kindkk.  3.  Aufl.  1864.— de Man, Arch.  f. d. holl.  Beitr.
    HI.  p.  1.   1864.—Prag.  Vtljschr.   Bd.  74.  p.  U.—Danis, Diss.  Strassb.
    1864.—Trousseau, Med.  Klin.  p. 158.   1866.— Veale, Edinb. M. Journ.  1866.
    p. 404.—Arnold,  Bay. Intell.  1867.  Nr. 40.— Wunderlich, Eigenw.  1. Aufl.
    1868.  p.  320.—Thomas,  Jahrb.  f.  Kndrhk.  H.  p. 233.  1869.—V. p. 345.
    1872.—Steiner, Arch. f.  Derm.   I. p.  237.   1869.—Mettenheimer,  Journ.  f.
    Kind.  Bd. 53.  p. 273.   1869.—Squire, Brit. med. Journ.  Jan. 29.  1870.—
    Emminghaus, Jahrb.  f.  Kind.  IV. p. 47.   1871.—Gerhardt, Lehrb. d. Kind.
       Vol.  11.—9 
130
THOMAS.—RUBEOLA.
   1871.  p. 74. — Vogel, Lehrb. d. Kind.  5. Aufl. p. 416.—Dunlop, Lancet.  II.
   p. 464.  1871.— Fleischmann, Wien. med. Woch.  1871.  Nr.  29-31.—Kunze,
   Lehrb.  2. Aufl.  1873.—Liveing, Lancet.  March 14, 1874.  I.  11.  p. 360.


                     HISTORICAL NOTICE.

   There are few diseases in regard to which  opinions vary so
much as about rubeola, or rather about that which is designated
as rubeola by various authors.  The work of separation and dis-
crimination, which has by degrees given us a definite conception
of the other acute exanthems, has by no means reached its final
result as regards this.  Until very recently it has seemed to many
so difficult to  bring  order out of the chaos of  rubeola, that, in
their writings, they have either passed it over in almost complete
silence,  or have preferred to adduce, almost without criticism, an
orderly array of individual opinions.
   The  name "rubeola" was brought into use by German phy-
sicians  about the middle of  the last century for an acute exan-
them, which, according to the concurrent observations and expe-
riences  of all, could belong  to no  one of the acute contagious
or non-contagious cutaneous eruptions,  though closely resem-
bling measles and scarlet fever.  Somewhat earlier still, we find
in English and  French writings  the description  of a similar
exanthem, to which was  applied the name  "roseola,"—the
term rubeola being  used by them to signify measles.  The his-
tory of  medicine throws but little light upon  the origin of rube-
ola.   Some affirm that  it was known  to  Arabian  physicians
under the name "Hhamikah ;" others, that it was first recognized
about the middle of  the last century,  from which time  the more
accurate descriptions date (Orlow, 1758).  Whether the benig-
nant  "  Rossalia epidemics " of earlier centuries were rubeola or
not, cannot be ascertained, owing to the lack of accurate descrip-
tions.
   Partly owing to  the natural confounding of the rubeola of
the Germans with the "rougeole" of the French, partly owing
to the  vagueness of type of rubeola  and roseola, partly on
account of the  lack of opportunities  for observations of true
rubeola in hospitals, there now arose  that inconceivable mystifi- 
HISTORICAL NOTICE.                   131
cation in regard  to  this disease which has not even yet reached
its  end.   Many,  under a more or less clear impression of the
existence of rubeola, considered themselves justified in regarding
as  true rubeola  an  acute, red, somewhat peculiar eruption of
short duration, and in doubting the genuineness of the rubeola of
others, the result of which was, that  various mutually dissimi-
lar forms of disease were described under this name, and the true
rubeola was nearly lost sight of in the confusion.  Thus Goden
in 1822 confounded  rubeola and scarlet fever, and  taught that
the former was a protection against the latter ; that both, how-
ever,  only appeared in  combination.   Jahn, in 1835,  was con-
vinced that rubeola did not exist, and that the cases observed
were for the most part cases of scarlet fever.  Even as late as the
middle of this century, rubeola, in accordance with this idea, was
for the  most part regarded as an anomalous scarlet  fever, and
the celebrated Heim even states that it is more dangerous  than
the latter (according to Formey there died  between 1784-94, in
Berlin, 457 (!) from rubeola, 172 from scarlet fever, 53 from mea-
sles),  while others declared it a variety of measles.   The natural
consequence was  the entire rejection, in many places, of the term
rubeola and the distribution of these cases between measles and
scarlet fever (Naumann); while others, regarding the peculiari-
ties of rubeola as  too well marked  for this, preferred (v.  d.
Busch)  to ascribe to it "a certain individuality," basing such
an ascription especially upon the fact that epidemics of it could
appear distinct from those of measles and of scarlet fever.  They
distinguished, therefore,  in accordance with the varying appear-
ances of the eruption, the rubeola of measles and that of scarlet
fever (rubeolse morbillosae et scarlatinosa^), a division which has
endured even till  the present  time (Niemeyer).   It is extremely
probable  that much of  that  which  has  been described under
this name was nothing more than  measles  or  scarlet fever,
and that  the  diagnosis of rubeola was  often  made merely  to
conceal  the embarrassment of the  diagnostician ; as  to some
reports,  however,  this view is untenable.  Others imagined, with
Hildenbrand  and Schonlein, that they  had unvailed the mystery
of rubeola when  they assumed that this was no indefinite dis-
ease, but  a hermaphroditical form of measles and scarlet fever, 
132
THOMAS.—RUBEOLA.
or at least a disease lying  midway between the two,  the  sup-
position  being  that  an infecting agent of a special nature was
generated outside the organism  during the  simultaneous preva-
lence of epidemics of measles and scarlet fever ; while at another
time a simultaneous infection with both contagions was regarded
as the cause of the special affection of the  individuals.   Schon-
lein  explained  the variation in  the eruption during  different
epidemics by an antagonism in the symptoms  of the  skin  and
of the mucous membrane, the nature of which is manifested by
the fact that when  the symptoms of the mucous membrane
resemble scarlet  fever, the exanthem  resembles  measles,  and
vice  versa.  This  conception is still retained by some.  Simon
declared rubeola as  partly anomalous scarlet fever, partly con-
fluent measles.   According to Canstatt,  the conception of rube-
ola is  rather vaguely limited, and under it may be comprised
every red, blotchy exanthem, in regard to which the considera-
tion  of the general  or  mucous-membrane symptoms gives  rise
to doubt as to whether it should be looked upon as scarlet fever,
measles, erythema, or urticaria.   He regards it as an erythema,
or an urticaria, or a "hybrid form of skin disease, which  por-
trays locally the reflex action of very various genetically differ-
ent conditions," and distinguishes, accordingly, a roseola scarla-
tinosa, morbillosa, typhosa,  variolosa, vaccinica, cholerica, rheu-
matica or arthritica, sestiva, autumnalis, gastrica, etc.,  and  con-
siders it unjustifiable  to assume  a peculiar rubeolous morbific
process  which  cannot  be included in  this category.   Hebra
objected to several of these forms of roseola,—which,  it should
be  stated, had already been  set forth  by Willan  and  his
followers—on  the ground  that unbiassed  observation teaches
that such roseolas represent  either light cases of measles, with or
without moderate  catarrh, or cases of  an imperfectly developed
exanthem of scarlet fever of moderate intensity, or even, finally,
cases of  urticaria.  He believed it, therefore, entirely  superflu-
ous to describe an individual exanthematic eruption  under the
name of  roseola or rubeola (Kotheln).   West expresses himself
similarly ; for, according to him, when rubeola is neither scarlet
fever nor measles, it may be regarded as nothing more than a
simple case of roseola,  in which nothing specific can  be detected. 
HISTORICAL NOTICE.
133
Gelmo, in accordance with Hebra's views, and  in  spite of an
apparently favorable opportunity for observations  outside the
hospitals of a great city, divides the rubeolous exanthems, and
refers them  partly to an anomalous form of scarlet fever,—the
scarlatina variegata  of Hebra—partly to confluent measles, and
partly to a non-specific  roseola,  this  last  occurring  only in
sucklings, and consequently desires that the whole conception
of rubeola should be dropped, since the different cases comprised
under it can be easily included in these three well-characterized
species.
   Later observers, however, like the earlier ones,  are continually
manifesting  their discontent with these attempts  at  explanation
)n the part of  greater and lesser authorities, and  adducing from
'heir own experiences a number of cases, resembling each other
in character, which  cannot, like those of their predecessors, be
brought under any of the proposed schemes, but force them to
assume an independent rubeola.   While, however, the minority
of these  content themselves with  asserting the individuality of
rubeola and deny its contagious nature,  the majority,  on the
ground of the observation of more or less extended epidemics,
allege its decided contagiousness, and declare it a specific acute
exanthem, perfectly  comparable to measles and scarlet fever, the
diseases with  which it was formerly usually confounded.  The
number of the  advocates of the distinctness and contagiousness of
rubeola has of late  markedly increased,  and there  is a general
effort to establish symptoms by which it may be as  perfectly as
possible characterized and permanently distinguished from non-
specific forms of roseola, as well as from measles and  scarlet fever
with a somewhat anomalous exanthem.  Among the  older adher-
ents of an independent and specific rubeola, I mention especially
Wagner  and Trousseau;  Collin, Tripe,  and Meissner have not
been quite clear in their writings, nor uninfluenced by the indefi-
nite opinions of their contemporaries ; but, since the beginning of
1860, the specific nature of rubeola has  been defended decidedly
and with ever-increasing success by Thierfelder, de Man, Hen-
nig, Dnais,  Veale,   Mettenheimer, Lindwurm and  Arnold, A.
Vogel, Wunderlich,  Dunlop, Squire, Gerhardt,  Emminghaus,
Klister, and myself. 
134
THOMAS.—RUBEOLA.
                          ETIOLOGY.

   The assumption of a specific rubeola is based chiefly upon
the fact that at certain times  epidemics appear, the  distinct
cases of which show by  definite  symptoms  an unmistakable
mutual relationship, and conversely also  a difference from scar-
let fever and measles upon the further fact, that, as in the case
of other infectious diseases, one attack of this affection  affords
almost  perfect  protection against  a  second  similar one, but
none against an attack of measles or scarlet  fever, just as these
afford  not the slightest protection against rubeola.  It must cer-
tainly  be granted that second  attacks  of  measles and scarlet
fever may occur ; trustworthy cases of  this are, however, exceed-
ingly rare,  so  that  the possibility is  suggested that the occa-
sional  assertion of the contrary rests  upon  the confounding  of
measles and scarlet fever with their congener, rubeola.  In favor
of this supposition  is the circumstance that those who regard
second attacks  of measles and scarlet fever  as frequent, are ex-
clusively such  as do not accord to  rubeola a specific character.
A correct judgment in regard to sporadic cases is far more diffi-
cult than when  epidemics of rubeola are present, since in a single
case  the extension by contagion cannot  be taken into account,
and we are limited solely to the consideration of the products of
the disease.   Certainty in such cases  can only be attained by
establishing  accurately all individual peculiarities, and even then
perfect  conviction cannot  always be secured.  The fact must,
however, be here borne in mind  that very  various  causes can
educe extremely similar forms of the affection of the skin.  All
other rubeolous  exanthems, in the production of  which the
agency of a specific cause (measles, scarlet  fever, variola, vari-
cella, typhus, dengue, etc.) can be excluded, and which  usually
also in other respects afford sufficiently frequent differences from
specific rubeola, are not to be classed under infectious, but under
skin diseases.   A slight reservation must here be made in regard
to the  infrequent, and therefore too little studied forms of ro-
seola.
   We are now prepared  to  confine our  attention solely to  the 
ETIOLOGY.
135
 consideration of the contagious and essentially epidemic, and
 therefore specific and infectious exanthem, to which  the name
 "rubeola" can alone be properly applied.
    Starting with the incontrovertible fact that anomalous erup-
 tions of  measles and scarlet fever occur, the imperfectly charac-
 teristic nature of which is due solely to individual idiosyncrasies
 (which is proved by the fact they generate again, by contagion,
 cases which are perfectly normal), we must also not  expect  of
 epidemic cases of  rubeola,  connected by contagion, and there-
 fore proved to belong together, that their exanthem should be in
 all cases of a precisely similar type.  Different diseases  of the
 skin may be due indisputably to one and the same cause, e.g.,
 syphilis,  or  even to one which is  not  infectious,  e.g.,  balsam
 of  copaiva!  A too minute and restricted  consideration of the
 conditions of the skin is clearly responsible  for the  confusion
 which has thus far prevailed in regard to the nature of rubeola.
 The more liberal the opinions were in regard to the admissibility
 of  the diagnosis of measles  and scarlet fever, the more the con-
 ception of rubeola became restricted, and the more easy it was  to
 attribute this to the indistinct picture of  a symptomatic roseola.
 Without neglecting, then, the alterations of the skin,  or under-
 valuing their diagnostic significance, it is yet considered at pres-
 ent impracticable to base the diagnosis  of rubeola solely upon
 them, and the necessity is recognized of  comprehensively consid-
 ering also other important conditions.
    Before the individuality of  rubeola was properly recognized a
 distinction was  often made between a form resembling measles
 and one  similar to scarlet fever,—rubeolas morbillosse  et scarla-
 tinosae.  According to my observations the  exanthem of rubeola
 possesses a similarity to that of measles only, not the slightest  to
 that of a normal scarlet fever.   I am willing to admit the possi-
 bility of  the existence  of an  equally important specific affection
 with a scarlatinous condition of the skin, although with all
 watchfulness I  have as yet never met with such a form.   Older
 observations, which allude to  such,  have reference  perhaps  to
nothing more than  light  cases of scarlet fever; at all events,
nothing more accurate can now be  advanced.  Until,  however,
new and  exact observations have furnished indisputable evidence 
136
THOMAS. —RUBEOLA.
that a scarlatinous form of rubeola exists, and that cases of it
originate by contagion from the usual rubeola exanthem resem-
bling measles, and vice versa, I consider it necessary to carefully
discriminate between rubeola proper and casual scarlatinous  ex-
anthems, possibly also such as indicate a specific origin.
   Rubeola is especially a disease of childhood, attacking indis-
criminately boys and girls, older and younger children, down to
sucklings.  Adults up to about forty years are not infrequently
affected; young women are apparently rather more often attacked
than men of  the same age or older persons.   After the fortieth
year the susceptibility is nearly lost, and we may consider it as
essentially weakened at puberty, and as steadily diminishing
subsequently.  Seitz reports a case in the person of a woman
aged seventy-three.
   I have never yet observed a second attack of rubeola in  the
same person; if it occurs, it is certainly as rare  as a second attack
of measles, etc.  The opposite  statement with  regard to measles
is supported only by the confounding of the same with rubeola.
Emminghaus saw  in one case a relapse of rubeola one day after
the termination of the first  eruption, in  two  other cases after
fourteen days ;  in each case the previous  eruption  was much
weaker than the succeeding one.   Lindwurm also appears to
have observed relapses.   Kostlin, who describes accurately  the
peculiarities  of rubeola, and  yet regards it as a light form of
measles, saw in the same epidemic several children attacked for
the second time.
   The contagiousness of rubeola is  considerable, though some-
what less than that of measles.  Thus at times a few children of
a family in which rubeola is present may escape.  It attacks the
healthy as well as the sick.  The  contagious  principle  itself is
still entirely unknown; the vehicles by which it is conveyed are
probably the same as in the case of measles.
   Epidemics of rubeola have  not  yet been sufficiently studied,
doubtless from the mildness of the  symptoms or because they
have been regarded as light cases of measles.   It is  not known
whether, as in the case of measles, a rotation of  several years
exists, though  this appears to be  the case.   For example,  epi-
demics occurred at Leipzig in the spring of 1868, and at the same 
PATHOLOGY.
137
season in 1872 ; in the interval only sporadic cases were met with,
from which we may perhaps infer that rubeola may be, like scar-
let fever, endemic in thickly settled districts.
   I judge from experience that epidemics of rubeola are about
as frequent as those of measles, as far as may be decided upon
the ground of general estimation ; for while one hears everywhere
of the disease, only very few patients are registered.  I have had
the greatest difficulty in making  any observations.  Necessary
relations between epidemics of  rubeola and those of other  infec-
tious diseases do not exist.   Our last epidemic at Leipzig in par-
ticular can in no way be considered as having been the result of
the contagion of measles.

                         Pathology.

   The normally  developed  eruption  of  rubeola consists  of
numerous discrete hyperaemic  blotches from the size of a pin's
head to at the utmost that of a bean, with at times a tolerably
distinct outline or again a  less  colored and somewhat faded
border, and usually rising slightly above the level of the  skin,
so that this feels a little rough.   The eruption is due to capillary
hyperasmia of the papillary body and of the uppermost layers of
the corium ; this can give rise  to  slight  inflammation and exu-
dation between the uppermost stratum of the corium and the
epidermis, but it occurs only exceptionally in a  few cases, and
then only on single parts of the body, and involving only a min-
ority of the spots.  The spots  are generally round or oval, and
not indented, though at times moderately so, and then they are
connected here and there with  each other by delicate processes.
Nearly all parts of the body may be attacked; but especially the
face, which as a rule shows  the eruption sufficiently well to dis-
tinguish rubeola from scarlet fever.  About the mouth the spots
are usually well defined.  Their color can in a few cases and at
the acme of  the development  of  the eruption be quite bright,
though not equalling  the dusky red of a severe scarlet  fever, nor
the peculiar  bluish  red tint of intense measles.   It  is  usually
only a pale rose red,  but suffices,  however, for the most part to
bring  out the spots  in marked contrast with the normal  skin. 
138
THOMAS. —RUBEOLA.
It is everywhere of about the same depth, the color even of the
face not exceeding that of the other parts.  On isolated portions
of the skin, of greater or less extent, the spots do at times show
more clearly than elsewhere.  These variations of intensity occur,
however, only when the exanthem is as a whole but moderately
red, the slight partial excess being due to accidental  collateral
circumstances.  I have never seen them where the eruption was
strongly colored.
   Apart from the color of the exanthem the characteristic most
striking to the eye is the size of the separate spots.  This is not
always the same on all parts of the body in each individual case.
In this connection three  types may generally be distinguished:
one with large spots, one usually with spots of medium size, and
one with small spots.  The first is rather rare.   The  spots are
here proportionately sparse, but  can attain  the size  of  two-
fifths of  an  inch  square; they are never round,  but angular
and indented, and of the most various irregular forms.   Though
they determine the type of the  eruption, yet they  are  never
present alone, but are  always mixed in the most varying man
ner with the smaller, and especially the smallest spots, which are
wont to mass themselves noticeably around the larger spots, and
in some measure to form groups with  them.   In the  type with
small spots  the  single spots are  more crowded,  and at more
regular intervals;  they  are  about the size of  lentils, though
many are smaller, only a few larger.  The exanthem, therefore,
resembles in  some measure scarlet  fever, the spots of which are,
however, usually much smaller and more closely arranged.  In
the common  type the  single spots are least crowded,  and are
usually of the same size,  namely, that of a lentil, though smaller
and larger ones also exist.   The  type is chiefly determined  by
the moderate degree of  crowding, and the non-preponderance
either of the larger or of the very small spots.  Transitions, of
course,  exist.  Even on those parts of the body where the spots
are most abundant,  these are only moderately crowded together.
They occur most  profusely, and relatively most densely, though
rarely confluent,  upon the  face,  especially  on  the   forehead,
cheeks, chin, and produce here the appearance of a light oedema,
particularly if any swelling of the lymph glands is added.  They 
PATHOLOGY.
139
often lie quite closely crowded together on the neck and trunk,
especially on the neck ; more often, however, they are no more
abundant than  on the thighs and upper parts  of  the  arms.
Then, too, the posterior aspect of the thigh and the gluteal region
are also not infrequently profusely covered with spots, the result
of keeping warm  in  bed.   The scalp is  always attacked,  and
often severely.  The  forearms, hands, lower parts of the legs,
and the feet, are generally less  markedly affected, not only as
regards the number and closeness of the spots to each other, but
also as regards their size and color.  Here the rather pale spots
often occur  only singly, though they are never wholly absent.
On the palms and soles they are  usually harder to  find, since
on account of the greater thickness of the epidermis they are
more indistinct  here  than elsewhere; but careful examination
will always detect them even here, if the exanthem is elsewhere
tolerably profuse.
   The rubeolous  spots are generally discrete,  without  special
tendency to become confluent.  When this in rare  cases does
occur, it is not  general, but most marked in the face (Metten-
heimer), or upon the extremities.  In the first epidemic which I
observed, the  spots upon these  last were  frequently so closely
crowded  together, and were  so bound together by slender pro-
cesses that the  legs in particular  looked as if they had  been
sprinkled.   In the second  epidemic, with fewer observations,
the spots on these parts were more discrete, and the same  was
the rule also upon the palms and the soles.   The duration of the
spots was often  scarcely two, but sometimes four days.  In cor-
respondence with this the duration of the period of their most
marked development  was only very short; a half-day was per-
haps the longest, while it  often  lasted  only  a few  hours.
After the disappearance of the spots a very delicate and fleeting
brownish or yellowish pigmentation often  remained, or at times
none at  all,  even  when the color of  the eruption had  been
marked.   Desquamation was entirely absent in most cases;  in a
few there were traces of it referable rather to the dryness of the
skin, with  consequent  exfoliation, than  to the  exanthem, the
slight intensity  and duration of which may  explain  the ab-
sence of this symptom; it is never  lamellar, as in scarlet  fever. 
140
THOMAS.—RUBEOLA.
In rare cases the exanthem undergoes a further development on
certain portions of the body, especially on the back ; this  con-
sists in the formation, upon the hyperasmic spots, of  a varying
number of vesicles  resembling miliaria (rubeolas vesiculosa?);
they are nearly always of small size and often only rudimentary,
and very probably owe their origin to  external conditions, and
chiefly to the influence of a high  temperature  of the air  sur-
rounding  them.  In such cases there of course  occurs later a
correspondingly slight branny exfoliation.  Dunlop thinks  that
he has seen petechias at times; I have  never found this condi-
tion.
   The eruption was itchy in a few cases, as often  occurs in sen-
sitive children in the case of any other eruption.   The  symptom
of itching is very frequently alluded to in the older descriptions ;
among the more recent it is especially mentioned by Vogel.  An
eruption like urticaria,  such as sometimes occurs  on a few parts
of the skin, with an intense development of measles, I have never
encountered  in connection with  the  far more moderate  red-
ness of  rubeola, not even with such eruptions as itched.   Nor
have I, any more than all later observers, been able to perceive
any special odor of rubeola.   It is also  chiefly on account of
the similar odor that Heim regards it as a variety  of scarlet
fever.
   It  cannot  be overlooked that the exanthem of rubeola  pos-
sesses a great similarity to that  of measles, and this circumstance
alone is perhaps the reason that even skilful investigators have
regarded rubeola as a light form of measles.   But a more atten-
tive and repeated observation of the same soon  affords, in every
case, means to distinguish from each other, thoroughly and at
once,  the far larger majority of  cases of  the two diseases.  These
distinctive features  pertain chiefly to the size, form, and color of
the single spots.  The size of the  spots of rubeola is  decidedly
less, their form more round;  they are not so angular and in-
dented, nor so often provided with  processes;  owing to the very
slight swelling, they seem paler and more as if they had  been
sprinkled  over the surface.  If the characteristics concerned were
always and everywhere  so sharply pronounced as in the majority
of cases, no  one certainly would  ever confound measles  with 
SYMPTOMATOLOGY.
141
rubeola.   But it  is not so.  Measles are not  always perfectly
typically developed,  and in an exceedingly small minority of
cases of rubeola the spots are large, indented, and bright colored,
as in measles.  These require, therefore, for the establishment of
a diagnosis the consideration also of other circumstances ;  since,
however, these latter are not so patent as the exanthem, they are
frequently neglected, whence the great  confusion in the doctrine
of rubeola.

        Course of the Disease and Symptomatology.

   As to the course of the disease,  the observation  of children in
the incubative stage of rubeola has never shown any disturbance
of the health with increase of temperature or other appearances
of disease.
   For the estimation of the duration of this stage of latency, I
have only statistics of the interval between  the  beginning of
the disease of the infecting, and that of the infected child,—data
from which  the actual duration of  the period of incubation can-
not be reckoned, since the act of infection, which is unrecogniz-
able, need by no  means coincide with the commencement of the
disease in the  first child.  Noticeably often,  however,  in  such
cases, the second  attack follows in from two and a half  to three
weeks, and it is therefore  probable  that this is about the  dura-
tion of the incubative stage.   In favor of a definite duration of
this  period,  varying only  within narrow limits, is the  circum-
starice  that members of one family, after a  presumably simulta-
neous infection, also fall ill at exactly the same time.
   The most important symptoms, after those of  the skin, are
afforded  by the mucous membranes of the air-passages, and of
the  buccal  and pharyngeal cavities.   The former are almost
always  in  the condition of  catarrh,  less intense  than  with
measles,  yet so that  coughing and sneezing are rarely absent,
especially in the beginning of the disease ; at times  slight hoarse-
ness  occurs.   Towards the end of the attack these  symptoms of
irritation diminish by degrees,  with increase  of the  secretion.
Congestion of the conjunctival vessels, burning pain in the eyes,
and some photophobia are likewise frequently present.  A some- 
142
THOMAS.—RUBEOLA.
what congested condition of the mucous membrane of the palate
is never absent.  If this also appears in some measure confined
about single foci, instead of being equally distributed over the
palate, it is yet far removed from affording a so typically spotted
picture as the skin offers.  By the term mucous-membrane exan-
them, as this condition is frequently called, we must not under-
stand anything perfectly analogous  to the eruption upon the
skin.  Upon the skin there is no sign of hyperasmia  between the
individual  spots; the mucous membrane, however,  is more or
less affected as a whole, and the parts of it which perchance are
normal by no means preponderate over the reddened portions,
which, at least among the most numerous patients—the children
—are distributed most irregularly in streaks and spots.  In the
case of an  adult one would be more apt to find upon a univer-
sally  injected mucous membrane single spots of a  deeper red.
The pharyngeal mucous membrane is usually somewhat injected,
and at times even the tonsils are moderately swollen, in which
case a painful difficulty in swallowing would also probably exist.
The tongue constantly shows a white coating, pierced especially
at the tip by separate, swollen, papillas-like red knobs.
   In conjunction with the affection of  the mucous membrane of
the mouth  and  pharynx, we find, though not invariably, accord-
ing to the observations of different authors (Thierfelder, Metten-
heimer),  the lymphatic glands of the neck and nape generally
moderately but often severely swollen, so that they can even be
the cause  of moderate oedema of  the corresponding regions.
Slight swellings of the lymphatic glands are ■ also frequently
observed on  other parts of  the body,  although, as far as my
observations are concerned, they are by no means always present.
Chronic  swellings  of  the  lymphatic  glands are of  course very
frequently to be found  on children with rubeola.   According
to Thierf elder, swelling of the subauricular and superior jugular
lymphatic  glands was the only constant prodromal  symptom;
this swelling also could often be plainly seen,  even as late as the
third  week after the beginning of the  disease.   Suppuration of
the lymphatic glands has never been observed.
   Further anatomical disturbances, especially a marked partici-
pation of the digestive mucous membrane, or an affection of the 
SYMPTOMATOLOGY.
143
kidneys, as with scarlet fever, do not occur with normal rubeola.
The urine was, in all  cases in which I carefully examined it.
perfectly normal, and at all events free from albumen, only the
chlorides being  present  in  excess.  Emminghaus  observed in
one case of an adult with rubeola (together with  other unusual
symptoms pointing to a  vaso-motor neurosis) a light albumi-
nuria during the time of the exanthem.
   As a rule the exanthem is the first, or at least among the first
symptoms of disease ;  its appearance in a normal case is never
preceded by a prodromal stage of any long duration, as, e.g.,
in measles, where it lasts  three days.  If, therefore,  the eruption
shows itself during a feverish condition of some duration, the
case may be put down as an anomalous one.
   The friends of the patients often report  that these had begun
to show symptoms emanating from the mucous membranes, as
early as from half a day to a day,  rarely earlier (Emminghaus),
before  the  first  spots were  noticed ;  more  rarely we hear that
fever with  its associate  manifestations set in just before the
eruption.  According to  these reports, and to experiences in
cases which could be observed as early as during the stage of
incubation, the beginning of the eruption and that of the fever,
in the cases at least where there was any, must have been separ-
ated by only a  very short  interval, so short  that they might
very properly be regarded as coincident.  In  normal cases of
rubeola a prodromal stage of  more than at most a half  day
cannot be assumed ; the contrary constitutes an anomalous case,
and  proves that it is either  a  complication or a  secondary
rubeola, or evinces  at  least an abnormally great sensibility on
the part of the children attacked.  For the most part, however,
no increase of temperature at  all  is noticed at  the  beginning
of the exanthem, and it is improbable, according to the course
of disease  as  stated,  that  any  such was present before the
beginning  of  the observation.  Since,  now,  the assumption of
a prodromal stage relates only to the existence of  a feverish con-
dition before the exanthem, the  question  in regard to it  is in
these cases, and according to my  observations in the majority of
cases of rubeola, a thoroughly idle one.
   As regards the commencement of the  eruption,  I  could not 
144
THOMAS.—RUBEOLA.
notice, in cases to which I was  called early,  any appreciable
initial erythematous reddening of the  skin, such as is at times
found in the beginning of the acute exanthems.  Feverish chil-
dren,  perspiring under  warm  feather-beds,  were the only ones
to manifest  the moderate injection of the  skin  natural  under
such  circumstances.  Emminghaus describes  a barely percep-
tible,  slightly reddish coloration  of the  skin,  like erythema,
from which  within a few hours the characteristic roseolas were
produced.
   As regards the eruption of the exanthem upon the different
parts  of the body, rubeola follows the  same law as measles and
variola.  In all regular cases the face and scalp are primarily
attacked, and the eruption spreads gradually from here to the
other parts  of the body, first  to  the trunk and arms, finally to
the lower half, especially the legs.  This manner of extension
presupposes the same relations of the specific contagion  to the
vaso-motor  nerves  which exist in the other  acute exanthems.
As an unimportant anomaly it  may possibly happen that the
manner of extension will deviate  slightly from that stated; thus
the face in particular may be only subsequently affected.
   The  development of  the individual roseolas requires  but  a
very short time.   I have frequently been able to convince myself
beyond a doubt  that no trace of the eruption had been present
a half day before the appearance  of the well-marked infiltrated
red spots.   The spread of the exanthem  over the body is corre-
spondingly  rapid; it takes place, according to its intensity, in
from  one to  two days.   It  therefore happens with tolerable
frequency that the maxima of its development occur at varying
times upon the different parts of the  body.  I have repeatedly
noticed how the  exanthem was at its  height on  the face,  neck,
and upper part of the trunk, while on the extremities, especially
upon their  lower portions, scarcely any suggestion of the spots
was present.  And when at last, after from twelve to twenty-four
hours, they had reached here also the acme of their growth
(usually fainter than on the face), there was then often but little
still to be  seen upon the parts first affected;  the face was even
at times already quite pale  before the  maximal development
upon the extremities had been attained.  It is very different in 
SYMPTOMATOLOGY.
145
 measles, with its  essentially simultaneous  maximum over the
 whole body.  The different behavior of rubeola may,  I  think,
 be  partially explained by the  absence  of fever,  causing  neces-
 sarily a diminished congestion of  the skin.  This  congestion
 usually disappears entirely from  all parts  of the  body  within
 two or three days after its commencement  upon the  face.  The
 duration of the maximum upon separate parts  of the skin  is
 much shorter than in measles ;  it requires perhaps at most a half
 day, frequently only a few hours.
    The course of the temperature in rubeola is also very different
 from that in measles.  In most cases, at least at the time during
 which I observed my patients, I failed to find any increase, unlike
 Emminghaus, who found it as a constant thing.  If, therefore,
 any increase  existed, it  must have  been present  before my
 examination, and  have already disappeared soon after  the  out-
 break of the exanthem upon the  face,  which, especially  as the
 friends noticed none, is not very probable.  The majority of cases
 have no fever during the  whole course of  the disease,  and the
 presence of temporary fever, at any particular time, is usually
 due to  alterations in the temperature of the house, which may
 induce, for the time, a slight elevation in the temperature of the
 patient also.   In the minority of cases  fever, at times consider-
 able, may exist;  for the temperature  may rise from 2° to 4°
 Fahr.  above  what  is normal,  though usually only about  1.5°
 Fahr.   The elevation of temperature is either only an  initial one,
 disappearing by the  second day of the disease, or it may endure
 on  the second,  and even on the third day, at about the original
 height, in which case it may be ended by a speedy crisis, or may
 gradually sink to a normal condition.   By the  time the most
 essential symptom of the  disease, the  exanthem,  has  reached
 its  end,  the temperature in ordinary cases has become normal
 again ;  and this usually occurs, as stated, before, though  some-
 times after, the initial elevation.   In the normal course  of the
 temperature in rubeola there is  most certainly no maximal eleva-
 tion immediately  before  the crisis,  coinciding with a universal
maximum of  the exanthem as in measles.  Thus we see that the
course of the temperature during rubeola is a very  varying one,
for  there  occur cases  with normal temperature  throughout,
      Yoh. II.—10 
146
THOMAS.—RUBEOLA.
cases  with fever during the whole eruption, with a rapid initial
increase and a defervescence  with  crisis  or lysis,  and  finally,
cases with an initial fever and a defervescence concluded before
the expiration of the eruption.  The  difference from measles is
sufficiently characteristic  if we consider what has been stated
under that head.
   The course of the disease is, therefore, in the majority of cases,
somewhat  as follows: after the patients  have coughed  and
sneezed somewhat, and manifested slight photophobia for from
a few hours to  a day, one notices—either  at  once, or after the
attention has been excited by a gradually increasing temperature
—the beginning of the exanthem upon the face.  While now the
exanthem gradually spreads over the  whole body, the tempera-
ture, if  increased, becomes more or less speedily normal again.
In cases with only slight fever, the general health is frequently
not disturbed,  though when the fever is more severe and  per-
manent, slight  indisposition  may exist.   Children  generally
object to  staying in bed, and would even prefer to be out  of
doors.  In normal rubeola no  other local  sjanptoms of disease
occur except those  mentioned, namely, slight catarrh,  and  at
times some difficulty in swallowing, if much angina is present,
and so also, some transitory and slight disturbance of the appe-
tite.  Any nervous  symptoms, chills, heat,  thirst,  etc., occur
only with fever, in the manner usual under such circumstances.
   Although it may be affirmed with  certainty, from the course
and appearances of the disease, that measles and rubeola are two
specifically distinct infectious diseases, yet this is rendered even
more evident by the fact that  the two diseases afford  no  mutual
protection; both may occur in the same  person within a few
weeks of each other. Nor does rubeola protect  from  scarlet
fever, or vice versa.  This fact is testified to most conclusively
by the most different observers, and it can therefore be regarded
as beyond question.  Further proof is afforded by the epidemic
nature  of  the disease, especially of our epidemic of rubeola in
1872,  as  also by the fact that in the different families and
domestic  circles  infection always  produced the  same  disease.
Opposing testimony will be sought  almost in vain, even  from
the advocates of the identity of measles and rubeola. 
           COMPLICATIONS, PROGNOSIS, TREATMENT.         147

   After the disappearance of the exanthem, or even before it,
the slight symptoms of inflammation of the mucous membranes
subside,  either simply  or  with the formation of a moderate
amount of  mucus.  Convalescence, as  the rule, runs  an undis-
turbed course.

                       Complications.

   In several  reports statements may be found  in  regard to
complications  of  rubeola.  It is possible that  in such  cases at
times a confounding with measles has taken place; this  possi-
bility, however, does not invariably exist.  Such complications
were  chiefly severe attacks of  bronchitis and  affections of the
lungs of different natures, occasioned evidently by the specific
catarrh of  the upper air-passages.   As regards sequelas,  Thier-
felder observed  a febrile oedema of the  face, Emminghaus a
similar  disturbance upon the  legs, Mettenheimer a  nasopha-
ryngeal catarrh, permanent swelling of the tonsils, inflammation
of the gums, etc.

                         Prognosis.

   The prognosis  of simple primary rubeola is thoroughly favor-
able ; it is the lightest of the acute exanthems, as we see from its
almost feverless course.   Complications can, however, according
to their severity,  occasion grave disturbances, or even death.  A
light rubeola,  secondary to some other disturbance, and casually
appearing during its course, rarely exercises a  lasting or in any
way considerable  influence upon  the course of  the first disease,
and the prognosis of the same is therefore not affected.


                        TREATMENT.

   The treatment of rubeola is restricted to a suitable regimen,
protection  against exposure, bland diet, and keeping in  bed if
fever exists, cool sponging for any annoying  itching,  keeping
watch upon the catarrh of the  air-passages and of the pharynx, 
148
THOMAS —RUBEOLA.
  since this may call for active interference if at any time it should
  become severe.  Complications  are  to  be treated according to
  their nature, all the more because they rarely occur during the
  rubeola, but rather make their appearance long  after this has
*  run its course. 
SCARLATINA.
                          BIBLIOGRAPHY.

On the subject of Scarlatina, one may consult the works on pathology, skin dis-
    eases, and diseases of children, which are mentioned in the literature of measles;
    and among the works which appeared in the beginning of this century, the
    monograph of  Most  (Versuch  einer kritischen  Bearbeitung der Geschichte
    des  Scharlach,  Leipzig,  1826),  which  contains a  good compilation  of  the
    older literature,  as also  the  monographs  of  Ereysig (1802), Struve (1803),
    Reich (1810),  Pfeufer  (1819), Berndt (1820 and 1827),  Bohm (1823),  Seifert
    (1827),  Weisenberg (1828), Steimmig (1828), and Fischer (1832), are especially to
    be recommended.  Many single articles  have been written  on scarlatina;  the
    older ones may be found compiled in the second volume of  CanstaWs Hand-
    buch der medicinischen Klinik (Erlangen, 1847), p. 99.   Of the  more recent I
    refer, without attempting to be exhaustive, to the following, though of course I
    have had access to only a portion of the original writings.  Anonymous publica-
    tions, discussions, etc., may be found in CanstaWs Jahresbericht 1842. I.  p. 524.
    1844.  IV. p. 235 and 233.   1852.  IV. p. 20L—Virchow-Hirsch,  Jahresbericht
    1870.  II. p. 264. p. 259. p. 416.—Schmidt's Jahrb. der ges. Med. 4 Supplbd. p.
    116.  lip. 89.   18 p. 254.   25 p. 372.   39 p. 365.  153 p. 242.—Journal  fiir
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    59 p. 103.—Jahrbuch fiir Kinderheilkunde 1859.   II.  1. H. p 44. 1861.  IV.
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150
THOMAS.—SCARLATINA.
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151
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p. 250.—Palmer,  Wiirt.  Corr.  I.  1832.   p. 6.—Panck,  Schm. Jb. 52 p. 7.—
Panum, Wiirzb. Verh.  1851.   II.   p. 294.—Passow, Monatsbeil.  d. d.  Klin.
1869.   Nr. 25.—Paul, Cst. Jber. 1856.  IV. p. 300.— Paulicki, Memor.  1868.
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128.—Pride, V.-H.  Jber. 1869.  n.  p.  244.—Prior, Oest.  Jb. f.  Pad.  1870.
p. 223 d.  An.—Puchta, J. f. Kkh. 58 p. 58.— Puzin, J. f. Kkh. 6 p.  66.—Pyle, 
156
THOMAS.—SCARLATINA.
Ctrbl.  1871.  p. 655.—Raffi, V.-H. Jber. 1872.   n. p. 253.—Ranke, Jbch. f.
Khkde. 1869.  II.  p.  43.—Ratter, Schm. Jb.  1  Suppl.  p. 178.—Ravn u.
Aarestrup, V.-H. Jb. 1867.  II. p. 6—Redenbacher, Cst. Jb. 1802.  III. p. 252.
—Jbch. f. Khkde.  1861.  IV. BeiL p. 16.  Schm. Jb. 125 p. 18.—Reeves, Cst.
Jb. 1845.   IV.  p. 170.—Reevis, J. f. Kkh. 35 p. 320.—Rehn, Jbch. f. Khkde.
1869.  p.  439.—Reisinger, Oest.  med. Jbch.  59.  Bd.  1847.   4 Qu. p. 129.—
Reisland,  Diss.  Leipzig,  1870.—Renz, Wiirt. Corr.  1854.   XXIV. p. 225.—
Retzius, Schm. Jb. 116 p. 318.—Richardson, J. f. Kkh. 22 p. 253.—Ibid.  48 p.
295.—Schm.  Jb. 116 p. 125.—Richter, Wiirt. Corr. 1856.   XXVI. p. 248.—
Richter, Schm.  Jb. 159 p.  207.— Rieken,  Schm. Jb.  42 p.  113.—Riess,  Reich.
u. Dubois's Arch. 1872.  p.  240.— Ringer, J. f.  Kkh. 46  p.  99.—Cst. Jber.
1862.  IV. p. 126. 127.—Schm. Jb. 143 p. 154.— Ritter, Cst. Jber.  1864. VII.
p. 109.— Robert, Cst. Jber. 1850.  IV. p. 140.— Roberts, Arch.  f. Derm. 1871.
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7 p. 71.—Wiirt. Corr.   1837.  VII. p. 389.—Ibid.  1839.  IX.  p. 329.—Cst.
Jb. 1844.   IV.  p. 230.—Roser, Schm. Jb. 47  p. 295.  Pr.  Vjschr.  8  p. 51  d.
An.—Wiirt.  Corr. 1854.  XXIV. p. 209.—Ibid. 1855.  XXV.  p. 33.—Roger,
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Rohde, Med.  Jahrb. 1865.  XXI.  2. Bd.  p.  13 d. An.—Romberg, Schm.  Jb.
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1850.  IV. p. 137.—Sanderson, Jf. Kkh. 36 p.  460.—Sandwith, Schm. Jber. 1
p. 14.—Sansom, Schm. Jb. 148 p. 12. 153 p. 167.—V.-H. Jb.  1871.  II. p.
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    Compared with  other diseases,  the phenomena of which may
be of  an equally intense and decided character, scarlatina is dis-
tinguished by much diversity, not  alone in  regard to  the organs
which it affects  by preference, but  also in regard to the intensity
of  the disease as manifested in the individual case,  in the  mem-
bers  of a  family, or  in  the entire epidemic.   While  in one in- 
HISTORY.
159
stance  its character is so mild that the patient experiences but
little fever, and can move about in the open air without danger,
in others, the severest accidents may follow an apparently mild
course  like this ; and, lastly, the disease may be so intense from
its very onset that death inevitably results in a few hours. More-
over, during the continued intercourse of people with each other,
some individuals will  be  affected  in a mild  manner,  while others
will experience severe and very intense attacks;  and lastly,
others  again,  who live under the same  conditions,  will remain
entirely unaffected, though their neighbors may die rapidly or
undergo slow consumption with the most alarming symptoms.
   The symptomatology of  scarlatina is most  definitely charac-
terized, first, by a peculiar hypersemic exanthem of more or less
diffusion over the entire surface of the body;  and secondly, by
the usual occurrence at an early period of an angina of  variable
intensity.  The fever and nervous symptoms are less prominent,
but certain phenomena in the joints, serous membranes, kidneys,
and subcutaneous cellular  tissue are most characteristic.  The
entire  disease is the expression of an infection of the  organism by
a contagious specific principle.

                           HISTORY.

    In  ancient times  the character  of  the exanthem  was  not
deemed of sufficient importance  to demand an exact description
of it; hence we have no evidence of the prevalence of scarlatina at
that period.   Unequivocal epidemics  of scarlatina, in which suffi-
cient attention was paid to the exanthem, are not found before the
sixteenth century.  But even in the beginning  of the seventeenth
century,  Sennert refers  to  scarlatina as  only another form of
measles;  and Morton, at the close of  the seventeenth century, in
opposition to the then generally accepted  differentiation, main-
tains that both are nevertheless one and  the same disease,  differ-
ent only in the character of the exanthem.  It  is not remarkable,
therefore, if the same opinion was occasionally expressed even in
the nineteenth century.  But Morton's contemporary, Syden-
ham, established the specific nature of scarlatina by observations
made  during the epidemics  which occurred in  London from 1661 
160
THOMAS.—SCARLATINA.
to 1675, and thus laid the foundation of our positive knowledge
of this disease, which numerous observations of the eighteenth
century have materially extended.   It was soon recognized that
the character of  the epidemic  was liable to great variation; a
series of years during which the disease had been mild  and
benign  were followed by  others  which  manifested an unpre-
cedented malignancy, and  established the dangerous nature of
the scarlatinous disease.  Epidemics of scarlatina have retained
this peculiarity up to the latest times, especially in England and
Ireland, where, after an unusually mild appearance during the
beginning of the  nineteenth century, scarlatina, since the fourth
decennium, suddenly began to assume not only much more dan-
gerous forms, but also attained a very unusual  spread.   Accord-
ing to the statistical communications of  Farr, the annual mor-
tality from scarlatina in England  and Wales from 1848 to 1855
comprised  one-twenty-fifth and in some  years even one-twentieth'
of the entire death rate.   This also accounts for the many excel-!
lent writings on  scarlatina which have emanated from British1
authors.  Other  civilized states,   however,  have  also  suffered
much from scarlatina, for everywhere it is a chief factor in mor-
tality statistics.  From  Europe it  has extended over the rest of
the world, and the increased commerce of later times has given
rise to its appearance everywhere.  Thus it has been proved that
scarlatina first appeared in Iceland in 1827, in Greenland in 1847
and 1848, gradually extended over large  tracts of land in Asia,
and lastly, according to Maunsell and Cunningham, also attacked
India, which had  enjoyed immunity from it for  a long time ; then
it also appeared  in Africa,  but especially in America (where it
appeared first in the North in 1735, but spread very slowly, so
that South America experienced its first epidemic in 1829); since
1849  scarlatina has also  appeared in Australia.   Among modern
German authors must be  mentioned Hufeland, Kreysig, Stieg-
litz, Pfeufer, Berndt, Seifert,  Goden,  Fuchs, Jahn, Eisenmann,
v. Ammon, Hauff,  Heyfelder, Kostlin, Loschner, Rosch, Schnee-
mann, Kubik, and Steiner ; among the  French, Rayer, Roger,
Guersant and Blache, Barthez and Rilliet, Trousseau  and Noi-
rot; among  the English, Alison,  Bell, Bennet, Brown, Gillespie,
Graves, Kennedy, Miller, Murchison, Richardson, and Wood. 
ETIOLOGY.
161
                          ETIOLOGY.

   It is indisputable  that  the cause of scarlatina is a peculiar
substance which  is transferable from the patient to  the unaf-
fected individual.  Though its existence has been  disputed by
various authors, their reasons have  not deserved earnest consid-
eration.   The proofs in support of the contagiousness of scarla-
tina rest chiefly on the fact that the disease breaks out among a
few or many persons in a locality  only after the material, which
must be looked upon as the cause  of the malady, has been intro-
duced into the place—either through  the medium of  any sub-
stance to which it adheres or directly by a scarlatinous patient—
and then as a rule only a very short  time after the introduction ;
and further, that  these newly affected individuals during their ill-
ness likewise produce a substance identical in its properties to the
one which originally infected them.  But not all individuals in a
locality become affected, for the susceptibility is not universal,
nor equally developed in  those susceptible.   When,  therefore,
scarlatina occurs  in a house  or family, short  intervals elapse be-
tween several cases, and the nurses and friends of scarlatinous
patients are also much more liable  to become infected than others
who are perhaps equally susceptible, but remain distant from the
morbid  atmosphere.   It thus happens that  numerous cases of
scarlatina occur  when, in  a children's hospital,  scarlatinous
patients are transferred to the  general wards,—an error which
was frequently  committed in former times.   But where the con-
tagious principle  has never obtained  ingress, there also scarlatina
has never made its appearance.  The immunity of certain isolated
regions,  especially islands,  from  this disease up to the time when
the ingress of the contagion gave rise to a diffused epidemic, fur-
nishes proof for  this assertion.  Other regions became infected
only after European commerce had brought over the contagious
principle.   Isolation of scarlatinous patients, especially in chil-
dren' s hospitals, has likewise prevented the further spread of the
disease, and the same result has been attained by the proper dis-
infection of articles which may have been in the same atmosphere
with the patients.
     Vol. IL—11 
162
THOMAS.—SCARLATINA.
   Lastly,  we  have further evidence of the contagiousness of
scarlatina in the communicability of the poison from a patient
to a healthy  individual by inoculation.  This fact, of course,
needs further elucidation.  Inoculation was first performed with
the object  of  generating a milder form of  the  disease than the
inoculated  individual would have experienced naturally.  Wil-
liams, however, states  that this object was not attained ; indeed,
that the generated disease was as violent as that of spontaneous
origin, and that the operation was not  repeated after this  expe-
rience.   Rostan speaks of cases in which  the  scarlet  eruption
appeared seven days after inoculation.  Miquel reported to the
French Academy that  he had inoculated a number of children,
who had never had the disease, with the contents of vesicles from
scarlatinous patients ;  thirty hours after, there  appeared at  the
place of  inoculation a red areola, which corresponded in  every
respect to  the scarlatinous eruption ; this redness increased for
three days, and disappeared on the fifth day ; the inflammation
was not  traumatic, for a second inoculation in the same indi-
vidual had no effect.  It appears, too, that children who had
been successfully inoculated were  not affected  subsequently,
when there was abundant opportunity for  infection.   On  the
other  hand, Leroy denies that the inoculated substance fur-
nishes security;  but then he  experimented on himself alone,
and may not have had any predisposition.  According to Guer-
sant, Petit-Radel has  ineffectually attempted the inoculation of
scarlatina by introducing scales of epidermis under the skin of
individuals not  previously infected.   Stoll,  on the other  hand,
has performed this experiment with success.
   Such  experiments,  in  connection with clinical observations,
leave little doubt but that the poison is present somewhere in the
skin of the patient.  It is probably also present in the pulmo-
nary exhalation, for contact with the morbid atmosphere alone
suffices to cause infection.  Other secretions may also be the
carriers of the contagion, as,  for instance, the nasal and pharyn-
geal secretion, perhaps also the urine.  The view that the poi-
son  circulates in the blood is  supported by the fact that chil-
dren have been born with scarlatina.  Moreover, Coze  and Feltz
introduced a small quantity of scarlatinous blood under the skin 
ETIOLOGY.
163
of sixty-six rabbits.  Of  these, sixty-two died in the course of
from eighteen hours to fourteen days, having had high tempera-
ture, then diarrhoea and emaciation, and the remaining four only
recovered after  an intense fever.  An examination of the  blood
revealed a peculiar aggregation of the  red blood-corpuscles, so
that then- contour was lost, and the margins of the majority of
the isolated corpuscles were indented ;  in addition, punctate and
rod-like, active bodies (bacteria and bacteridia) were found, just
as in  the blood of  the scarlatinous patients who  had furnished
the inoculated matter.  According to Hallier, the blood  of scar-
latinous patients contains micrococci in great abundance,  either
single  or in  colonies, within the blood-corpuscles  or on their
external surface;  occasionally they are  also  found as  short
chains and germinating.   Riess examined  the  blood  freshly
drawn from a vein  in the arm of a patient dying of scarlatina,
and found that '' the serum was filled with  an infinite  number
of small, rapidly oscillating bodies, which, under a magnifying
power of five hundred diameters, appeared  as  dark points be-
tween  the  groups of blood-corpuscles.   In addition,  there were
also rod-like formations,  which at many places were recognized
as being composed  of three or four or more of these first minute
bodies disposed in  rows."  Riess injected a few drops of this
blood under  the skin of the back of a  rabbit, with the effect of
developing like small bodies  in its blood, and causing its  death
in twenty-four hours.  Further inoculations made with this rab-
bit's blood gave rise to identical results.
   These experiments, therefore, render it highly probable that
the contagions  principle  having entered the blood,  is dissemi-
nated by it throughout the body, and  further, that it stands in
some very  intimate  relation with these finest spores of micrococ-
cus.  Hence it is not remarkable that  the exhalations from the
skin and lungs, and the secretions should contain  the contagious
principle.  The  observation of Zengerle, however, that the per-
sons who applied leeches,  and who were often much defiled with
the blood of scarlatinous patients, did not take the disease, while
the mere spectators or visitors became affected with scarlatina,
is no  argument against the view that the blood is the essential
seat of the contagion.  For, aside from  the fact that only those 
164
THOMAS.—SCARLATINA.
who are predisposed will become infected, while those who are
not can expose themselves without danger, it is certain, as Ziil-
zer has proved, that the contagion  of scarlatina can  no more
enter the organism through the intact epidermis than does the
poison of variola.
   The shortest contact with the contagious  atmosphere of the
sick-room may suffice for infection.   According  to  Palante,  a
mother,  after remaining only  a  moment with  a scarlatinous
patient, immediately  returned  home,  a distance of about six
miles, but communicated the disease to her children,  in whom
it developed  a few days after.   Hennig tells of a child who
was affected  four  days  after having been but a  short time in
the company of another child who  had  been taken sick  with
scarlatina six weeks  before.  Kostlin  was also convinced  that
at times a very short contact  with a  patient was sufficient to
cause infection.  On  the whole, however, the volatility of  the
contagion of scarlatina seems to be much less than that of mea-
sles, and, therefore, spreads less rapidly throughout  a  dwelling
than the latter; on this account the isolation of those in a family
who are unaffected, if established at a sufficiently early period
and properly carried out,  is frequently effectual in  preventing
a further  spread.
   It is an undoubted  fact that a dilution of the  contagious
principle  by  attentive ventilation of  the sick-room very much
diminishes or entirely removes the opportunity for infection.
   The view that scarlatina can be  transmitted  to  unaffected
individuals through the medium of  substances which  have re-
mained in the morbid atmosphere, is  indisputably proved by
numerous examples.  Many cases of so-called spontaneous ori-
gin must be explained in this manner.

   Thus Richardson attributes the infection and death of a child and its mother to
a letter which the former had conveyed to the latter from a house several miles dis-
tant, in which scarlatina had prevailed.  Petersen attributes the infection of a young
girl to the same cause; Maclagan saw a case in which the medium of communication
was a woollen shawl, in which a scarlatinous patient had been wrapt; Moore main-
tains that a  piano, which had stood in the sick-room, was the only means o£ com-
munication.   According to Ogle, the contagion which gave rise  to a case after the
epidemic had subsided, was spread  by soiled linen; in another case, two old rock- 
ETIOLOGY.
105
ing-chairs, with defective cushions, alone could have been the medium,  v. Hilden-
brand, without the agency of scarlatinous surroundings, became infected by wearing
a coat which had been worn formerly upon visits to scarlatinous patients and had
been stored away.  The first  case of scarlatina  in the Bahama Islands, that of a
child  six years old, who had been successfully isolated on the continent, occurred on
December 20th, after the patient, according to Duncome, had remained in a  region
entirely free from the scarlatina  poison since October 13th ;  infection, consequently,
was probably caused through the medium  of materials which  had been brought
over from the continent.  In  one instance Mason Good thinks that  a box  of toys
was the means of transportation.  Murchison confidently believes that in a few cases
a letter or  a lock of hair was the carrier,  v. Tscharner saw a case in which the
medium was a piece of bedding.  In an otherwise obscure case, Behrend's attention
was drawn  to a bed-pan, which  had  been used  by a  scarlatinous patient fourteen
months before.  Heslop calls  attention to the necessity of separating the ordinary
washing in a hospital from  that which is infected, as he has seen a non-observance
of this  rule followed by a spread of scarlatina  through the whole house, and has
also seen it disappear as soon as this rule was obeyed.  The spread of the  disease,
therefore, may be prevented by attentive ventilation and cleansing  of all infected
substances, especially the clothes and bedding.

    Considerable attention was but recently paid  in England to
the  question whether  milk could become the transporting me-
dium of the scarlatina contagion.

   Bell ascertained that several cases of scarlatina had occurred in all houses,—with
the single exception of one  occupied  by old ladies,—to which milk had been con-
veyed by a peasant and her son, the milk-boy, who had both undergone attacks of
scarlatina, and he therefore asks, whether the milk, the receptacle, or the boy was the
medium.  Taylor observed that one of the first severe cases which initiated an epi-
demic, occurred in the house of  a milkman,  whose wife milked the cows; the milk
being supplied to about twelve families in the city.  In six of  these,  cases of scarla-
tina occurred in rapid succession, at a time when the disease was not epidemic, and
without any communication-having taken place between those that became affected
and the person who  had brought the milk.   It is very probable that in this instance
the milk was  the carrier of  the contagion, as,  previous  to its  distribution to the
several consumers, it had stood in a kitchen, which before had been used as a hos-
pital  for scarlatinous patients.

    It  is  an  indisputable fact  that unaffected  individuals  who
have nursed  scarlatinous patients can  spread the contagion, prob-
ably through the medium of their  clothing.

   I observed a case in which a nurse  coming directly from a scarlatinous patient
,communicated  the disease, in  the short space of three hours, to a  child who had 
166
THOMAS.—SCARLATINA.
 almost recovered from a tracheotomy.  Willan observed a similar case. According to
 Williams, Sims relates several cases in which midwives communicated the disease to
 lying-in women.  Many physicians made statements to Murchison, which convinced
 him that they had transferred the disease by their clothing; this circumstance led
 obstetricians in active practice to avoid patients with scarlatina.  In the above-men-
 tioned case of Palante, a mother communicated the disease to her children, notwith-
 standing her short sojourn in the infected dwelling and her immediate journey home.
 Pyle tells of a healthy female  teacher, who, without being affected herself, commu-
 nicated the disease at home by the dress which she had worn while nursing a scarla-
 tinous patient.  According to Rehn, a grandmother transported the contagion from
 Stuttgart to Hanau, thus infecting her grandson.  Pons carried the contagion into a
 small city.   According to Kostlin, a child who had been strictly isolated, being
 convalescent from measles,  was taken sick with scarlatina (may the physician have
 been the carrier ?). Michel saw a family taken sick upon the return of the father from
 an infected dwelling, after a seven hours' journey.  Another physician reports that
 the contagion was carried five  miles by clothing (Arch. d. Vereins f. w. Hkde.).   In
 the epidemic near Eidsvold, in Norway, observed  by Thoresen, the intense cold of
 winter .prevented the children from leaving the houses, and the majority of infec-
 tions (in twenty-four places) could only have taken place through the medium of
 healthy individuals.  Zengerle states that a healthy woman, after a visit to a scarla-
 tinous patient, communicated  the disease to her daughter, who was the first patient
 affected in the whole city.

   Just as healthy human beings may be the  carriers of the conta-
 gion, so also can the poison of scarlatina be communicated to sus-
 ceptible individuals through  the medium of animals.   It is also
 believed that animals may be affected with a disease correspond-
 ing  to scarlatina in man.  Ziirn says that Spinola has observed
 it in the horse ; others assert its occurrence in dogs, cats,  swine,
 and other domestic animals.  Thus Heim observed that a dog
 who  had lain  in the same  bed with  a scarlatinous child, was
 taken with fever, followed by scarlatina and desquamation ; and
it is stated in the Transactions  of  the  Saint Petersburg Medical
 Society that a  cat had  a  general  characteristic eruption, with
angina.   Letheby speaks of the frequent occurrence of scarlatina
in swine,  and Krauss relates that during the epidemic of scar-
latina at  Walddorf,  young   cattle  were affected with  cervical
enlargements.   However, it is still an open question whether the
contagion of scarlatina really engenders these  diseases  in ani-
mals,  and whether these, in turn, may infect man.
   The scarlatina contagion has  an extraordinary tenacity. 
ETIOLOGY.
167
   Murchison often  found that when a  family  had left  an infected dwelling,
fresh cases of scarlatina occurred upon its being reoccupied, after several months ;
Benedict tells of an instance where several children were affected immediately after
their return to a room in which a death from scarlatina had occurred two months
before, although it had been thoroughly cleaned and ventilated; Richardson reports
that the contagion had become so fixed in the straw roof of a house, that, five months
after the first case had occurred, children became infected when they attempted to live
in the room under the infected roof; v. Ilildenbrand's coat retained its contagious-
ness for one year and a half. According to Prior, the remaining children of a mother,
who had lost two out  of three  affected with scarlatina, were taken sick after the
clothing of one of the deceased was worn, though the residence had  been changed ;
Guersent,  Hennig, and Pyle  noticed that the contagion retained its integrity for
several, Ogle for at least ten, and Fitzpatrick  for nine weeks after the disease had
subsided in the first child.  All these observations indicate that the contagion is not
a volatile gas, but a solid material, which easily and firmly adheres to  other sub-
stances, so that, on account of the resistibility and minuteness of its elements, the
ordinary means of purification and cleanliness  are  inert, and continuous and ener-
getic ventilation can but imperfectly accomplish  its removal.  According to Ilil-
lier, it is only destroyed by heat at the boiling-point; Thoresen states that intense cold
does not affect its vitality.  In this connection Henry's experiments are noteworthy :
he caused unaffected children from six to thirteen years of age to wear the flannel
jackets of scarlatinous patients, after these garments had been subjected to a dry heat
of 212° Fahr.;  notwithstanding the facility with which the contagion is carried by
woollen garments, no infection  followed.   From this  we may conclude that it is
destroyed by  heat, a fact which, according to  Behrend, was also  proved in  Berlin,
where the garments were kept in a close and heated chamber,  until  it had cooled,
with the result of destroying the vitality of the poison.

    Observations have proved that the duration  of the incubation
(latent period,  period of germination) of scarlatina can  vary,  and
certainly is less constant  than that of measles and variola.   Few
but  reliable  reports  show that its period of  incubation may be
very short, differing in  this respect from the other two diseases.

   The best known case is one which Trousseau relates.  An Englishman, travelling
with his daughter towards London, from  Pau, where scarlatina was not prevalent,
arrived  in Paris at the same  time with another daughter, who, on  her way from
London, had contracted scarlatina.  Both girls lived in the same room, and twenty
four hours  after meeting each other, the daughter who had come  from Pau was
also  attacked.   In Hanau,  where there   was no scarlatina,  Rehn saw a child
attacked two  days after its grandmother had  returned  from nursing a scarlatinous
patient in Stuttgart.  Russegger saw a child, who had visited a scarlatinous patient
at  noon, taken  sick at night; in another instance,  three children  visited  a sick 
168
THOMAS.—SCARLATINA.
friend in a neighboring village: two of these children took  scarlatina two days
after, and the third was affected on the third day.  At Wangen, where previously
no  case  of  scarlatina had occurred, Zengerle reports that a girl, ten years of  age,
was taken sick two days after her mother had visited a family sick with scarlatina
in a neighboring town.  Hennig relates the case of a child, in which the incubation
did not extend beyond two to three days at the furthest. Loschner states that a boy,
four and a half years old, who entered the hospital for the treatment of a sarcoma,
was attacked one and a half days after his admission, and that the hospital could
have  been the only source of infection.  Murchison  tells of a lady,  twenty-two
years old, who was taken sick in less than twenty-four hours from the time at which
a visit had communicated the contagion ;  also of a girl, twenty years old, who was
taken sick after a like short period from nursing a scarlatinous patient;  of two girls,
twenty-one and twelve years old  respectively, the former being taken sick after a two,
and the latter after a three days' sojourn in an infected dwelling ;  of a boy, eleven
years old, who was taken sick a day and a half after  a visit of only two hours' dura-
tion to a house in which there were scarlatinous patients; finally, of a man,  twenty-
two years of age, who  became  affected three  days after a visit to a  scarlatinous
patient.  Voit recalls the case of a child, in whom the incubation lasted three days
at most.   In a case observed by Marson, to which Murchison  refers, the infection
must have taken place between twenty-six and a half  and thirty-one and a half hours
before the beginning of the attack;  the stage of incubation could not therefore have
exceeded one day and  a  half at most.   Fleischmann observed the infection, by
scarlatina, of two  variolous children,  who  had  been placed near the scarlatina
ward,  and  in each case  three  days  intervened between their admission to  the
hospital—i.e.,  the earliest possible period of infection—and the beginning of the
disease.  With  like certainty,  however,  the occurrence  of  a longer period of
incubation has  been established.  Gerhardt reports that a man was attacked with
scarlatina four days after an abscess from which he suffered had been  opened with
a knife  used for  the same  purpose in a scarlatinous patient a few hours before.
Murchison saw a girl, four years old,  taken  sick  four days, and a youth, sixteen
years old, taken sick four  and a half days  after having entered an infected locality;
also a man, forty-four  years old, taken sick  five days after visiting  an  infected
locality.   Gunz relates a case  in which the  incubation  lasted three days, the
infection being traceable to a  hospital;  the duration was the same in a case of
Henoch's, that of a girl who had remained with the  infected brother only up to the
commencement of the disease, and  then had been immediately isolated.   In  this
and similar instances, we cannot, of course, overlook the circumstance that the indi-
vidual secondarily affected may have been  infected at some other time than when the
disease commenced in the first patient; for instance, during the period of  incuba-
tion, if we allow that the contagion may be produced at that time, and then, also,
the contagion may have been derived from an older source, such as the clothing or
other articles used by the first patient.  In this consideration only those cases are of
positive value which can be  proved to have had but a single contact with the conta-
gion.  Pons calculates the period of  germination with certainty at four days, in  a 
ETIOLOGY.
169
case to which he had himself brought the contagion; Thoresen, in his above-men-
tioned observations, estimates it at from two to four days; Zehnder, at from two
to five days; Moore reports the case of a woman whose period of incubation lasted
seven days, also one of a girl with a period of incubation of not quite five days.

   A longer period of incubation was contended for by Veit, who
placed it at  from twelve to fourteen days;  by Paasch, who saw
the brother of  two infected children taken sick twelve days after
they had manifested symptoms of the disease ; by Boning, who
observed  an interval  of fourteen days under similar circum-
stances.   Gerhardt was also  disposed to  accept  an interval of
from twelve to thirteen days, and assures us that very accurate
observations made by his assistant, Reinhold,  indicated an inter-
val of eleven  days.   Now,  although the possibility  of  such a
long interval cannot be denied, I am nevertheless inclined to the
assumption,  on account of  the great majority of those cases
(occurring in families) which were followed by secondary infec-
tions after from four to seven  days,  that  the latter period is
the  normal,  or at least the  most frequent interval,—to  which
view Gerhardt, in his latest publication (Arch. f. klin. Med. XII.)
also inclines,—and that, on  the other hand, shorter or longer
intervals must  be looked upon as exceptions to the rule.  Some
cases, in which the interval  is longer, might be classified with
those uncertain cases in families where from  three to five weeks
intervene between the several attacks, and these are certainly not
dependent on  an uncommonly long  stage of incubation,  but
rather on a retardation of the necessary individual susceptibil-
ity ; these cases also form the transition to those in which a still
longer interval elapses between the affection of different members
of a family,  and where  the action of  a new source of infection
is  necessary  to call forth the later attacks.   The few successful
cases of  scarlatinous  inoculation  would  indicate a moderately
long duration of the period of incubation ; thus that of Rostan,
cited by Moore (a supporter  of the seven days'  view) in which
there was an interval of seven days.  The  difference in the period
of incubation of scarlatina from that of varicella was illustrated
in a  very interesting manner in Hirschsprung's case: a girl, eight
years of age, who was ill with both diseases, also infected another
girl with both ; but in the second girl varicella appeared  eleven 
170
THOMAS.—SCARLATINA.
days subsequently to the scarlatina, which period corresponded
to the short incubation of the latter disease, in contrast to the
interval of about seventeen days of the former.   I think that the
latent interval of scarlatina is best ascertained by the observation
of such  cases  as have derived the contagion from  a common
source, and in which the disease manifests itself simultaneously ;
this is best accomplished by observing  the disease as it occurs in
families.  In these cases a  short interval  of from four to seven
days generally elapses between the commencement of the affec-
tion in the first case,—i.e., probably the earliest period at which
the other members can become infected—and  the time at which
the first symptoms develop in them.  Observations like those of
Veit and Boning, in which the interval lasted from eleven to six-
teen days—the average period therefore comprising about four-
teen days—have been reported less frequently.   These observa-
tions,  therefore, which perhaps might be explained as due  to
variations in the contagiousness of the disease and in the indi-
vidual  susceptibility, cannot alter the rule, that the period of
incubation of scarlatina has an average duration of from four to
seven days.
   In this  variation of  the incubative period scarlatina differs
from all other acute exanthemata, and  the cause which occasions
it is unknown.  It has been asserted, indeed, that it is dependent
on the intensity of the epidemic, the severity of the disease, the
continued exposure to the contagion, the unfavorable condition
of the infected individual;  but all these assertions are not sus-
tained  by evidence, nor do either measles or  small-pox furnish
an analogy under similar circumstances.   Though it cannot be
denied that an intense case may develop a more powerful conta-
gion than a very mild one, I believe that this variation should be
ascribed rather to the degree of the individual susceptibility than
to the intensity of the contagion; as will be shown later, the
individual predisposition to scarlatina  is less  general and tem-
porarily more  variable  than  in  the  case of either variola or
measles.
   The question, at which period of his affection a  scarlatinous
patient  may communicate  the  disease, and the duration of this
capacity of infecting others, is an important one, and difficult to 
ETIOLOGY.                       171
 answer; in the first place, on account of the great difference in
 individual susceptibility—for only where this exists can we prove
 the contagiousness of the poison, as long as our  chemical and
 microscopical resources are inadequate to detect it in the secre-
 tions and  excretions of the patient—and then, because of the
 above-mentioned extraordinary tenacity  of the scarlatina poison
 and its great power of clinging to objects.   The last-named pro-
 perties will usually render it impossible  to determine whether an
 infection by a scarlatinous patient during  the last stages of the
 disease proceeded from a contagion which was generated at the
 time  of  infection, or from one which was produced at an early
 period of  the disease, and which, owing to its tenacity, had
 retained its  vitality up to that time.  If we simply follow the
 facts which are verified daily in regard to the incubation, namely,
 that  single cases in a family, into which scarlatina has been car-
 ried by one of its members, as a rule manifest symptoms of the
 disease  a  few days after the affection  of  the  first  patient, we
 should incline to the assumption that  scarlatina  possesses the
 proper!}' of infection  from  its  commencement.  This  fact is
 proved by Trousseau's case, if we suppose that the contagion was
 not  carried  from London in the garments of the daughter who
 was first affected, which,  of course, is possible though not prob-
 able.  In like manner, the case of Marson is fairly above suspi-
 cion,  where the  boy who  was affected second visited  a house in
 which the first  boy had  just been taken  sick.   In this  respect
 scarlatina  has an analogy in variola.   A patient, in  the prodro-
 mal stage of variola, sustained a severe injury, and underwent an
 amputation.   Without being aware of  the variolous infection,
 Schaper availed  himself  of pieces of skin from the amputated
 limb, for the purpose of transplantation, with the result that the
 individual on whom the latter operation was performed became
 infected with small-pox.  Now,  just as  the apparently healthy
 portion  of skin here used contained the variolous contagion, it
v seems probable that the scarlatinous contagion is also dissemi-
 nated throughout the tissues  of  the body in the commencement
 of the scarlatinous disease, and that they are capable of produc-
 ing the contagion at that time.   On the other hand, however, we
 must  bear in mind  that when  scarlatina  appears in a family 
172                  THOMAS.—SCARLATINA.
and the well are  immediately  separated and isolated  from  the
affected individual, it is often noticed that no other cases  occur,
though  this fact cannot be explained on the ground of an  ab-
sence of susceptibility to  scarlatina, for a fresh opportunity for
infection will often call forth the disease in the others.  It is dif-
ficult to explain this phenomenon other than by the assumption
that in the first stages the disease is endowed with only a  mode-
rate contagiousness.   The view of Girard,  therefore,  that infec-
tion can only take place  on the first day of the fever, but  not
later, is not tenable ; for daily experience  teaches that scarlati-
nous patients  produce an  abundant contagion and may cause
frequent infection during  the  bloom of the eruption, as well as
in  the  later stages of  the disease.  The contagiousness of  the
post-exanthematic period is usually ascribed to  the scales of epi-
dermis which separate  during the process of desquamation; but
it seems to me that there is not  the shadow of evidence to prove
that  the contagion is  contained in them either exclusively or
even chiefly; for it may be  presumed that the  contagion enters
from the blood  into  all secretions and excretions of the patient.
Volz, in fact,  totally denies the contagiousness of the epidermal
desquamation.

  In this connection a report may be of interest, which  states that scarlatina
occurred  in a Berlin infirmary, though the reception of scarlatinous patients was
prohibited; dropsical children, however, who had had scarlatina, and, if I remem-
ber rightly, had passed through the stage of desquamation,  were received into the
house without question. In  spite of thorough cleansing, etc., the  contagion was
produced at this late period.  Hamburger reports  a similar  instance: a boy, thir-
teen years old, was taken sick with scarlatina followed by dropsy, and, three weeks
after the commencement of the latter, was taken several miles to his home.  Here he
remained six weeks, when  death ensued.  One week before it, his brother,  four
years old, was taken sick,  and soon after other persons  in the neighborhood. It
thus appears that the first patient was able to develop a contagion in the third month
of the disease.  Bokai, on the contrary,  does not consider  dropsical scarlatinous
patients infectious, if after a bath they are allowed to remain in the common room.

    It is  certain  that  the  contagiousness diminishes as health
becomes restored ; but  it is impossible to say when it ceases.
    The  individual predisposition to scarlatina is much more
general  than that to  measles and variola, and in no manner iden- 
ETIOLOGY.
173
tical with the same.  Thus Roser observed that a girl,  six years
old, did not  infect her twin brothers with measles,  but that the
latter communicated scarlatina to the sister.   While almost all
individuals are affected by the contagion of measles and  vari-
ola—in  the latter case, where they have  not been vaccinated,—
many individuals remain exempt from scarlatina, notwithstand-
ing manifold opportunities for infection.   This is well illustrated
by an observation,  among others, of Heyfelder's, who found that
during a simultaneous epidemic of measles and scarlatina, many
convalescents from scarlatina became affected with measles, while
very few convalescents from measles were  affected with scarla-
tina.   Epidemics in which, as in the case of measles,  the entire
population,   except  those  persons  who  had  had  the  disease
before, has been affected (as this occurred in the village of Thal-
heim (population of 1,300 inhabitants)  where all the children
and many  adults  were affected with  scarlatina or allied dis-
eases),  are exceedingly rare.  An intense family predisposition is
more frequent,  showing itseli by numerous and severe attacks
of scarlatina  among the several members of a family,  as  soon
as one  infection has taken place in it;  the cause  of this  is as
obscure as the nature of  the predisposition.   This fact is a suffi-
cient cause of anxiety for the remaining members of a family,
when two or  more children are attacked in quick succession.

   Harlin reports that the parents and nine children of a family were attacked
within a short period. Mfiller reports that in a family of eight children, four out
of five attacked died after  two or  three days.   In a family under Loschner's
care, all the children, five  in  number, died within a fortnight; according  to Cope-
man, five children  in one family were attacked so suddenly, and four of them
with such severity that it was suspected  they had been poisoned; these four died
and the disease was explained by the regular course of scarlatina in the fifth case.
According to Corson, all the members of a wealthy family, composed of the parents,
eight children, and two grandchildren, who lived in the healthiest locality, were
attacked with scarlatina, and of these twelve individuals, seven  children, from one
and a half to seventeen years  of age, died within six days.  Fitzpatrick states that
the immediate isolation of  four children upon the attack of the fifth child did not
save them, for all died within a short time.   According to a notice in the Wiirt.
Corresp.-bl., 1857, p. 183,  three children were attacked and died  within two days
after an older sister with scarlatina had been received into the  house.  In some
families Fenini saw the disease manifest an exceptional severity. 
174
THOMAS. —SCARLATINA.
   Fortunately such an intense family predisposition is  excep-
tional.  A greater intensity of the influencing contagion does not
explain it, for the infecting cases are frequently of a mild char-
acter,  and we often find very  benign attacks amidst the most
malignant, both having evidently originated in the same conta-
gion.  On the other hand, there are  families in which the sus-
ceptibility to scarlatina seems to be entirely absent ;  such indi-
viduals become the carriers of the  contagion, without being
affected themselves.
   When scarlatina enters a household,  it is  common for only
one  or several  members to  become affected, while the others,
though not separated from the sick, or at  least not isolated with
any  particular  care, remain entirely unaffected.  Occasionally
this  immunity lasts through life in some individuals, in others
only for a longer or shorter time.

   Thus Moore reports that a woman who had nursed her daughter with great atten-
tion, during an attack of malignant scarlatina in 1834, was not then affected, while in
1843 she underwent a very severe attack, having been infected by her two younger
children, who had been born since; he also tells of a clergyman who was not infected
by his sister who had  scarlatina, though he nursed her personally, while one year
later he was infected after visiting other patients, and died. v. Hildebrand had cer-
tainly attended numerous scarlatinous patients before he  took the disease himself.
The influence of individuality is so powerful that in a family, children living under
the same conditions, having the same parents, and exposed to infection in the same
epidemic, may either remain well or become infected in the most variable manner.

   When epidemics of scarlatina appear  in  a population which
has enjoyed immunity from it for a long time, the disease does not
always find a particularly susceptible population ; in this respect
scarlatina differs  from measles.  Thus Hauff, in his description
of the  epidemic of 1855, states that it was rare for more than one
child to be  affected in a  family,  though the  disease had been
absent for thirteen years.  At any rate, it seems as if.  at certain
times,  some individuals are exempt from the predisposition to
scarlatina, but that gradually, under the influence of the con-
tagion, it is again developed.  It often happens that individuals
who have undoubtedly been exposed to the influence of an appa-
rently intense contagion for a  long time, are  attacked uncom-
monly long after there is opportunity for  infection. 
ETIOLOGY.
175
  Thus, according to Zehnder's reports, among thirty-two families in which he
attended more than one scarlatinous patient, from two to four of the members were
attacked at the same time in seven families; in sixteen  families, from two to five
members, within from five to seven days; in the other families the  cases com-
menced after intervals of one month or even  three months.  Majer (Illm) has also
observed the latter interval in one family.  I observed the case of a boy, who had
remained three months in a close room with his brother, while the latter underwent
a very severe attack of scarlatina, and who was only attacked with scarlatina upon
accompanying his brother to the country, where scarlatina did not prevail, and
where they had no intercourse with  sick  people.  Evidently the susceptibility of
the second brother was absent during the commencement of the disease in the first,
but  had developed during the continuance of the disease,—which was marked by
dropsy and uraemia—had continually increased, and was finally called into activity
by an insignificant circumstance (the contagion in the long-discarded Sunday clothes
of the first boy ?).

    The  fact that scarlatinous patients have been transferred to
the general  hospital  wards without  detriment to  the  other
patients, must  be  explained by the limited  predisposition to
scarlatina,  or,  more frequently,  by  its entire  absence  in many
persons; this also accounts for the  diminished  contagiousness or
entire absence of it in the last cases of an epidemic which has
appeared in a separate congregation of individuals.
    The  predisposition to scarlatina seems to be extraordinary in
those patients who are affected so intensely that death ensues in
a short time.   In some cases the continued presence of the con-
tagion may  have caused  its  exaggeration.   This  intensity  is
found especially in  young  children,  but  occasionally also in
adults.   Thus, Roser reports the case of a girl, whose sister was
undergoing an attack of scarlatina ; during the day she vomited
several  times, but ate with an appetite towards evening ;  during
the night,  however, she  suddenly  died.   Such cases are infre-
quent among  adults.   In  them the  predisposition is usually
rather slight, and the  disease  manifests itself generally  by the
occurrence of a  very mild rudimentary affection, even after the
individual has been exposed to  the influence of an intense con-
tagion for a sufficient length  of time.
    The question whether social position and external relations,
in other words,  nutrition and mode of life,  have any influence on
the predisposition to scarlatina,  has been  answered in various 
176
THOMAS.—SCARLATINA.
ways.  Statistics, however, show that the mortality increases with
poverty and decreases with affluence (Lievin)—though its depend-
ence on the latter is  not  so apparent as in the case of measles.
But from this the conclusion must not be drawn that position
and wealth  in themselves are of essential  influence ; the  lesser
mortality among the affluent is rather attributable to  the better
care which their patients receive,  to their more complete protec-
tion against infection by  isolation, and lastly also to  the  lesser
concentration of the poison in their roomier, cleanlier, and better
ventilated habitations.  If affluence in  itself were of any  mate-
rial influence on the individual predisposition, the disproportion
between  the poor and the  rich  would be much more manifest
than is the  case.  But scarlatina usually finds its victims  in all
grades of society, and there is no very marked difference in the
number of cases, especially of the severe and rapidly fatal ones,
among the several classes of a population.   By this fact alone, in
the absence of  a knowledge of the influencing agents, can we
judge of the extent  of individual predisposition.   The  cause,
therefore, of the  larger  number of  scarlatinous patients and
deaths among the poorer  classes, is to  be found in the existence
of certain conditions which are of minor importance as regards
the predisposition in general.
    Conditions of the soil may also occasionally exert an influ-
ence, especially  when some classes of  the population are affected
either in a very severe or a very mild manner, and  when the
above  law, as an  exception, does not seem applicable.  It has
often been noticed, that while scarlatina attacks one village with
severity, a neighboring locality, in spite of  the active intercourse
between them,  remains  entirely free  from it or  suffers very
mildly ; this  fact has frequently been used  as an  argument
against the indisputable contagiousness of  scarlatina.   We meet
with it in the etiology of typhoid fever and cholera, and explain
it by conditions of the subsoil  essentially independent of  any
human agency.  The  same explanation might serve in the case of
scarlatina.  Thus, if in  a large city  the  wealthier classes live
on  ground  which favors the disease,  while  the poor live on
that wdiich  is less favorable, it may happen that the former
class  will  be affected  in a greater  degree  than the  latter, 
ETIOLOGY.
177
while in the opposite case the rich would suffer proportionately
less than the poor; it would seem then that the law of an equally
divided individual predisposition to scarlatina does not apply in
this  instance.   This exception, however, depends on an acci-
dental, and, as a general rule,  rather insignificant  complication.
Probably every physician can  recall instances where numerous
and  intense affections  occurred in families  who resided  in  the
most favorable localities.   According to Cremen,  the wealthy
classes of Cork enjoyed an extraordinary immunity in  an epi-
demic of scarlatina; one hundred and twenty-three out  of  one
hundred and twenty-five deaths having occurred among the poor.
   The absence of  any marked difference between country  and
city in the number of cases and  mortality of scarlatina may be
ascribed to the slight influence which external circumstances are
capable of exerting on personal predisposition.   In contrast to
some reports which state that the disease  showed a milder charac-
ter in cities than in the country, as in Baden in 1869, there are
others which attribute the greater spread and malignancy of the
disease in cities to  the overcrowding of many people into a small
 space.  On the  other hand,  reports  of  diffused and  malignant
epidemics in the most isolated localities are sufficiently numerous.
 In these cases, conditions of the soil probably have an essential
 influence on the predisposition of the population; further inves-
 tigations bearing on this question are desirable.
   Thus,  according to Marchioli, the village of Recorsano, which lies in a swampy
 region, was alone attacked, and with such severity  that forty-four out of five hun-
 dred inhabitants were affected, of which number nine died ; all the neighboring but
 better situated villages of the Commune of Vollido remained exempt.   Are con-
 ditions of the soil responsible for the remarkably intense predisposition in England ?
    It is possible that a residence in certain localities, through
 unknown influences, increases  or diminishes the predisposition to
 scarlatina.
   Thus Wood reports that during an  epidemic of  scarlatina at  Edinburgh, out of
 one hundred and seventy-nine boys in a strictly isolated private institution, forty-
 four took scarlatina; in another  institution containing one  hundred girls,  not a
 single case occurred, though outside communication  was not prohibited. Richardson
 described extensive epidemics of scarlatina which  occurred among the  large and
 closely crowded crews of the frigates Agamemnon and Odin, and had been occasioned
       Vol. II.—12 
I'o                  THOMAS.—SCARLATINA.
by the presence of children on these vessels while they were in port: as soon as the
frigates gained the high seas, the hygienic condition improved and no further cases
occurred.  Carpenter finds the cause of an intense scarlatina and the death of all the
children on a lonely farm, in the circumstance that blood  had been poured on the
manure heap which adjoined the dwelling.  Cremen  asserts that the presence  of
putrefying substances in the soil, drinking-water, and air augments the predisposition
to scarlatina; again, Scott Alison maintains that cleanliness  by drainage and good
ventilation has no visible influence, to which opinion Hillier also inclines.
   Age has  a most decided  influence on the individual predispo-
sition.   While this is very limited  in  the youngest  children,  it
undoubtedly increases during the second six months,  is strongest
from the second to the fifth or  seventh year,  and rapidly dimin-
ishes  after  the tenth  year, so that  adults,  and  especially the
aged,  have  only a slight predisposition, the  occurrence  of  the
disease among the latter being very rare.   Murchison's statistics
of 148. 829 deaths from scarlatina in England  and Wales in 1847,
and from 1855 to  1861,  show with what frequency  the disease
occurs at different ages :
                                      Males.
    Under 1 year................   5.575
    From 1 to  2 years..........  10,817
                      ;    .........  12,324
                      '    .........  11,400
                      '    .........   9,051
                      '    .........  19,219
                      :    .........   4.023
    Under 5 years...............  49,107
    From 5 to 15 years..........  23.242
       "  15 to 25   "    .........   1,806
       ';  25 to 35   "    .........     537
       ';  35 to 45   ';    .........     319
       "  45 to 55   '•'    .........     157
       "  55 to 65   "    .........      89
       "  65 to 75   "    .........      37
       "  75 to 85   "    .........      14
       "  85 to 95   "    .........       3
          Over 95   "    .........       2
" 2 to	3
" 3 to	4
" 4 to	5
k' 5 to 10	
" 10 to 15	
Total..............   75,373   73,456  148. S29 
ETIOLOGY.
179
    According to these, 63.87 per cent, of  the deaths from scarla-
tina  occurred under  five  years. 89. S per  cent, under  ten years.
95.63 per cent, under  fifteen  years of age.   On  the other hand,
only 1.75 per cent,  over twenty-five  years.   It has been asserted
that  the predisposition  to  scarlatina  is not  stronger in childhood
than in later years,  and  that adults only  escape the disease
because they have experienced it when young.   However,  if  the
mortality  from scarlatina is  calculated at only 6 per cent.—a
very low figure—we find,  as Murchison says, that the number of
individuals attacked  with scarlatina in England and Wales is
considerably less  than  one-half the  births,  so that consequently
a large  number of  people  must remain exempt and attain middle
age without being  protected by a previous attack.  Observations
of epidemics  in isolated regions, where scarlatina seldom prevails,
give  the same result.

   In a Canadian city, according  to Stratton. the disease attacked two-thirds of the
children,  while only five per  cent, of  the adult population were affected.  Panum
affirms that, in the last epidemic in Iceland, children and young individuals were
almost exclusively attacked, and  hence concludes that youth seems  to predispose
to scarlatina,  just as observations on the Faroe Isles have established this fact in
regard to measles.  Other observers, chiefly German, have obtained the same results.
Veit states that only from four to  eight percent, of those affected in Berlin, in 1SGT,
were over fifteen years of age; Gauster treated seventy-eight patients,  among whom
there  were only nine adults; van Holsbeck treated  few adults, and  none over
forty years of age ; Bokai seldom saw a patient over nineteen years of age; Berg
saw none over twenty-three years old ; Belitz, among fifty patients, only had f our
adults; Boning seldom saw adults affected, and Marchioli never; Fenini  saw no
cases beyond the age of twenty  years; Rosch attended young adults but seldom;
Krauss saw few beyond the sixteenth year; among five hundred  patients which
Vose treated, none were over seven years of age. Zengerle is the only author who
saw more adults  than children affected during the epidemic near Wangen, in Wiir-
temberg, in 1840. The following authors have observed the disease in older indi-
viduals :  Braun, in a man said  to have been one hundred and forty-one years of age;
Ballard, in a patient seventy-four  years old; Lees and Tourtual, in one seventy years
old; Faber, in one sixty-eight years old; Krauss, in two sixty-two years old, and in
four between fifty-three and sixty; Berndt, in a few sixty years old ; Belitz, in  one
fifty-seven years  old; Stratton, in a man fifty-one years old.  Kelso states that he
has seen "old people" affected with scarlatina.

   Opposed to these meagre reports  concerning  the appearance 
180
THOMAS.—SCARLATINA.
 of scarlatina in adults, and especially in older people, there are
 numerous notices of the occurrence of the disease in children.

   According  to Fleischmann,  they are especially affected between the first and
 fourth  years;  according to  Bokai, between the second and seventh years; Berg
 found the predisposition equal in the first, sixth and seventh years, while the ages
 of one-half of his patients varied between two and five years; Belitz observed that
 scarlatina generally occurred between the second  and eighth  years, and Fenini, up
 to the seventh year;  Marchioli never  observed it beyond  the tenth year; Boning
 most frequently observed it between  the second  and ninth years; Rosch observed
 it up to the sixth year, then the cases gradually decreased until after the tenth year;
 Roser saw it up to the tenth year;  Krauss, up to the eleventh year, and then a rapid
 decrease ; Senfft found that scarlatina occurred especially between the second and
 ninth years, gradually decreasing up to the fifteenth year; Niese found it especially
 under ten years; Vose saw it up to the seventh year; Voit, most frequently from the
 first to the fifth year, less frequently from the sixth to the ninth  year, and very
 seldom at a later period; Loschner found that, except in the first year, it occurred
 frequently up  to the sixth year, when a rapid decrease took place up to the tenth,
 after which period there were but few patients;  Forster saw it from the third to
 the ninth year, but more especially from the third  to the sixth year; Schieffer-
 decker observed it from the  second to the tenth, but more especially in the third,
 fourth, and fifth years; Gaupp saw it up to the ninth year.

    Compared  with the  numerous  observations of  the  disease
 during  the  second and  following years, the number of  cases
 which have occurred  during the  first year are so few in number
 that we may safely assume for the latter period a very limited
 predisposition ; in this respect scarlatina differs  from measles, in
 which the susceptibility,  during the first year,  though less, is not
 so  much diminished.   It  is  true that apparently this statement
 does not correspond with the English  statistics  given above ; we
 must  therefore call attention to  the  fact,  that the  number of
 deaths  from scarlatina during the  first year  does not comprise
 even one-ninetieth  of the entire mortality,  whereas the number
 of deaths from the  same cause during the second year represents
 one-fifteenth of the entire mortality ; it is possible that the rela-
tive susceptibility during the first year has also increased in Eng-
land, where the predisposition to scarlatina is  stronger.

   Haller observed a  scarlatinous patient five months old; Fleischmann saw none
under six, Eulenburg,  none under eight, I, none under five months ; Senfft saw only
one patient under one year; Gaupp only two; Boning none.   According to Bokai, 
ETIOLOGY.
181
infants at the breast are rarely affected;  the youngest patient that Voit saw was
two and a half months old; Kupfer attended a scarlatinous patient two months
old.  These notices prove that the predisposition to scarlatina during the first year
is very slight on the continent.

    Nevertheless, even the youngest individuals may have a pre-
disposition to scarlatina.

   Veit reports the case of  a child, born on October 3d, 1856, who was taken sick
with scarlatina on the 17th, after  the brother, eleven years old, had been seized on
the 1st of October.  Meynet tells of  a woman who, three weeks after the convales-
cence of her husband, and three months after the death of her child from scarlatina,
was delivered of a girl, who was somewhat red when born; the redness became more
intense on the following day, and the skin felt very hot.  These symptoms dimin-
ished after a  few days, but again became more intense on  the thirteenth day; on
the fifteenth day M. noticed the well-developed redness of scarlatina on the whole
body, tongue, and palate;  the tonsils were swollen, and there was fever and appar-
ent difficulty of deglutition.  On the  seventeenth day the redness had almost entirely
disappeared, and the general condition was good; but during the subsequent fort-
night desquamation had not yet appeared, which makes the case somewhat doubt-
ful.  Asmus's case is also doubtful, as desquamation frequently  appears even in
healthy new-born children, in whom there is no suspicion of scarlatina.  A mother
had lost two children towards the end of her  pregnancy from scarlatina, and soon
after her confinement became dropsical.   In her new-born child, who was very
much emaciated, the epidermis over the whole body separated in large sheets; from
the hands it came off like gloves ;  the child afterwards recovered completely.  Ac-
cording to Noirot, Potier observed that a woman took scarlatina on the morning of
the day of her confinement, and  died a fortnight after, and that her child, though
immediately isolated after birth,  nevertheless  became  affected with intense scarla-
tina, but recovered completely.

    It is difficult to ascertain whether children are born with scar-
latina, because the majority  are  born with a red or yellowish-red
skin,  which resembles the  eruption of scarlatina, and is followed
by desquamation.   But as children are born of  variolous  moth-
ers, or of  women  who during pregnancy have  been exposed to
the contagion of small-pox, and at birth have been found affected
with the  disease, why may not this  also happen in  the case of
scarlatina \

   According to Noirot, Baillou, as early as 1574, established the occurrence of such
cases, when he wrote: " Uxor Bodini septimestrempartum excussit vi morbi, eodem
modo maculatum quo mater......Duae uxores excusserunt partus eodem 
182                   THOMAS.—SCARLATINA.
modo maculatos ; " and Ferrario has also published an undoubted case.   According
to Naumann, F. saw several cases ; in one, a dead child, whose skin and digestive
mucous membrane were covered with red  spots, was born of a scarlatinous mother
in the eighth month of pregnancy; from the absence of other signs, the case is cer-
tainly a dubious one.  Tourtual reports the case of a woman, thirty years old, who
had never had  scarlatina, and who, after  nursing her husband and son—both of
whom were sick with the disease—during the eighth month of her pregnancy, up to
shortly before her delivery, was delivered of a boy on the 19th of September, 1823 ;
the  child could not swallow, and  had an uncommon redness of  the skin, which
Tourtual did not hesitate to consider as a characteristic eruption of scarlatina, the
more so as also the tongue and mucous membrane of the mouth were of a glistening
red  color.  The difficulty  of  deglutition  lasted to the fifth day, when the child
drank eagerly, and on the ninth day abundant desquamation commenced, just as in
older children;  later, also, a separation of the nails of the fingers and  toes took
place; the child recovered  completely. During an epidemic of scarlatina, a son
was born to Gregory on April 23d, 1839; the child was clearly suffering from some
form of fever, and on the following day had a decided angina maligna without an
exanthem, as a  result of which the child emaciated and died on May 1st.  Stiebel
tells us that a woman, twenty-five years old, manifested a very abundant eruption of
scarlatina toward the end of her pregnancy; after birth, the child could not swallow
for several days, the skin  was of  a scarlet-red  color, and desquamated  in larger
scales than usual.—According to Hiiter, a woman, who four days after delivery
died of metrophlebitis during an epidemic  of puerperal fever, gave birth to a child
"praeclare scarlatina in stadio florescentise affectus."

   On  the other hand, Murchison has had two opportunities of
observing the  birth of healthy children  by women who at the
time were suffering from  scarlatina,  and Elsasser  also  reports
that a primipara, twenty-six years old, and already affected with
the eruption, bore a healthy boy, concerning  whose fate nothing
is said, so that he probably recovered,  while the  mother died
four days after.
   There is no evidence to prove that sex influences the predispo-
sition to scarlatina.  During the various epidemics it was soon
ascertained that while in one case more males were affected  in
the  other the affection occurred more frequently in  females, and
generally the  difference was inconsiderable.   Young  boys are
more frequently affected, because their  number is  greater, and
women among the adults seem to be more predisposed, because
their frequent  and close  attendance  on the  sick offers more
opportunities for infection. 
ETIOLOGY.
183
   The assertion by some that females during menstruation are
predisposed to scarlatina in a greater degree, cannot be sustained
by  sufficient evidence.   The frequent concurrence of  the erup-
tion with menstruation proves nothing, for, as in small-pox,  the
menstrual discharge may be influenced by the disease.  In  like
manner it cannot be said that pregnancy favors the occurrence
of scarlatina; probably it  does not, for  Senn, Tourtual,  and
Trousseau  saw no pregnant  women affected during severe  epi-
demics ; in  such cases, according to Miquel, Dance and Hervieux,
abortion frequently occurs.  Lying-in women seem to  possess a
kittle  more  predisposition  to scarlatina, as  Cremen especially
emphasizes ; on this point, however, the reports of asylums  are
unreliable,  because a nidus of contagion may possibly have  ex-
isted  in  them, and hence new-comers  would  become affected
because, while predisposed,  they came in contact  with the con-
tagion, and not on account of their pregnancy.   This accounts
for the occurrence of  the disease soon after the delivery. .Ac-
cording to the reports  of Senn and Hervieux, the disease gener-
ally manifested itself  after  a short period of incubation (from
twenty-four to forty-eight hours) in  those who were admitted
during labor, and it is possible that  this short  interval  is only
due to the  stronger predisposition of  lying-in women to diseases
in general,  caused perhaps  by the exhaustion  after labor,  the
increased irritability,  the changed bodily  relations,  etc.   The
scarlatina of lying-in women is not to be confounded with  the
so-called puerperal scarlatina (scarlatina puerperalis in  contra-
distinction  to the true  scarlatina in puerperal women),—a severe
general affection of the  system with  a scarlatino-erythematous
dermatitis,  which is called forth by  the puerperal state and is
not produced by the contagion of scarlatina nor communicable
from the patient to other persons, and besides is sufficiently dis-
tinguishable by its symptoms from  true  scarlatina.  Nursing
women possess no greater predisposition to scarlatina, even when
their infants are infected, and they have often remained exempt,
though not having had the disease before.
   Whether any particular occupation increases the predisposi-
tion to scarlatina is unknown.  The majority of those who
ascribe their infection  to this cause have a right to do so, only 
1S4
THOMAS.—SCARLATINA.
because their position in  life  has brought them into more fre-
quent contact with the poison.   Thus, according to Murchison,
almost one-third  of  the scarlatinous patients received into the
London Fever Hospital are nurses and servants who have served
in families in which the disease has prevailed.
   The  occurrence of scarlatina in those who have been operated
upon and in the wounded is interesting, and it really seems as if
such persons, in consequence of their general condition, possessed
a greater susceptibility to the disease.  This  assumption, per-
haps, may not be quite true of the majority of cases in which a
scarlatinous eruption appeared under such circumstances ;  for it
must be borne in mind that such exanthemata have appeared
under circumstances where there was no  suspicion  that the poi-
son of scarlatina had been transferred by the operation, or imme-
diately  after it,  in the hospital. Thus Murchison  states that
several cases occurred in a London hospital from which scarlati-
nous patients were excluded with great strictness ; May reports
the case of a boy, living in a village free from scarlatina, who,
six days after receiving a wound on the back of the head, had
fever and a scarlatinous  eruption,  but  without angina.  But,
on the  other hand, the fact that the exanthem is said to have
been followed by a  desquamation characteristic  of  scarlatina,
and also partly by glandular affections, especially cervical suppu-
rations, speaks for its connection with scarlatina.  Paget  thinks
it probable  that his patients,  who were taken sick a very short
time (from three  to  six days) after  the  operation, had already
been infected with scarlatina before it,  but that the effects of the
infection would not have set in so soon, and perhaps not at all, if
the health had not been disturbed by operative interference.
For the present, therefore, we must  assume that the etiology of
scarlatinous exanthemata after  operations and wounds is two-
fold : besides those cases which  very probably or undoubtedly
are of  scarlatinous origin (and here we must  again refer to the
great tenacity of the scarlatinous poison and its  adherence to
substances, instruments for instance) there are others which are
less  suspicious and can  only be classified with the others on
account of the similarity of the eruption.  The mortality in these
cases seems to be greater than in  those of  simple scarlatina; 
ETIOLOGY.
185
Paget believes that many a death occurring a few days after an
operation, with obscure symptoms, is attributable to a scarlatina
with an anomalous course.
   It is doubtful whether previous diseases increase or diminish
the susceptibility to the contagion of scarlatina.  It is said that
scarlatina does not often affect phthisical patients, nor, according
to Gillespie, scrofulous subjects; while the same author asserts
that deaf-mutes are more susceptible.   Children suffering with
whooping-cough are also  said  to escape  infection frequently.
More extensive experience on these points will only be acquired
gradually, and our knowledge will be uncertain so long as we are
ignorant in regard to the nature of  the predisposition, and can
recognize its existence only when the individual becomes affected.
   Many individuals possessing the necessary susceptibility have
undoubtedly remained  unaffected, even after  the  most intense
epidemics of  scarlatina ; a want of active contact with the conta-
gion, or with a sufficient amount of it, was the only cause of their
exemption.   Our better knowledge of the  same relations in the
case of measles proves this to be true.
   It cannot at present be decided whether race has any influ-
ence on the  spread and  character  of  scarlatina,  as we lack
accounts concerning its appearance  in distant lands, and as  the
relations even in our part of the world are in the highest degree
variable.  Though Hirsch states  that all epidemics of scarlatina,
which have so far been observed in the tropical and sub-tropical
regions, have been of a very malignant type,—in the Antilles, the
Brazilian  coast, Chili,  Peru,  Smyrna—these  reports  have refer-
ence chiefly  to the  white races,  which have  also  experienced
epidemics of  considerable intensity in Europe.  According to
D'Alves, scarlatina first appeared among the Brazilian Indians in
1828, and  then occurred sporadically ; but in the year 1833 and
afterwards, it raged with fearful intensity.  During the middle of
the fifth decennium it was there considered the most malignant
disease, and in Montevideo affected whites and blacks in equal
degree.  According to  Murchison, scarlatina has never  made a
distinction between the several races and the natives of New
Zealand; South and North America have  suffered like Europe.
Stratton, on the contrary, among his Canadian patients had com- 
186
THOMAS.—SCARLATINA.
paratively fewer Indians and half-breeds than French and Eng-
lish ; Stevenson, in Pennsylvania, declares that negroes  are less
susceptible than whites.  According to Laudenbach (Majer) Jews
are also distinguished by a slighter predisposition to scarlatina,
though other authors again deny this.
   As  a general fact,  it cannot be  disputed that scarlatina
belongs to that class of diseases which occur but once; neverthe-
less exceptions appear  to be of comparatively frequent occur-
rence,  as is also the case not only with  the other acute exan-
themata, but also with the other acute infectious  diseases.  In
the literature, to which I have had access, I have succeeded in
collecting, after a rather superficial search—for concerning some
cases  the notes are  incomplete—about two hundred cases of a
second infection, besides a  few reports of  a third and fourth
infection in the same individual.  It  is remarkable,  therefore,
that Willan, with  an experience of two thousand cases, should
never have  met with a  single individual in whom the disease
occurred for the second time ;  while  it appears  plausible that
S. G.  Vogel should not have  observed a re-infection,  as his
experience was accumulated, in regions where scarlatina seldom
appeared.  Most writers state that after  a  close  observation of
a considerable  number of cases  during many years, they have
never succeeded in establishing the occurrence of a second infec-
tion, and that  consequently they are  compelled  to declare the
statement of the  parents,  or  of the  patient  himself, to the
effect that he had undergone an attack of  scarlatina before, as
erroneous;  that the previous exanthem was  probably  due to
another cause,   and mistaken  for that  of  scarlatina.  Now,
although as  a  general rule measles cannot be confounded with
scarlatina, the suspicion arises  that  rubeolse  have often been
mistaken for scarlatina, partly on account of the susceptibility
of the patients to the disease, which is said to be equally great in
some epidemics of scarlatina, but chiefly on account of the simi-
larity of the exanthems and the accompanying symptoms.  This
may be the reason why for a long series of years,  and almost up
to a recent  period, rubeola has  been looked upon as a kind of
scarlatina rather than a kind  of measles.   I believe that my
endeavor  to understand the diagnostic characteristics of rube- 
ETIOLOGY.
187
 ola,—characteristics which may be  observed, beyond all doubt,
 in  entire epidemics—has been successful;  and I affirm  that  in
 the only case of secondary infection of scarlatina and subsequent
 scarlatinous disease,  which I have  observed, there was not the
 slightest possibility of confounding it with measles or true rube-
 ola.   This case is the only one among hundreds of  cases  of
 scarlatina which I have observed, in which I have been convinced
 of the possibility of a re-infection ;  in  a few others the statements
 of  the parents were unreliable, and could not be corroborated by
 the attending physicians.  We must therefore assume that secon-
 dary infections of scarlatina are of  rare  occurrence, and  this
 would also appear natural from the fact that  the individual
 predisposition  to  scarlatina essentially diminishes in  the later
 years  of childhood.  It is  the more remarkable, therefore, that
 the experience of Trojanowsky in Livonia compels him to almost
 directly oppose this  conclusion, when, after deducting all cases
 which did not  attain  full development, he estimates that  six per
 cent, of his cases of scarlatina were recurrences, i.e., secondary
 infections.  Now,  if we assume that some of the rudimentary
 cases must certainly be counted among the recurrences ; further-
 more,  that at the time when he made his  report not all of the
 primary cases were in a condition  to  be attacked with  a recur-
 rence, we must conclude that the susceptibility of the individual
 to  the contagion and its subsequent  action is much less often
 exhausted in Livonia than in other regions.   This difference  in
 individual predisposition is probably attributable to conditions
 of  the soil, for Trojanowsky could not ascribe it to age, sex,
 constitution, hereditary relations, etc.
    Scarlatina, as it occurs in this part of the world, is especially
 distinguished from the majority of  the other  acute exanthemata
 and infectious diseases by a  peculiarity which is rarely and in-
 completely present in the case of measles, and is least manifest  or
 entirely absent in the case of variola.  This peculiarity lies in the
 fact that, under the  influence of an intense contagion, not only
 those who have passed the susceptible age without having scarla-
 tina, but also those who have already experienced the disease,
are quite often attacked with  a usually moderate or mild angina,
generally without the slightest trace of a simultaneous affection 
188
THOMAS.—SCARLATINA.
of the skin, though occasionally the latter shows signs of either
an incomplete or fully developed  desquamation.  Under these
circumstances it is evident that even the mildest angina is highly
suspicious, and must be ascribed rather to an incomplete infec-
tion  than to the result of a cold, etc.,—for the differentiation of
which, however,  our resources are inadequate.  Is  it possible
that in Livonia, under the influence of an unknown agent, these
insignificant, more local manifestations may develop into  a com-
plete scarlatinous infection?  The greater frequency  of recur-
rences in that region  might thus  be  accounted for.   To settle
this  question we require more exact observations regarding the
frequency of these mild  infections and their  connection  with
scarlatina, and in Livonia a comparison of these similar derange-
ments—if such occur there—with the cases of recurrence.
   Putting aside for the present the  further discussion  of this
question, we understand a secondary infection of scarlatina to be
one in which the characteristic symptoms of scarlatina are mani-
fested with as much prominence as  when we were justified in
diagnosticating the first  attack of scarlatina.   It  exists when
there is  a characteristic  exanthem, and may also be  assumed
when an intense  angina  is present, due apparently to the re-
peated influence of an intense scarlatina contagion, but especially
when accompanied by a  somewhat rudimentary exanthem.   In
this  definition we exclude all those relapses in which  the fever
and other morbid phenomena again become prominent—though
in a  less characteristic manner than in the beginning—before the
disease has run its complete course.  On the other hand, I recog-
nize  those cases as new attacks of scarlatina, in which, after a
decided retrogression of the symptoms, the exanthem appears a
second time in a characteristic manner in company with other
morbid phenomena, with or without a subsequent commencement
or completion of the desquamation.  Those cases only are to be
excepted which are characterized by a protracted febrile course,
and in which, say during the second or third week, an  extensive
scarlatinous exanthem, usually transient in character, appears
on the whole or greater  portion of  the body,—an exanthem,
moreover, which is more than a  simple erythematous  hyper-
semia.  I would designate this incidental phenomenon  during 
ETIOLOGY.
189
the ordinary course as a pseudo-relapse or reversio eruptionis;
those cases characterized by distinct signs of a new scarlatinous
infection and following in the wake of the first attack, I would
call relapses ; while, lastly, I would apply the expression, second
attacks of scarlatina,  only to  those  new cases which  occur a
shorter or longer time after the first affection, but without any
causal connection with it.
   Why in  rare cases,  contrary to the common experience, the
susceptibility to fresh infection is not destroyed by one attack is
as unexplainable as the causes which usually secure immunity
for life after having had the affection  once.  We can, therefore,
only frame hypotheses to explain whether the secondary affection
is the consequence of an insufficiently  diminished susceptibility,
or of one which has increased to an extraordinary degree during
convalescence, or of both circumstances combined, especially as
we know nothing of the anatomical reasons for the susceptibility.
I will, therefore, only mention facts.  According to some observ-
ers, it seems as if the tendency to repeated attacks were a family
peculiarity ; thus Robinson states that four members of a family
were  taken sick simultaneously (without exanthem, however) for
the second  time.  Trojanowsky was able to establish the fact
that in two of his cases of secondary scarlatina both parents had
also  had the disease twice, and in a third case, that at least the
father had been affected twice; Murchison observed relapses of
scarlatina in two sisters. Sex has no paramount influence.  Gil-
lespie alone records the more frequent occurrence  of secondary
affections among deaf-mutes.  In several cases a disturbed devel-
opment of  the exanthem seems to  have been of Influence, as,
according to Trojanowsky, during the first affection it was only
developed on the upper, and during  the second,  only on the
lower half of the body, while Berton observed the reverse.
   In many of my notes the interval between the first and second
affection is  stated as having been merely long or short, or that
the first affection occurred in childhood,  the second in youth or
adult age.   Older girls and young women appear to be more
liable to a second attack than young men,—a fact due, as stated
in several reports, to the accidental influence of an intense scarla-
tina contagion derived from younger members of the family,  v. 
190
THOMAS. —SCARLATINA.
Pommer's oldest patient (forty-nine years) evidently was infected
a second time by his son, who was suffering from a very severe
attack.   Rudimentary affections of older individuals, during the
course of scarlatina in their children, are very common.
    In quite a number of  cases the interval between the first and
second attacks of scarlatina is more accurately stated.
   Thus West, after Hillier had already made the same estimate, ascertained  it
in one case to be thirty-six days, which, though a short interval, is almost too long
to allow the occurrence of a relapse in the ordinary sense.   Landeutte put it  at
two months; Hoist and Wetzler at three; Salzmann at five; Easton and Troja-
nowsky at six ; the latter at nine; Billing at ten;  Cohen and Webster, the latter  in
two cases,  at eleven months; Braun, Henoch, Thomson, Vogt, Wetzler ("two cases)
and Trojanowsky fixed it at  one year, the latter at one and a half years; Salzmann
at fourteen months; O'Connor, Trojanowsky (two cases), and Thomas at two
years; Salzmann at two and two-thirds years; Salzmann,  Thomson, and Troja-
nowsky, in four cases, at three years; the latter, in  two cases, at three and a half
years; also in two cases, with Berton, at four years; Trojanowsky at five; Luz-
sinsky and Clemens at six;  Harlin, Trojanowsky, and  Horing,  in two cases,  at
seven; Murchison at ten;  Lewin at eleven;  Clemens at fifteen ; Heyfelder, in his
own person, at twenty-seven  years.  Indefinite reports have been made by Bartels,
Becker, Cramer, Easton, Elvert, Faber, Formey, Gillespie, Hirschsprung, Horing,
Kostlin, v. Pommer, Rupprecht,  Seifert, Wood.

    As analogous to the relapses of typhoid fever, those cases in
which the  second attack sets in before  the  patient has entirely
recovered from the  first, may be designated as true relapses.
But few of  the reports inform us regarding the number of days
which intervened between the cessation of febrile action and the
symptoms of the fresh attack.   I do not think, however,  that
we  shall err if we include in  this category all those cases of
a second attack which are  reported as having  occurred immedi-
ately after the first  one,  and those also in which it is stated that
the  fresh affection began not later than  four or five weeks after
the  first.  Such true cases  of relapse have  been  described by
Bartels,   Barthez and  Rilliet,  Faye,  Gaupp,  Jenner,  Hillier,
Kjellberg, Lefevre,  Muller, Marshall Hall, Peacock, Richardson,
Robbelen, Schwarz, Smith, Solbrig,  Steinbeck,  Steinmetz, Stein-
hal,  Stiebel, Trojanowsky,  Wood,  and an unknown  author,
according to Thomson.   In the  majority of  cases  the first and
second attacks  were developed with equal completeness ; in some 
ETIOLOGY.
191
cases  the second attack was  more rudimentary ;  in a very few
cases  the first attack  was not  entirely characteristic.  At  one
time the  report states  that the first, at another, that the second
attack was  the severer  of the two ; in several  cases the greater
intensity  or mildness of  the  subsequent attack seems to  have
been  determined  by the  contrary behavior  of the  antecedent
attack, so that both seem to have completed each other.

   The relapses among the crew of the frigate Agamemnon occurred  somewhat
later than usual.  According to Richardson, out of about seven hundred men, three
hundred were  affected  the first  time, so that  the ship had to be cleared,  thor-
oughly disinfected, and ventilated for more than one month.  On April 4th it was
again manned, and already, on April 9th, relapses occurred  in eighteen of the
one hundred and two convalescents who  had returned to the ship; but the disease
also recurred in many of those who had remained on land in the hospital, as also
in one who had obtained  furlough  to return home.  It is not reported how manj
days elapsed between the  first and second attacks of the several cases; but as all
the  first attacks  probably occurred in  February, and the  relapses in April, the
interval evidently lasted much beyond one month in most cases.  The second affec-
tion was either mild or as intense and characteristic as the first.

    With the exception  of  several cases reported by Jenner, Pea-
cock,  and  Smith,  who observed fatal  results in children, the
relapses  of scarlatina  always  ended in  recovery.   When the
second attack occurs later, it  seems that recoveries are still more
frequent; at  least, I can  find but one report of  a  fatal result,
that of West and Hillier,  in  which case the second attack began
thirty-six days after  the commencement of the first.
    A third and still further attacks of scarlatina are of extremely
rare occurrence.

   Richardson states that  he  has experienced scarlatina in  his own person three
times, and Gillespie has also observed this.   Sir Gilbert Blane tells of a young lady
who had scarlatina three times, the diagnosis of which was unequivocal.  Another
case has been related by Bins.  Moore reports that a woman, who, when a child, had
had scarlatina with angina, and after her first confinement had had angina scarlati-
nosa without exanthem, was attacked a  third time,—three days  after a visit to her
son, who was  sick with scarlatina—and  was bedridden for eight days. Thompson
reports the case of a girl,  sixteen years old, who, three years before, had suffered
severe scarlatina at the same  time with  others of her family, and  now had under-
gone another attack which was foUowed by dropsy; fourteen days after convales- 
192                THOMAS.—SCARLATINA.
cence from the scarlatina, an affection of the throat set in, followed three days after-
wards by a fresh, transient eruption; nine months after this she died from dropsy.
   The occurrence of  a fourth attack of scarlatina was observed
by Stiebel, in a woman about fifty years of age.  In four succes-
sive  years "she had as many  attacks  of  complete scarlatina,
the skin desquamating in parchment-like pieces half a foot in
length."  Stiebel does not state whether the patient had had
scarlatina during childhood, or at any other previous time.  Jahn
relates the following  very singular  case: A  woman, forty-two
years of  age, who had had scarlatina when six years old, and a
recurrence since  her  menstruation, but without any connection
with this function, claimed to have experienced the same disease
seven times; she stated  that the disease in no respect differed
from scarlatina, and in previous attacks had been diagnosticated
by eminent physicians as scarlatina; that besides the angina,
there was a characteristic exanthem, and after  the twelfth day
the skin came off first in scales, and afterwards in larger sheets.
Jahn calls the  disease scarlatina habitualis, attempts to estab-
lish its relation with scarlatinoid eruptions,  which are due to
various causes  and circumstances,  and  adds that in this con-
nection should be mentioned the observation of Henrici, who
during the epidemic  of scarlatina in Kiel, from 1797 to 1798,
attended a woman who was then  undergoing  her seventeenth
attack of scarlatina,  with all its symptoms.  In the absence of
further confirmatory evidence such observations are unreliable.
   The recurrent form  of  scarlatina, which Trojanowsky has
described, is peculiar.  A short time (from seven to  seventeen
days) after the first eruption of scarlatina, a second eruption,
similar to the first, or identical with it, and so to speak complet-
ing it, makes  its appearance, so that both  attacks combined
seem to  form one complete scarlatinous affection.  Both attacks
were accompanied by an unusually high fever,  similar to that
of relapsing fever, and separated from each other, as in the latter
disease, by a complete remission, during which all morbid  signs
disappeared,  again to recur with the commencement  of the sec-
ond attack;  in addition to the ordinary symptoms of scarlatina,
the spleen, as in  relapsing fever, increased rapidly in size from
the commencement of the attack, the white  blood-cells became 
ETIOLOGY.
193
abnormally numerous, and there was extraordinary prostration
together with muscular pains.  Now, as most  of  the patients
affected in this manner lived in low and  marshy  localities, in
which  relapsing fever occurred almost every year, and also  to a
certain  extent during epidemics of scarlatina,  we may  freely
assume that  these cases were the expression  of  a peculiar com-
bination of relapsing fever and scarlatina.  In the  meantime we
must await confirmations of Trojanowsky's observations.
   Cases of scarlet fever occur either in sporadic or in epidemic
lorm ; it must be remembered, however, that epidemics often  con-
tinue  for so  long  a  time, and the single cases appear to have so
little connection with each other, that they might be looked upon
as a  moderate accumulation of sporadic cases.  In  the large
majority of cases  the scarlatina poison  can  be  proved to have
emanated from sick persons ; or we can,  at least,  trace its course
with more or less certainty from these to the newly affected  per-
son.   Nevertheless, there are cases which appear to have had no
local or temporary connection whatsoever with others, which fact
has given rise to the opinion that scarlatina could originate spon-
taneously through the agency of certain unknown atmospheric
and telluric conditions.  But if we remember how easily the poi-
son may be transported to great  distances, and how long it will in
a latent condition adhere to substances, it will be difficult to pro-
duce evidence of its ever having originated spontaneously in an
isolated  instance,—not to mention  the question why this indi-
vidual alone should  have been influenced by  these  hypothet-
ical agencies.  There is abundant evidence  that scarlatina  has
never occurred spontaneously in the isolated  islands of any lati-
tude,  but that it  has always been introduced from without by
persons or substances.  Again, a  certain amount of intercourse
has always taken place between  the most distant localities of
civilized countries and the external world.  Such cases of appa-
rently spontaneous  origin,  therefore,  only  demand  a  further
investigation  of the ways and means by which the  contagion
reaches susceptible individuals.  Moreover, the defenders of the
theory of spontaneous origin are by no means agreed on the cir-
cumstances which  control its occurrence. While one attributes it
to cold and  moisture, others lay it to great  heat with moisture,
       Vol. II —13 
194               THOMAS.—SCARLATINA.
to marshy exhalations, or even to bathing in ordinary river-water,
or to any disturbance of the organism itself.  We for our part
cannot believe that a contagion which determines such positive
symptoms can originate in such various ways.  When we speak
of sporadic  cases, therefore, while admitting their origin by
means of the ordinary contagion, we mean simply that they have
originated without any positive demonstrable connection with
other cases  of scarlatina, and further, that the cases have not
accumulated in sufficient numbers to constitute an epidemic.
   The spread of scarlatina in a population which has enjoyed
immunity for a long time, and hence probably contains numerous
susceptible individuals, often takes place  in a manner which, in
many respects, seems obscure and inexplicable to us.   Some vil-
lages which  have many cases are located near others in which no
cases occur,  notwithstanding the active intercourse carried on be-
tween the two; while perhaps at a later period, when the disease
has  ceased  in  the former village,  the latter localities will be
attacked in an intense manner.  An epidemic spread of the dis-
ease from village to village, from district to district, can be estab-
lished only  in exceptional instances.   Some districts in larger
cities may often have very  much  scarlatina, while,  for  some
unknown reason, little or  none prevails in the others; and then
at other times a directly opposite condition  may occur without
any  apparent cause.  Though in  such cases our  attention  is
directed to the  influence which  a temporary or  local  condition
may exert in a greater or  less degree on  the individual predis-
position, we  must at the  same time confess our complete igno-
rance of the factors which here come into play.
   The  most complete reports concerning the influence  of sea-
sons on the prevalence of scarlatina have emanated from Eng-
land. The greater prevalence of the disease in the fall  of the
year has been recognized since Sydenham's time ; during  spring
its decrease  is not so decided as in other diseases which prevail
with like frequency during this time.  Of 55,956 deaths in Lon-
don  from scarlatina within  twenty-four years (up to 1863 inclu-
sive), 17.87 per cent,  occurred during spring, 22.75 per cent, dur-
ing summer, 35.54 per cent, during the fall, and 23.85 per cent, in
winter (the latter comprises the last four months of the old and 
ETIOLOGY.
195
first nine weeks of the new year); in other words, the largest num-
ber of deaths from scarlatina occurred between the middle of Sep-
tember and the middle  of November,  the smallest number toward
the end of March  and  beginning of April.  The greater number
of deaths, however,  in the  fall of  the year were certainly not
caused  by a greater malignancy  of the  disease at this season.
Similar results are obtained by calculating the deaths which have
occurred in all England,  according to the  different seasons of the
year.
    Other but much smaller data in our own country also indicate
the influence of the fall of the year on the spread of scarlatina.

   A statement of the number of scarlatinous patients treated by the charity physi-
cians of Leipzig during the years 1842-1869, showed the following results: for the
months of December, January, and February,  110, 70, 59 patients; for the spring
months, 50, 57, 34; for the summer, 82, 119, 132; but for the fall, the maximum
numbers  of 151, 161, 144.  According to Spiess,  during the twelve months of the
year the deaths from scarlatina in Frankfort, from  1867 to 1871, amounted to 17, 13 ;
16, 9, 11; 10, 12, 17; 20, 24, 17 ; 30.  Passow reports that 1,579 deaths from scarla-
tina in Berlin, from 1863 to 1867, were thus distributed:  101, 68; 91, 89, 113; 131,
151, 105; 155,  228, 179; 168, so that 35.6 per cent,  occurred dnring the fall, and
18.6 per cent, of all deaths during the spring months.

    Other countries do  not furnish such extensive figures as Eng-
land.

   French physicians  state  (according to  Murchison) that epidemics of scarlatina
 occur more frequently in the spring and summer than at other times.  According to
 Hirsch's  statistics, in Scandinavia and Russia, 6  epidemics occurred in the winter
 months (Dec. till Feb.), 4 in spring, 10  in  summer, 13 in the fall; in Germany, the
 Netherlands, and Switzerland 51 occurred in winter,  38 in spring, 39 in summer, 42
 in the fall.   Thus in our country a special prevalence of the disease in the fall does
 not appear to be so marked as in England; but we can only arrive at conclusions by
 accurate  and more extensive estimates, which as yet are wanting. Gutmann's statis-
 tics indicate in round numbers  about 120  epidemics for the winter, 80 for spring,
 90 for summer, 100 for autumn; the tables are compiled from reports of all coun-
 tries.

    The reports of  epidemics do not show an aggravation of the
 disease under the  influence of  a  changeable, cold,  and  moist
 weather.  Of course scarlatina has often prevailed during  such 
196
THOMAS.—SCARLATINA.
weather, but it has not been absent under opposite conditions,
and in England especially it has attained a wide spread during
warm weather.  The  condition  of  the  weather  can therefore be
said to exert but moderate influence on the frequency of scarla-
tina.  It is very probable that its  spread is entirely independent
of  temperature,  atmospheric   moisture, atmospheric  pressure,
winds, and  electricity.  Barker, however, maintains that ozone
promotes the  frequency of scarlatina,  contrary to what is found
in other diseases.
    Pride states that the condition of the drinking-water seemed
to be of influence, in so far  as the disease appeared more fre-
quently, and  with greater malignancy,  in  those families  which
used water defiled by organic  ingredients,  than where this was
not the case.  But of what disease next,  pray, shall we not attri-
bute the cause to drinking-water!
    The elevation of the ground has no influence on the spread of
scarlatina, for epidemics have occurred in every altitude,—on the
sea-coast as well as in the highest localities.  Epidemics of scarla-
tina are  likewise independent of the geological structure  of the
soil; according to Gutmann they occurred on all formations from
the primitive rock to the most recent diluvial formations ; no dif-
ference is  occasioned by granite,  gneiss, mica, clay, slate, sand-
stone,  shell-limestone,  calciferous marl,  lias  formations, sand,
Juracic-, Alpine-, and tertiary lime, tufaceous  limestone, turf, or
reclaimed land.
    On the  other hand, location and the condition of the subsoil
seem to have some influence on the spread of scarlatina and the
degree of its prevalence.

   For this assertion there is abundant evidence.   Thus,  among other authors, With-
ering reports  concerning the Birmingham epidemic of 1778, that it raged  in many
high and dry localities, while the inhabitants of moist and low houses were spared
entirely or to a great extent.  In 1856  Zehnder  found that the disease prevailed
along the shores of the lake of Zurich, and  along the bottoms of the valleys in the
higher districts, while in 1857 it prevailed in the higher localities, and in 1858 in the
flat  lands.  Perhaps continued observations concerning the processes which have
become so important in the etiology of typhoid fever and  cholera, may in future
increase our knowledge of the behavior of scarlatina.  In this respect we cannot as
yet even make conjectures. 
ETIOLOGY.
197
   Observations on the origin and spread of epidemics of  scar-
latina continue  to prove the paramount importance of personal
intercourse.  Though we cannot understand why this intercourse
in a few, or even many cases, has not been followed by a marked
spread of the poison,  we cannot, at the same time, shut our eyes
to the fact that in the majority  of  cases it is  the only causal
factor which we are able to demonstrate.  In the case of children,
the most susceptible class of the population, it is a most impor-
tant  factor, as the contagion is  almost sure to spread rapidly
through the schools, and particularly through the "Kindergar-
ten" ; the latter have the disadvantage of  spreading the con-
tagion among  those  children who are not  yet old enough to
attend school, who are at the same  time the most susceptible,
and  in  whom the disease is often more dangerous than in school
children.   In addition, the  schools and "Kindergarten" contri-
bute much towards the further  spread of the  disease, for the
reason that the size of the  school-rooms does not always corre-
spond to the number of scholars, and their ventilation is neces-
sarily imperfect.  If, therefore, the contagion has once entered
such localities, it rapidly develops under the favoring influences
of warmth, bad air, etc.,  as in the above-mentioned ships, and
the predisposed individuals  may thus become infected in much
larger numbers  than  would be possible under the ordinary cir-
cumstances of daily intercourse.
   But  increased personal intercourse cannot always  overcome
the causes which, in densely populated districts and overcrowded
localities, diminish—in some manner  unknown to us—the  indi-
vidual predisposition.  This explains why smaller localities some-
times suffer more intensely than larger, and why sometimes there
is no proportion between  the predisposition to and mortality of
scarlatina and the density of the population.

  Thus, according to Murchison, the number of deaths from scarlatina in four of
the poorest and most crowded districts of London, in 1863, was one death in 668
inhabitants, while at the same time, in the four richest districts, the proportion was
one in 447 inhabitants.

   It is at least doubtful whether scarlatina can be spread in
any other  way than by either direct  or indirect personal inter- 
198
THOMAS.—SCARLATINA.
course.  According to Carpenter the  contagion may arise from
the offensive odors emanating from the ground, when slaughter-
house offal is used for manuring purposes ;  a number of cases
are cited as examples where under these circumstances scarlatina
has been of very frequent occurrence.  If it is true that animals
can be affected with  scarlatina,  their offal is certainly  capable
of spreading the disease; but,  in accordance with the  modern
views concerning the  nature of the contagion, we must contest
the view of Carpenter that it can originate from the blood and
tissues of healthy animals.  If these  substances  exert an influ-
ence on the spread of  scarlatina, it is probably by increasing the
predisposition of  those living  in the  vicinity,  who  become
affected with scarlatina in consequence of an accidental contact
with the  contagion from other regions, not, however,  by  the
spontaneous  evolution of the poison from these offensive sub-
stances.  In support  of this latter view  it has been found that
improvements in privies and sewage in houses have no influence
on the spread of scarlatina.
   Scarlatina,  to  a greater degree than perhaps  any other dis-
ease, appears at one  time in  the form of a severe, at another in
the form of a mild epidemic, and the  same variation is noticed
in the sporadic cases,  of  which many have incorrectly asserted
that they are less dangerous than  those  which occur  in  the
course  of an epidemic; Ranke, however,  supports the  directly
opposite view.  The epidemic which Sydenham described was so
mild that he considered scarlatina hardly deserving the name of
a disease,  while two years later Morton represents the continua-
tion of this same  epidemic as  exceedingly severe.  Of  modern
English epidemics the following have been of wide extent and
characterized by malignancy: those of 1801-4, 1833-34, 1847-48,
1858-59, but especially that of 1863, which  not only raged over
the whole country, but  also  caused  so  many deaths that the
mortality from scarlatina in London during this  year comprised
one-fourteenth of the  entire death rate, or 4,982 : 70,312 ;  in other
years it was four times less (Murchison).  In Stuttgart during
the epidemic of 1846  not one death resulted  from scarlatina, so
that it may almost be doubted whether the disease prevailed at
all at that time.  As a counterpart to this we refer to the report 
ETIOLOGY.
199
of Santlus, who states that in 1840, in Warsaw, 2,559 children
died of scarlatina in five months.
   That this variable character of the epidemics is the result of
local, and not, as  was formerly believed, of atmospheric condi-
tions, is proved by the fact that scarlatina may infect neighbor-
ing localities in a mild and malignant manner at the same time.
Thus Stiebel mentions the epidemic at Frankfort in 1816 as one
of the mildest, while the same  is described by Kopp in the neigh-
boring town of Hanau as one of the severest.
   The slow spread, variable  course, and protracted  disappear-
ance of the epidemics of scarlatina contrast markedly with the
rapid onset, short and high culmination, and rapid disappearance
of epidemics of measles.   The former never attain such intensity
as those of the latter, but, as a rule,  hold their once-attained
maximum intensity much longer than the latter;  or,  if  they
have  abated at an early stage, they again rise to the same height
after  a short time.  While it is very common for an epidemic of
scarlet fever to be preceded for a long time by sporadic attacks,
either single or in small groups, so is  it usual for it to be fol-
lowed by such sporadic cases,  which  cause the prolonged appear-
ance, often  for years and even longer, of scarlatina,  even  in
smaller localities,  while in larger localities  they give  rise to the
suspicion that  the disease is endemic.  This is due to the action
of the less  volatile,  more fixed contagion  of  scarlatina, which
finds  susceptible individuals in smaller numbers than does that
of measles ; its progress is  therefore not so stormy as that of the
latter, which suddenly attacks a larger number of individuals at
one time ; on  the  contrary, it generally spreads from one indi-
vidual to another  in  a gradual manner,  and therefore requires a
longer time  to travel through  the susceptible classes of the com
munity.  This  explains why  sporadic cases of scarlatina occui
more  frequently than those  of measles, and  in regard to the
latter the doubt sometimes arises whether we have to deal with
a large number of sporadic cases or with a small epidemic ; for
the same  reason   scarlatina  lacks  the  regular periodicity  of
measles.
   On this last point  the opinions of various authors differ, but
apparently only to a  slight extent,  for  what one calls  a small 
200                    THOMAS.—SCARLATINA.
epidemic, the  other  declares to be an accumulation of sporadic
cases.

   Fleischmann maintains that in the case of Vienna the epidemics of scarlatina
occurred in systematic succession (1854,1858,1862, 1866, 1870), and that the interval
between them always amounts to four years, so that he prophecies another for 1874,
though the term epidemic for the years 1854 and 1870 (forty-seven and seventy-six
cases respectively) is far-fetched.  According to Gerhardt, a more or less marked
epidemic of  scarlatina may be expected about  every four or five years.   In  the case
of Dresden, Forster finds irregular intervals  between the epidemics:  1824, 1829,
1831-32, 1834, 1839, 1845, 1847, 1851, 1856, 1862, 1867, therefore about every  five
or six years, with occasional  exceptions,  when  the  interval is shorter.   Munich,
according  to Hauner and Ranke, experienced severe epidemics in 1842-43, 1844-45,
abundant sporadic cases in 1849-50-51, small epidemics in 1859-60-61 and 1861-62,
and towards the  end of 1867 only a few sporadic cases;  here, therefore, scarlatina
is gradually diminishing  in importance, as perhaps  nowhere else. According to
Voit, Wurzburg  has experienced since 1842  small epidemics  only in 1849, 1856,
1863, large epidemics in 1867-68 and 1870-71; according to Kiittlinger, Erlangen
in forty years has had  only two epidemics of considerable magnitude, namely, in
1833-34 and 1840-41-42,  while smaller ones were observable in 1826, 1830, 1853-
54-55, and in 1857-58.   According to Barensprung  and Weineck, scarlatina ap-
peared sporadically in Halle in 1830-31, 1839-1843, 1848, 1849-50, 1857-58, 1859-
60, 1868-1871, and epidemics occurred in the years 1832-33, 1844, 1846-47, 1851-
52, 1853-54, 1862-63, 1865-66.   Of epidemics in Prague, Loschner records those
of 1837, 1844-45,  1850,  1853, 1855-56-57, 1860-61;  in  the  interval there were
numerous  "sporadic" cases.  Kostlin  states that up to 1866 Stuttgart  had epidem-
ics in 1830, 1846, 1853,  1856-57, 1862-63, and since 1849 sporadic cases have often
occurred in the intervals.  According  to Schiefferdecker, severe epidemics occurred
in Konigsburg in 1859-60-61-62 and 1867-68-69; in 1857 and 1862-65  frequent
sporadic cases occurred.   Geissler designates the following epidemics  for Meerane:
1835-36, 1844-45, 1849-50, 1855-56, 1861,  and 1867-68.  Leipzig  has experienced
epidemics  of some size since  1842: in 1843-44, 1851-52, 1856-57-58, 1864, 1867-
68, 1870-71 ; sporadic cases, from which the smaller  epidemics could not be  dis-
tinguished, occurred almost every year in about equal numbers.  In Berlin, Passow
declares the years 1864-65-66, 1866-67, and the latter  part of 1867 to be the periods
when epidemics  prevailed; but scarlatina also occurred outside of these periods.
The statistics of Spiess show that in Frankfort-on-the-Main, since 1857, only one
considerable epidemic  has occurred, namely,  in 1861-62-63, and a smaller  one  in
1868-69 ;  at other times there were more or less numerous sporadic  cases.

    According to these  reports it would seem as if a certain peri-
odicity had shown itself in some  localities,  while in  others it was
entirely  absent;  this periodicity,  however,  did  not show  itself 
ETIOLOGY.
201
with such regularity as in  the case  of  measles.  The peculiar
behavior of  scarlatina is shown, among other circumstances, by
the fact that in populous cities, with active external intercourse,
quite long intervals occur in which it seems to be entirely absent,
as, for instance, in  Stuttgart from 1830  to 1846.   On  the other
hand, it is found that in some locations, especially cities, the dis-
ease, without being exactly so disseminated that it  might be
called  an epidemic, does not cease to occur, and only varies in
frequency at different times.  Scarlatina is only  endemic in  the
largest cities, but there  it is  also influenced by the seasons.
   Occasionally scarlatina, like small-j)ox and measles, assumes a
pandemic character, or  at least spreads over large tracts of land,
as,  for instance,  according  to  Hirsch, in Germany in 1818, in
Denmark, England, Germany, and France in 1825 and 1826, in
Ireland and Russia as well as here in 1832-35, in Germany, Den-
mark,  and England in  1846-49, in the United States in 1821, and
over the whole of South America from 1831 to 1837.
   The statistics of epidemics compiled by Gutmann show, how-
ever, that since the commencement of our knowledge  of scarla-
tina, epidemics have occurred in every year.   The factors neces-
sary for its  production  must therefore be present somewhere at
all times.
    Some  authors  recognize a certain  relation between   the
epidemics of scarlatina and those of measles.   Thus Loschner
states  that it is a constant  observation to find both the smaller
and the larger epidemics of scarlatina following  in the wake of
epidemics of measles, so that every exacerbation of measles has
been followed also  by an increase in the number of scarlatinous
patients, and  that extensive epidemics of scarlatina are also fre-
quently  combined  with great  epidemics of measles.    Kostlin
makes the same statement.  He observed that an epidemic of
measles in Stuttgart always  immediately preceded a well-marked
epidemic of scarlatina,  and  he  is forced to conclude that there is
something in  the prevalence of measles in epidemic form, which
promotes the spread of scarlatina, that possibly the thorough
infection of a population with measles disposes it in a peculiar
manner for the reception of the contagion of  scarlatina,  On the
other hand,  the relation does not appear to  be mutual, as great 
202
THOMAS.—SCARLATINA.
epidemics of measles have not followed scarlatina.  In the two
epidemics of scarlatina which Ranke observed in Munich,  the
increase of scarlatinous cases at one time corresponded with the
decrease, and at another time with the increase of the cases of
measles.   But it does not follow that the greater prevalence of
measles should always and necessarily give rise to a greater num-
ber of cases of  scarlatina.   Thus scarlatina did not appear in
India until a recent  period, though  measles have  frequently
occurred.   Such facts  cast a doubt on  the relations of both dis-
eases in the above sense.  Gutmann  denies  that there is any
relation between scarlatina and other diseases ; that epidemics of
scarlatina do not  exclude epidemics of other diseases, and are
not excluded by others.
   It may be said  that the pathogenesis  of scarlatina is still a
mystery.  The  question  of how the  contagion  acts  and calls
forth symptoms, whether directly by its increase or by the poi-
sonous products which are thereby engendered, or according  to
the older view, by a species of fermentation, will  only be eluci-
dated when its character shall be better understood than at pres-
ent.   Hypotheses appear  to me  useless.   Scarlatina, in  this
respect, is still the problematic disease which Hufeland (Jahn)
spoke of forty years ago.

                         PATHOLOGY.

                    Anatomical Changes.

   The scarlatina exanthem is an eruption of the skin due essen-
tially to a hypergemia, and has been variously described by dif-
ferent authors, undoubtedly because its character varied at dif-
ferent times and in different  places, in a  manner corresponding
to the variation of the entire disease.
   In the commencement of  its development it  usually consists
of very numerous  and closely aggregated points about the size
of a pin's  head,—larger in some places, but seldom as large as a
lentil,—whose redness, not very marked  in the beginning, at a
later  stage  becomes  quite brilliant.   The skin between  these
points has a natural, pale color; in normal cases these points are 
ANATOMICAL  CHANGES.
203
equally distributed over the whole surface of the body, with the
exception of  the face and the palmar and plantar surfaces; on
the genitals,  especially of the female,  they are also commonly
less distinct.   The scarlet points are most perfectly developed on
the neck and trunk, on the thighs, arms, and forearms, while as
a rule they are less crowded together and  sometimes larger on
the legs and dorsal surfaces of the hands and feet than on other
parts; in fact they sometimes attain here the size of a lentil, or
may even be larger.  They are either entirely flat, or, as is more
often the case, very slightly elevated, but not  near as much so
as the roseolae of  measles ;  the only places where they are more
elevated above the surface  and resemble more closely the spots
of measles are the dorsal  surfaces of the hands  and feet, and
also those parts in the vicinity of the wrist- and ankle-joints, but
they  are distinguished from the eruption of measles by being
usually somewhat  smaller, and by  having edges which are less
indented.  The spots are generally nearly circular, though some-
times elongated on the forearms and legs.   They are always so
closely crowded together that about the same amount of  skin is
exempt as that which  is covered ; this circumstance, taken in
connection with the tolerably uniform  distance  between the sev-
eral points and their nearly equal size,  contributes in  a great
measure to make  the eruption a very characteristic one from the
very onset.  In order to cause a general confluence of the erup-
tion,  but little additional growth of the single points is neces-
saiy; in severe cases, in which the exanthem is of longer dura-
tion, confluence very often occurs, which accounts for the frequent
description of scarlatina as  a hyperaemia that  is uniformly dis-
tributed over the  whole body.  Close examination, however, in
most  cases of moderate confluence, proves that the redness is not
uniform, for  here  and there on the surface  of  the body may be
observed isolated,  pale points of skin, while in cases of  greater
confluence there may be seen, upon close inspection, pretty well-
defined, darker-colored portions,  corresponding  to the originally
isolated red points ; only in the case of a strong and vividly red
exanthem, do these latter also disappear in the general, uniform,
intense redness.   A  confluence  of  the originally  isolated  red
points is much more  frequent in scarlatina  than in measles; in 
204
THOMAS.—SCARLATINA.
fact it is so frequent that a confluent  redness of the skin is often
designated as  being  one  of the characteristics  of  scarlatina;
nevertheless, it  is easy in the beginning of most  cases, by close
inspection, to observe its non-existence.   In mild  cases of scarla-
tina, with transient, feebly  developed exanthem, there is  never
confluence ;  the single red points remain isolated up to the time
when they become pale and disappear.
    Not infrequently, when the exanthem is  intense and markedly
confluent, there is an  increased  turgescence of the  skin,  which
then appears stretched and glistening.   But we very seldom find
eedenia  of  the  subcutaneous cellular tissue;  perhaps at  most
there may be a slight  puffiness of the eyelids and cheeks, pro-
vided these are at all affected.
    In my experience the exanthem rarely  appears in any  other
way than has been described above.  Now and then in scarlatina,
as in all diseases which  commence with a violent fever, there  is
an  initial, more  or less  diffused,  not entirely transitory erythema,
which may cover the whole body, and which afterwards insensi
bly merges into the characteristic redness of scarlatina.   Then if
the redness is moderate,  the  single points  appear as spots of a
darker  red, and in case  of profuse exanthem they disappear  in
the general intense, scarlet-red  injection of the skin.  Their ab-
sorption in it is  the less observable, the more intense  and rapidly
the exanthem develops.

   The description of the exanthem  by most authors  differs somewhat from the
above; the following  examples will suffice.   According to Barthez and Rilliet,
normal scarlatina is characterized by vividly red spots varying in size up to  several
centimetres; they are roundish and not elevated, and they have uneven and indented
margins, which coalesce with their edges, and thus have a tendency to cover the
whole surface of the body, but  never form semicircular  figures like the exanthem of
measles; the color is peculiar, owing to the existence of many small, dark-red points
on a bright-red base. Where these dark-red points are absent or  are not abundant,
the color is brighter; where they predominate, it is darker, or of a raspberry color.
According to Canstatt, the exanthem consists of many small red  points, which soon
expand into large,  scarlet-red, irregularly margined,  erythematous spots, which
coalesce and can gradually cover the  whole skin with a confluent, lobster-like red-
ness.  Neumann  has found the skin  in  scarlatina  in a condition  of general and
intense hyperaemia, and the superficial layers of the cutis at the same time slightly
oedematous;  the redness begins from  numerous  small  points, which by their 
ANATOMICAL  CHANGES.
205
coalescence produce a uniform, finely punctated redness of the entire surface of the
skin.  Niemeyer says that the redness of the skin begins as numerous small, closely
aggregated points, which then merge into each other and cause a uniform red sur-
face, while on the other hand we less frequently find the redness of the skin con-
fined to single spots  of varying size and irregular form.  Hebra  describes fine,
closely placed points, "which form a flat, apparently uniform redness."  G. Simon
finds, when the eruption has reached its  maximum development, a vivid redness,
which forms spots of varying size and irregular form, with intermediate normal
skin, or uniformly covers large sections of  the body.  We thus find that on the one
hand too little weight is attached to the originally isolated small red points, which
remain isolated throughout the whole course, and may even, when there is confluent
redness, stand out as  separate spots,  while on the other hand an entirely different
view of the scarlatina eruption is advanced by the description of large red spots,
which can be present at most in a few  places immediately before the development
of a definite general confluence.

    Generally, after the redness of the eruption has  increased in
intensity up to a  certain maximum,—which varies  in different
cases—it remains stationary a half or an entire day, and then dis-
appears more or  less  slowly, according to the intensity reached.
During  the  progress  of  the  disease, the color often  changes,
chiefly in connection with  exacerbations and  remissions of the
fever, but  also  with  the warmer  and  colder  condition of the
patient, etc.  Thus, for instance, the fact that  the  eruption be-
comes pale during the morning might create the belief  that its
maximum intensity had been passed, while the following evening
brings a much more intense,  perhaps  even the maximum redness ;
and,  vice versa, warmth may for a short time so increase the red-
ness  of a faded eruption that an unexpected change for the worse
would appear certain, were it  not for the absence of  otlier symp-
toms of a threatening nature  and for the transitory character of
the increased redness.
    It must  also be mentioned  that the degree of the redness may
vary from  a pale red  to a dark scarlet red ;  as a rule the redness
is  in direct proportion to the intensity of  the case.   A  some-
what bluish  redness appears when  respiration  is difficult.  In
fresh cases  and with  unimpeded respiration  the  redness  is clear,
and disappears completely under pressure of the finger, and  re-
appears when the pressure  is removed.   If the exanthem has
already existed twenty-four hours and longer, the pressed  point 
206
THOMAS. —SCARLATINA.
does not always  pale  completely, but gives place, especially in
very intense exanthems, to a somewhat yellow and perhaps also
in some spots violet or bluish coloration, which latter is depen-
dent on the escape from the vessels of the coloring matter of the
blood; the redness also is  restored somewhat more slowly  than
in the beginning of  the eruption.  If the skin is rubbed moder-
ately, or if, as Bouchut did, letters are traced on the skin with a
blunt piece of wood, a very interesting phenomenon results : the
eruption over the irritated  parts immediately pales to a marked
degree, thus rendering  the writing very prominent for a short
time on account of the red surroundings.  This depends on an
increased irritability of the capillaries of the skin, but is not, as
Bouchut asserts, peculiar to scarlatina and to be used  as a means
for differentiation in doubtful  cases.  Similar  spasmodic  con-
tractions of the vessels undoubtedly occasion the peculiar pale-
ness about the mouth in  scarlatina; this paleness also  abnor-
mally appears in  severe cases on other parts of the skin, but is
limited  to well-defined  regions, thus giving a very peculiar ap-
pearance to the eruption.
   In scarlatina the eruption rarely  affects the face in the same
degree as  in measles, in which disease it is  frequently the most
intensely affected portion of the whole body.  Undoubtedly there
are exceptional cases in which the face is  as much affected as the
neck and trunk, but this is not the rule.  Usually the forehead
and temporal regions show at first a finely punctate,  afterwards
confluent exanthem, while the eruption on the nose and cheeks is
distinguished by  a  sometimes diffuse,  sometimes circumscribed
but tolerably bright congestion; whereas the region of  the mouth,
and especially the upper and lower lips, the chin and the  angles
of the mouth, contrast  with this by being remarkably pale.   This
characteristic behavior of the eruption often enables  the  physi-
cian to make his  diagnosis at first sight; for the redness in fever
is not accompanied, as in  scarlatina, by paleness of the mouth,
nor is the redness of the cheeks, forehead, and temporal regions
as bright as in the latter disease; but much of the redness of the
cheeks in scarlatina is attributable to the fever.   The ears are
often as much congested as the cheeks, but without  the charac-
teristic marks of scarlatina; however, a small spotted  injection is 
ANATOMICAL CHANGES.
207
often found on their posterior surfaces, at least in the beginning
of the disease.  The hairy scalp usually shows a punctate exan-
them, as upon the neck and trunk and upper halves of the ex-
tremities.   Not infrequently the spaces between the spots are
wider on the  legs and forearms than on most parts of the body,
and sometimes entirely unaffected portions of skin, of small size,
are found here, but on the other hand adjoining  them there will
be portions of equal size, which are uniformly reddened ; conflu-
ent redness is frequently seen, especially in the vicinity of the
joints.   The exanthem also extends to the backs of the hands and
feet, but the eruption is somewhat different;  as in other parts, the
roseolae on the legs are flat, but are frequently papular on the
backs of the feet, though  between these papules the small punc-
tate spots are not entirely absent; a similar condition is found on
the backs of the hands.  But the exanthem on the palmar and
plantar surfaces is  always confluent and only moderately red,
even when there is marked redness of the general exanthem ; but
it is never punctate.  On  the external genitals of the female the
injection is also only moderate; while on  the  male genitals a
punctate exanthem  will be found on all the parts except the pre-
puce and perhaps a portion of the scrotum, which show a gen-
eral  redness.   The  glans  and labia  minora  may be either very
pale or again slightly injected, but not punctate or spotted.
   The  exanthem  quite  frequently  deviates from the  above
description ;  the  following  variations ought  to  be  mentioned.
First, the partial eruption.  Scarlatina may be developed only
on some parts of the body, as, for instance,  on the trunk  alone,
or only on  the  face (forehead,  temples,  cheeks),  neck, and
extremities, or only on a portion of the latter, particularly in the
region of the joints ; or, again, it may appear only on one extrem-
ity or a portion of it, etc.  When it appears on the face alone, a
correct  diagnosis can generally not be made except by weighing
the accompanying  symptoms; at other  times the face remains
entirely exempt, while a characteristic eruption covers all other
parts.   The exanthem, when partial,  is frequently anomalous in
other respects.
   The  exanthem may be very unlike the normal eruption  of
scarlatina, as for instance when it consists in  discrete, large roseo- 
208
THOMAS.—SCARLATIXA.
 los.  These  vary in  size from a lentil to a bean or the joint of
 a finger,  are  sometimes round, again  may have  more or  less
 indented  margins, are either not at all or only slightly elevated,
 and certainly not so marked as in measles, and do not have the
 characteristic  central elevations.  They are sometimes dissemina-
 ted over the whole body, including the face, but more frequently
 are confined merely to some parts, especially the neck and trunk.
 Sometimes  they disappear for a few hours to  reappear  on the
 following day for a  short time ; but  they may also  persist  and
 gradually develop into a confluent exanthem over the whole or a
 part of the  body.   In such cases it is not characterized by dark
 points, but  is rather of  a uniformly scarlet  color.   Undoubtedly
 the eruption on the face, and the similarity of the roseolae to
 those of measles, impart a strange character to this form of scar-
 latina ; nevertheless its nature is easily established by the accom-
 panying symptoms,  and especially by the occurrence of conflu-
 ence.   It is said that,  notwithstanding the occurrence  of  the
 latter, the outlines of the roseolae may still be distinguished by
 the existence of darker-colored spots, similar to the dark  points
 which appear  in those eruptions of scarlatina which  at first  are
 punctate and at a later period become confluent.
   According  to my experience those exanthems which appear
 at an  abnormally late stage of  scarlatina—deserving less signi-
 ficance when they are scanty, but, when  more profuse, entitled
 to the  term of pseudo-relapse "or  reversio eruptionis"—are
 specially  characterized  by the  partial, or at least  incomplete,
 character  of the eruption, or by its being confluent, with or with-
 out the spots spoken of above.  Occasionally such an eruption is
 found in  the commencement of the scarlatinous disease, and is
 then called "scarlatina variegata."
   Besides the hyperaemia  of the  exanthem there  is usually
 only a  very slight oedema of the superficial layers of  the skin
 (scarlatina laevigata); but sometimes  this oedema is much more
 considerable, so  that  one may rightly speak of a slight, general
oedema of the skin ;  and then probably the subcutaneous cellu-
lar tissue is also involved in the change to a certain extent.
This oedema is found more  especially  in the face ; its occur-
rence in the lower extremities, which are  sometimes swollen 
ANATOMICAL  CHANGES.
209
 in  the beginning of the disease,  may be due  to  other  causes,
 such  as  nervous  influences or renal  complication.  But the
 swelling of the skin is not always general ; it sometimes occurs
 only in those parts which were characterized by  a punctate
 injection at the outbreak  of  the eruption ; these swellings in
 the form of small but very abundant papules can  perhaps be
 better felt than seen (scarlatina papulosa).  They  are found on
 all parts of the body, and also on the face, where they sometimes
 cover the forehead in great abundance ; most often  they occur on
 the extremities, especially on the legs, the dorsum of the hands
 and feet, and in the latter situation they may even  precede the
 redness ;  they are  most profuse near  those roseolae which  have
 developed around  the opening of a hair follicle, in  the  regions
 last-mentioned.  A more or less general,  lichen-like and very
 itchy exanthem sometimes occurs in young children.
    A  miliary eruption  (scarlatina miliaris) is frequently engen-
 dered by the further development  of the papular form of scarla-
 tina.  Then  miliary vesicles,  about as large as a millet seed,
 and with turbid contents,  which are  said to have  an alkaline
 reaction,  may appear on all parts  of the body.  They  appear
 chiefly on the trunk, as a result of too great warmth with pro-
 fuse  sweating, or from  the  irritation of the skin by hydrothera-
 peutic manipulations;  they may appear on  those parts of the
 back which  are subject to pressure, as well as on those parts
 which are the usual seat of intertrigo (inguinal fold, genitals,
 nape of neck) ; the miliary eruption is also sometimes found on
 the face and lower extremities, in the latter case  especially on
 the papules situated upon the legs and feet.   In some epidemics
 miliary vesicles were so often  noticed, and in such abundance,
 that the normal eruption  was observed  only  in  the minority
 of the cases; in  other words,  the miliary eruption was  in fact
 the characteristic  of  the epidemic.   Such epidemics were for-
 merly called  miliary scarlatina epidemics or simply miliary epi-
 demics, and their  occurrence  was  erroneously ascribed to a
 peculiarity of  the  scarlatina contagion.  Experience, however,
has proved  that  the miliary eruption depends merely  on the
peculiar  disposition of the skin of the patients, and that its  con-
tagion can produce the  normal scarlatina exanthem Jn  others,
      VOL. II.—14 
210
TnOMAS.— SCARLATINA.
just as peculiar circumstances can  call forth the miliary form
in an ordinary normal case.   In ordinary cases of scarlatina the
miliary eruption is never  so  abundant as to obscure the scarlet
character of the eruption ; usually  only a few miliary vesicles
can be found on the skin.
   We mentioned above that when  the eruption is very intense,
very  minute violet points, due  to  the escape of the coloring
matter of the blood from the vessels, may appear on the skin,
wherever the  eruption  is present.   Under the influence of  a
hemorrhagic diathesis, which may be superinduced by a severe
scarlatinous affection, especially  under  otherwise unfavorable
circumstances, exudations of blood often  take place into  the
superficial layers of the skin, either in the form of larger points
than those above mentioned, or in  broad patches of  greater or
less extent; hemorrhages into the subcutaneous  cellular  tissue
may also occur.  According  to Hebra, in  adults these hemor-
rhages are found more  particularly in the region of the neck or
chest, on the back and around the joints ; according to Canstatt,
more  "on the inner surface of the upper  and lower extremities.
In children I have not observed that they occurred by preference
in any region ; I have  observed, however, that various transitions
take place to the milder forms of  hemorrhage, which are due
rather to the intensity of the  exanthem.   In severe attacks hem-
orrhages from internal organs and  mucous membranes are also
of common occurrence.   When the small points of hemorrhage
are very abundant and diffuse, the exanthem appears, on super-
ficial inspection, as if  of long  duration.  Mild hemorrhages often
occur at any period of the disease ;  they disappear in one place
while appearing more prominently  at another, etc.;  sometimes
the miliary vesicles also become hemorrhagic.
   Now and then the  scarlatina eruption is accompanied or  fol-
lowed by other forms  of cutaneous disease, such as herpes labia-
lis, acne, urticaria, pemphigus, ecthyma, varicella-like  and pus-
tular  eruptions, etc.;  there is no connection, however, between
them  and the scarlatinous exanthem ; they belong to the domain
of complications and sequelae. When convalescence begins,  and
the previously dry skin begins to  perspire,  sudamina  are  fre-
quently observed, but they are  not to be confounded with the 
ANATOMICAL CHANGES.
211
similar  appearances caused by the separation of the superficial
layers of epidermis, which contain no fluid.
   Immediately after  the disappearance  of the exanthem  an
abundant formation of boils has also been observed.
   In septic  conditions gangrene of the skin, with  or without
gangrene of the subcutaneous cellular tissue, is not infrequently
met with.  This is found especially on those portions of the skin
which have been subjected to pressure  (gangrenous  decubitus),
but also on those portions which were only characterized by an
intense exanthem.

   Thus Braun, in the epidemic at Furth, in 1840, saw dark, bluish-red, marbled
spots appear, usually first in the pubic region, and from these the epidermis sepa-
rated, as it does in a blister, and showed the gangrenous and fetid cutis beneath.

   Frequently there is no post-mortem  appearance of the exan-
them in the bodies of patients who have  died during the eruptive
stage ;  occasionally, however,  when the inflammation has been
very severe,  the skin still appears red, and in  these cases the
cutaneous  vessels  contain much blood.  When the latter are
injected with a colored fluid, a picture of the exanthem very sim-
ilar to that  in life may sometimes be produced.  According to
Noirot, the  epidermis of  scarlatinous cadavers, a few days old,
can be more easily removed than from  cadavers with a healthy
skin, especially from parts of  the body which have  lain under-
most.  Loschner ascribes  this phenomenon  to  the  effect of a
chemically peculiar exudation into  the rete Malpighii,  whose
nature he could not ascertain, and in which, under the micro-
scope, exudation cells of variable number, form,  and size could
be recognized.  Fenwick found  the rete mucosum quite thick-
ened, containing numerous round cells  with large nuclei. The
basement membrane of the sweat glands was also thickened, and
the lining epithelium was in some places entirely gone, though in
most  places it  had increased in size to  such an extent as to
occlude the sweat canals.  Some sweat  glands contained blood,
and were thereby irregularly and very much expanded ;  in other
cases the sweat canals and uppermost layers of the epidermis had
a hemorrhagic coloration.  At any rate, these changes were  all 
212
THOMAS.—SCARLATINA.
observed in the  superficial layers,  while the  deeper cutaneous
layers were normal throughout.

   These results might give rise to the supposition that some kind of a relationship
existed between the scarlatinous eruption and  the sweat glands.  In this respect a
report of Landenberger is of interest; he observed the exanthem, in a boy ten years
of age, on the cicatrix of a burn (covering a space about two feet square), which
extended over the thigh, abdomen, and back, " the skin having been destroyed in its
whole thickness.  The  cicatrix  was involved in the  scarlatinous process, was
hyperaemic and cedematous, and  a slight desquamation  began in it before it com-
menced in the other parts.  This, however, did  not end the case, for a portion, about
the size of the hand, underwent diphtheritic necrosis, and yet no signs of diphtheria
had appeared in the throat or elsewhere. A flat ulcer resulted, with sharply defined,
slightly reddened edges, a slimy,  grayish, easily bleeding base, and a thin, scanty,
sero-purulent secretion.  Within a few days the ulcer slowly enlarged, and would
have destroyed the whole cicatrix, if death had not occurred from other causes."

    The cutaneous affection of scarlatina, which, as we have seen,
is not merely a hyperaemia, but is also characterized by an exu-
dation into the rete Malpighii, is not concluded when the charac-
teristic eruption  has paled; other disturbances,  which   have
arisen  during the  inflammation  of the superficial  cutaneous
layers,  must also  run their course.  These result in an excessive
production of newly formed epidermis, which is followed, a short
time  after the exanthem has paled,  by an abundant exfoliation.
This desquamation varies according  to the time of its commence-
ment, duration, intensity,  and form. It  may follow close upon
the eruption, or a few days after it, but  only in rare cases  after
the lapse of a few weeks ;  and the process may either last  but a
few days,  or, when the  eruption  has  been intense and has ap-
peared  very early,  it may continue  for several weeks.  It may
affect either the whole body—sometimes  recurring  several  times
on  portions of the  body which have been strongly affected—or
only certain  parts,  those for instance which have a thicker epi-
dermis, as the palmar and  plantar surfaces.   In the latter case it
undoubtedly also occurs on the remaining portions of skin, but is
not recognizable on account of the minuteness of the scales.   To
a certain extent the intensity of the desquamation is dependent
on the  exanthem; an intense exanthem, however, is not inevita-
bly followed by an  abundant desquamation,  nor a feebly marked 
ANATOMICAL CHANGES.
213
exanthem by a slight desquamation.   This is proved by the fact,
which has been corroborated b}^ many authors, that a character-
istic desquamation may occur on  portions of the body on which
there has been no eruption whatsoever, and also in patients in
whom there has  been but little redness of the skin, or even none
at all.  The explanation of this circumstance is, that hyperaemia
is not the  sole expression of the cutaneous affection, and that
increased proliferation of the  epidermis can take place  without
it. The character of the desquamation varies in different patients
and on different portions of the body ; it may be branny (desqua-
matio furfuracea), but is  usually lamellar (desquamatio mem-
branacea), and the several lamellae may be either small and deli-
cate or voluminous and  thick.   Branny desquamation  usually
occurs on a delicate epidermis, after a mild exanthem, and usu-
ally follows that form in which the punctate portions of  skin do
not become confluent; it  also occurs in the face, excepting the
forehead, and greatly  resembles  the desquamation of measles.
The lamellar desquamation is most characteristic on the palmar
and plantar surfaces, from which in children broad pieces of dry,
unaltered epidermis may be peeled off; in the case of a finger, for
instance,  the whole epidermal  envelope may sometimes be drawn
off like a glove.  Broad surfaces  on the forehead and abdomen
are sometimes found covered with half-dried epidermis only par-
tially attached to the underlying skin.  Storch saw portions sep-
arate which were seven inches long by three inches in breadth.
Sometimes the epidermis is seen  to exfoliate in the following
manner:  it becomes elevated in the form of a small vesicle, about
as large as the head of a pin,  but empty, and gradually extends
towards the periphery, until,  by the coalescing  of  this  with
neighboring ones, the skin appears to be separated from its con-
nections  over quite large tracts.  These little vesicles at first
resemble the sudamina; afterwards,  besides being dry and con-
taining no fluid, they are distinguished from them by the con-
struct ion of their base, which  consists of completely formed dry
epidermis.  ' Such vesicles frequently lose their epidermal  cover-
ing at an early period, and then appear as  circular excavations,
which usually extend in  a rapid manner by the continued exfo-
liation of epidermal scales from their margins.   The branny and 
214
THOMAS.—SCARLATINA.
lamellar desquamation on the trunk usually takes place in this
way.
  Although not the rule, it is yet not  a rare thing to find a
second desquamation following the first, over a limited extent
of skin; for instance, immediately after the eruption has faded,
there may be a branny desquamation followed later by one in
which the epidermis peels off in lamellae, or  both times the des-
quamation may be lamellar in character ;  on the other hand, it is
rare for desquamation to occur twice over more extended regions
of the body or over the whole of it; a still rarer occurrence is it
for desquamation to take place more than twice.

   Jadioux describes  a case in which  a fifth and sixth desquamation appeared
within two and a half months after the cessation of the scarlatina, and even then the
process did not seem to have ended.  In some places  the desquamation had a pecu-
liar character; on the scalp it occurred in numerous branny scales, while on the rest
of the body it was lamellar in character; on the arms the scales were disposed in
parallel circles, like bracelets, several centimetres in breadth, but in such a manner
that their free margins were always turned towards the lower portion, and their
attached edges towards the upper portion of the limb ; on the trunk the  desquama-
tion was similar, but its circular form was less manifest.

   Several authors have made the  observation that the process of
desquamation can involve even the nails  of the fingers and toes,
and that the hair sometimes falls out.  Lentin  has seen warts
drop off after scarlet fever,  and Bicker has seen  the same thing
followed by excoriations.
   After desquamation has ceased, the skin usually remains free
from further disease, except in cases of  relapse, which are fol-
lowed  by renewed and sometimes very complete desquamation.
It is very rare, however, for new roseolae or other exanthems to
appear at this time, when the course  of  the  general disease has
gone on regularly.
   The changes in the organs of the throat constitute as  essential
a feature of the scarlatinous disease as the exanthem itself ;  the
latter  may  be  wanting  altogether or may  be developed only
slightly, while  the  former will rarely be missed.  It is only in
exceptional cases that the throat is involved to so slight  a decree
that one might possibly overlook this  feature of  the  disease. 
ANATOMICAL CHANGES.
215
While it is customary, for the sake of clearness in  the descrip-
tion, to recognize different forms of pharyngeal trouble, these are
in reality only different grades of one and the same process.
   The mildest form of angina scarlatinosa consists in a moderate
and uniform redness of the  soft palate and neighboring parts,
but more especially of the uvula, the anterior palatine arches and
the tonsils; in some cases the redness may be confined to only
one or more of these parts.   The posterior wall of the pharynx
usually remains free.   Swelling of the mucous membrane  and
increased secretion are also absent.
   When, however, the angina is more intense, the parts involved
become swollen, and the redness is of a deeper hue ; the conges-
tion also extends, though only to a slight degree, to the anterior
half of the velum, as far as to the hard palate, and to the poste-
rior wall of the pharynx, which shows an increased activity of
secretion.   Upon the reddened mucous membrane, especially of
the soft palate, small elevations arise, like the swollen follicles in
an ordinary catarrh ; they are of a darker red, about the  size of
a  pin's head, and separated  from each other  by pretty regular
intervals ; as a rule  they progress no further, but sometimes,
when  the  mucous membrane  is  more acutely inflamed, they
burst,  leaving  behind small,  superficial ulcers,  which  rarely
attain  the size of a lentil; I have never seen deeper collections of
pus resulting from these follicular formations.  The  oedematous
swelling of the mucous membrane  is restricted chiefly to the
uvula  and  anterior palatine pillars.  The tonsils are also en-
larged to  a variable degree, and small follicular abscesses some-
times form in them.  Generally, in the course of a few days, all
these changes disappear entirely.
   Where the throat is still  more severely affected, the mucous
membrane is of a dark, livid  color, the parts are more markedly
swollen, and there is  a more abundant secretion.  The redness
now involves not  only the pharyngeal  region, but also the entire
mucous membrane of the mouth, even to the  lips, and also the
nasal mucous membrane ; these parts, furthermore, may be swol-
len, and from the nose there may be an abundant secretion.
   The oedema of the soft palate  may be so considerable as to
render deglutition  very difficult,  so that when the attempt is 
216
THOMAS.—SCARLATINA.
 made to swallow,  the substances taken regurgitate  through the
 nose.   The  tonsils  are usually much swollen, occasionally to
 such a degree that they touch each other;  abscesses in them are
 more frequent in this than  in the previous  form.   Respiratory
 derangements, however, do not occur, nor is the larynx, judging
 from the voice and the entire absence of cough, affected, unless
 perhaps to  a slight  degree.  The duration of  such an intense
 affection usually comprises two weeks, and  enlargement of the
 tonsils frequently remains after it.
    From these remarks it appears that the pharyngitis of scarla-
 latina,  in the majority of cases, and at least in those  of moderate
 intensity, is not diffuse  and  general, but is  confined to certain
 sections of the throat.

   For those who wish to satisfy themselves of the specific character  of the scarlati-
 nous angina, Harlin recommends the removal of the affected parts from the cadaver.
 He maintains that the peculiar condition of the throat in scarlatina can be recog-
 nized even in those cases in which death has occurred at a late period, and in those
 which during life showed but slight subjective and objective symptoms. As a char-
 acteristic sign he describes  a deep, bluish-red injection of the mucous membrane of
 the tonsils and neighborhood, of the soft palate, of the uvula, of the posterior por-
 tion of the tongue, in the neighborhood of the highly swollen papilla?, of the poste-
 rior portion of the region of the cricoid cartilage, and of that portion  of the pharynx
 which includes these different parts, and measures about two inches in breadth; he
 maintains, furthermore, that the peculiarity of this coloring lies in the circumstance
that in the direction of its transverse diameter it is very sharply  outlined, never
passing gradually into that  of the neighboring normal tissues; and finally, that
 wherever the parts are inflamed, the mucous membrane will be slightly swollen, and
 the submucous connective tissue infiltrated with serum.

    The highest grades of scarlatinous angina, besides  causing the
 above changes, may be associated with very marked disease of
 the connective tissue  of the neighboring parts (angina maligna).
Besides an intense oedema of the mucous membrane of the throat
and parenchymatous  inflammation of the tonsils, the region of
the parotid  and submaxillary glands, and frequently the entire
 cellular tissue of the  neck, may take on such considerable swell-
ing that, in milder cases, large tumors develop at the angle of
 the jaw, while in intense cases a single broad swelling, hard like
 a board,  involves the  whole  lower jaw,  extending upwards as 
ANATOMICAL  CHANGES.
217
 high  as to the temples, and sometimes downwards nearly to the
 clavicle.   In  like manner the  retro-pharyngeal  and laryngeal
 cellular tissue swells, and then causes respiratory disturbances,
 similar to those of oedema glottidis, and impossibility of degluti-
 tion.   Dispersion of  these various inflammatory  processes may
 take  place,  but must be  expected in only the relatively mildest
 cases. Very often extensive abscesses result, either in the tonsils
 or in the connective tissue.  Large  cavities filled with pus are
 thus  sometimes  found in the  tonsils, and  they either burst at
 once  or one after the other, leaving indolent ulcers ; furthermore,
 there may be retro-pharyngeal  abscesses, abscesses in the neck,
 etc.   Lastly, these inflammations may result in gangrenous de-
 struction.   Gangrene of the tonsils  usually commences at  an
 ulcerated spot, where an abscess has recently broken ; sometimes
 it occurs even before the  abscess has discharged, a point on the
 summit of the inflammatory swelling assuming a livid hue.  Gan-
 grene may not only destroy the tonsils so that almost the entire
 gland comes away in one piece, but the destructive process can
 also spread  in all directions from this point of origin, destroying
 the arches  of the palate, the uvula, and even the whole of the
 soft palate.   Gangrene of the connective tissue of the neck may
 cause enormous  defects ; the skin having  been destroyed, the
 muscles are seen  discolored and bare, as if dissected out, and the
 vessels lie exposed to view ; not infrequently fatal hemorrhages
 result from  not only the smaller vessels, but also  from  the  caro-
 tid and internal jugular.  The exposed surface secretes a putrid
 ichor, and the disease, if it has involved a considerable area and
 has extended deep, usually ends fatally, with symptoms of gen-
 eral  blood-poisoning ; recovery can only take place when the
 gangrenous  portions are small,  as when the  destruction has been
 confined to the tonsils.
   Diphtheria is so often a complication of scarlatinous angina
 that many authors have assumed that  a necessary relation exists
 between both diseases, and that  the  diphtheritic inflammation
 of the throat is  a direct effect of the contagion of  scarlatina.
 The fact  that scarlatinous diphtheria is not distinguished by any
peculiarity of either form, seat, or course from simple diphtheria,
proves the incorrectness of this view ; like the  latter,  it  may  be 
218
THOMAS.—SCARLATINA.
confined merely to  the throat and to parts which are primarily
not affected in scarlatina, or can spread to the  nose and larynx,
or lastly, may affect the latter alone, as also the contiguous  por-
tions of the respiratory mucous membrane;  it  can extend from
the throat to the organs of respiration,  or from these to the
throat; it can remain mild and superficial, or spread in depth
and cause ulcerations, perforations of the soft palate, loss of the
uvula, destruction of the palatine arches, etc.  Diphtheria can be
a complication of the mildest, as well as of the severest scarla-
tinous throat affections;  in every case it naturally obscures the
characteristic appearance, and augments the intensity and  dan-
ger of the simple form, partly by the accession of the consequent
local symptoms, and partly also  by the diphtheritic constitu-
tional infection.   It can complicate scarlatina in every stage of
the disease ;  first, in the stage of  incubation, so  that the symp-
toms of scarlatina and diphtheria appear simultaneously ; or the
diphtheritic symptoms  may precede those  of scarlatina,   thus
causing the error of supposing that only one disease is present;
or, as most frequently occurs, after scarlatina has already existed
for several days, the  throat symptoms suddenly become aggra-
vated by the occurrence of diphtheria, or it appears immediately
after the scarlatinous process has run its course in the skin and
throat; or it occurs during the  convalescence from scarlatina
with or without  complications.  In like manner, scarlatina  may
at any time  complicate a diphtheria, though this is of  rarer
occurrence than the former case.
   In the beginning of the disease the tongue has a more or less
extensive white  coating, from which the more  swollen fungi-
form  papillae  project as red nodules, often surrounded by an
additional white margin; at the same time the whole tongue also
becomes reddened, especially at the apex and edges.  Soon, per-
haps already on the second or third day, the entire coating of the
tongue together  with the superficial epithelial layers, exfoliates
either at once or in successive sections in a manner found in no
other disease ; the tongue then appears of a uniform and usually
quite intense redness, without any coating, but with the above-
named small  nodules ; it is also swollen, so that the teeth cause
indentures at the margins.  Less often the coating is either not 
ANATOMICAL CHANGES.
219
cast off at all, or only to a limited extent, the posterior portions
of the tongue remaining covered with it, while the anterior half
shows the characteristic dark-red coloration and is smooth, ex-
cept where the papillary swellings project; still less often the
swollen papillae are absent entirely, and then the tongue resem-
bles that of  many other diseases.  As a rule, the tongue regains
its  natural appearance during convalescence ; as the exanthem
pales the  redness  disappears,  the papillae diminish  in size, and
the organ again becomes slightly coated.  At times an eruption
like miliaria appears on the tongue, and is most manifest  on its
anterior surface.   Betz describes this as a clear, serous, or also
occasionally sero-purulent exudation upon the surface of the
papillae fungiformes ; when the exudation is clear, it appears in
the form of dew-drops seated upon these fungiform  papillae.  In
severe cases, with high fever and well-marked cerebral  symp-
toms, the tongue often becomes  dry, and deep  and shallow fis-
sures occur  in  the middle and along the sides, as  in other dis-
eases, but at the same time it does not lose its characteristic red-
ness and exfoliated condition.  The fissures may be  the exciting
causes of  deeper ulcers and diphtheritic processes.
   The gums and mucous membrane of the cheeks participate in
the inflammation only in intense cases, and  then are moderately
reddened.  The mucous membrane of the lips is more frequently
and intensely reddened ; in severe cases they often swell, become
covered with  crusts  and  fissured, and even the seat of deep
ulcerations.
   When the course of scarlatina is normal,  the mucous  mem-
brane  of  the nose is usually pale,  and its secretion is not in-
creased.   When the disease is severe, however, the nasal mucous
membrane frequently becomes involved, though probably never
primarily; the trouble always originates in a preceding affection
of the throat, such as intense inflammation of the mucous mem-
brane,  parenchymatous affections of the tonsils (with or without
gangrene) or diphtheria of the throat.  In  the  latter case, the
mucous membrane of the nose also becomes affected with  diph-
theria, at least throughout its posterior portions,  while  those
more  anterior are frequently only affected with a  purulent ca-
tarrh ; but the formation of diphtheritic membranes may extend 
220
TnOMAS.—SCARLATINA.
even to the  nostrils.  After the diphtheritic membranes have
exfoliated, new  ones frequently form.   In the other forms of
severe inflammation of the throat the nasal mucous membrane,
already in the first days of scarlatina, or somewhat later, swells
more or less, is reddened, and furnishes a thick or thin purulent
or ichorous secretion, which, as in diphtheria of the nose, corrodes
the nostrils and upper lip, and causes  redness, inflammation,
and ulceration in them.  This is the much-dreaded scarlatinous
coryza.   In a favorable case the secretion gradually becomes
muco-purulent and then mucous, and at the  same time dimin-
ishes in quantity ; while in an unfavorable case, extensive ulcera-
tions result, especially in the posterior nares, and thus a chronic
nasal disease  is  engendered with a more or less profuse, often-
times offensive and ichorous secretion; more rarely gangrene of
the soft parts and necrosis of the nasal bones result.
   The scarlatinous  affection  of the nasal mucous  membrane
can also extend to the cavities adjacent to the nose, especially
the antrum Highmori.
   The eye may become affected at different times and in various
ways during  the  scarlatinous disease.  In severe cases, and gen-
erally upon the appearance of the exanthem, the conjunctiva of
the lids and sclerotic shows a glistening appearance with distinct
injection of the vessels, and with or without oedema of the lids;
this usually disappears sooner or later  after  the  eruption has
faded, the process being accompanied by either very little exuda-
tion or none at all.  In case of diphtheria of the throat, the same
process, according to Schroter, also occasionally attacks the con-
junctiva of the eye, and often  leads to ulcerative destruction of
the cornea.  Furthermore, according to Schroter, the cornea may
also be affected primarily and independently, usually  in the way
of rapidly progressing abscesses or suppurating ulcers or perni-
cious kerato-malacia, in which the cornea of  one  or  both eyes,
without any marked symptoms,  becomes  turbid in a few days, is
transformed  in  its totality into a turbid, dirty,  grayish-white
membrane, and  exfoliates  piecemeal.  Occasionally the inflam-
matory process may travel from here over  the whole uveal tract
and cause panophthalmitis and  phthisis  bulbi.  In rare cases  a
purulent choroiditis  or panophthalmitis  occurs  primarily from 
ANATOMICAL CHANGES.
221
embolic processes, as in typhus or puerperal diseases.  Lastly,
in case  of coincident renal disease, a peculiar  form of retinitis
must be mentioned, which usually appears in  both eyes simul-
taneously and with equal intensity, and which presents the typi-
cal picture of retinitis albuminurica upon ophthalmoscopic ex-
amination.
   During the existence of the scarlatinous eruption, and also
immediately after its cessation, affections of the ear frequently
occur in connection with the throat disease ; they are often tedi-
ous  and may become chronic.   Wendt  states that while in mea-
sles  the catarrhal form of inflammation either of the middle ear
or of the Eustachian tube is  the rule, in scarlatina that form of
inflammation  is by far  the most common  which leads to  the
accumulation  of pus or  muco-pus in the cavities  of the middle
ear,  and by perforation of the membrana tympani to a discharge
of the matter into  the  external auditory canal (otorrhcea).  As
a further consequence of the inflammation, important  acoustic
parts may become bound down by adhesions formed while the
mucous membrane was in a swollen condition, or they may even
become destroyed altogether ; ulcerative destruction of  the bor-
ders of  the perforation in the membrana tympani may also take
place, though  an extensive acute tissue necrosis rarely occurs in
this membrane. It is also rare for the mucous membrane lining the
cavities of the middle ear to undergo such tissue necrosis, either
with or without an accompanying caries of the subjacent bone;
in fact it never occurs, unless the parts have been affected with
diphtheria or  a very severe inflammation, or the  patient has a
poor constitution.   When the affection is severe the periosteum
of the mastoid process,  as well as of the squamous and petrous
portions, may also participate in the process of  swelling and for-
mation  of  pus; sometimes the bone and  periosteum  of these
portions become diseased, while the auditory apparatus proper
remains unaffected.  Lastly, we find severe inflammations of the
middle ear accompanied by swelling of the skin lining the exter-
nal auditory canal; also swelling of the soft parts around the ear
as collateral or inflammatory oedema; less frequently this oedema
is due to the  burrowing of matter, especially in the direction of
the parotid region. 
222
THOMAS.—SCARLATINA.
   The mucous membrane of the larynx  usually remains intact
in normal scarlatina; or at most, when the throat affection is
intense, it may be affected very mildly.   It is  only when the
angina is  very severe, and especially when it becomes gangrenous
and is accompanied by inflammation  of the connective tissue of
the neck—that is, at  the commencement of the attack—that the
connective tissue at the entrance of the larynx becomes infiltra-
ted, that the mucous membrane  in this region becomes ulcerated
and the seat of a purulent catarrh, which may last for a longer
or shorter period, and may even lead to  oedema of the glottis.
(Edema of the glottis, however,  may appear  at a later period of
the disease, during the existence of a  general dropsy, and either
with or without actual inflammation of  the laryngeal  mucous
membrane.   The larynx may also become diseased during the
course of scarlet fever from  still  another cause, namely, diph-
theria ; for the statement that  in scarlet fever  the  diphtheria
never extends to  the larynx is incorrect.  In fact,  diphtheria and
croup of the larynx may not only occur during the course of an
extensive pharyngeal diphtheria,  but may even precede it,  in
some cases  manifesting  itself as early as  during  the  prodromal
stage of scarlet fever.
   According to Ruble, diphtheria, when occurring as a complication of scarlatina,
sometimes produces very extensive destruction of the tissues.  Albers saw two cases
in which there were numerous ulcers extending even into the trachea.  Franque
found the thyroid cartilage entirely destroyed in one case; and  in Smith's case the
vocal cords and the ventricles of Morgagni were no longer recognizable.

   A moderate catarrh of the bronchial tubes is quite often pre-
sent during the early stage of the disease in severe cases of scar-
let fever, and when dropsy follows the attack a bronchial catarrh
is almost the rule. In those cases where there has been an oppor-
tunity of  making a  post-mortem examination, the reports state
that the redness  of the  trachea  and  large bronchi was uniform,
and that this change, together with a  certain  degree of swelling,
could be followed even into the finest  bronchial tubes.  In hem-
orrhagic  scarlet fever punctiform extravasations  of blood have
also  been observed  throughout  the bronchial  mucous mem-
brane; and  where there has been a diphtheritic complication, 
ANATOMICAL  CHANGES.
223
false  membranes may be  found  extending a long distance  into
the lungs.
   Pneumonia, either with or without a simple bronchitis, more
rarely complicates  scarlet fever than  measles, and when it does
occur it is only in the most severe cases.  It develops under a
great variety of forms: generally as a lobular broncho-pneumonia,
together with bronchitis,  though at other times as a lobular or
lobar croupous pneumonia.   In scarlatina haemorrhagica extra-
vasations  of blood, of varying number and size, may  be found
in the lungs ;  where pyaemia follows scarlet fever, wedge-shaped
deposits and  abscesses may form  in these organs.  Gangrene of
the lung has also been observed, either in connection with or inde-
pendently of gangrenous affections in other parts of the body.

   In  one case, where death had occurred  as a result of anuria and  convulsions,
Biermer found that the tissue of the lung, which naturally is peculiarly dry and
inelastic, had everywhere become slightly changed: the walls of the  alveoli were
thicker than usual and beset with numerous nuclei.  In the upper lobe of the right
lung a hemispherical nodule, about the size of  a hazel-nut, pretty tough in consis-
tency, and of a uniform grayish-red color, was found projecting slightly above the
surface; this mass, upon more careful examination, proved to be composed of a num-
ber of separate small round masses, about as large as millet seeds, which were also
to be  found singly in the neighboring lung-tissue.  The small cells of  which these
masses were chiefly composed, possessed relatively large and well-defined nuclei, and
were so closely crowded together that no trace of the structure of the part could be
seen;  it was only in the scattered masses that it was  possible to determine the fact
that the growth  of these cells proceeded from the walls of the  alveoli. Similar
growths were found in the connective tissue of the pleura.

    The lymphatic glands and the  cellular tissue adjacent  to
them are frequently the seat of disease.   As a rule, quite early in
 scarlet fever  the superficial glands (especially those of the axil-
lary, popliteal, and inguinal  regions)  are appreciably swollen,
and  a  post-mortem examination during the first stage of the
disease not unfrequently  reveals considerable  enlargement  of
the  deeper glands.   Most prone  to  be affected are  the  lym-
phatic glands of the neck,  owing no doubt to their intimate ana-
tomical connection with the  organs of  the throat, which fact,
 to-ether with the skin eruption, should be borne in mind in con-
 sidering the etiology of  the  disease.   But it must not therefore 
224
THOMAS.—SCARLATINA.
 be supposed that the intensity of the skin or throat affection is
 in  direct proportion  to the degree of enlargement of the lym-
 phatic glands, for many cases are met with in which the con-
 trary is true.   Frequently a very serious affection of the lym-
 phatic glands is associated with an insignificant angina or with a
 very slight exanthem, while on the other hand a slight affection
 of  the glands, with a well-marked lesion of the skin and throat,
 is a much rarer  occurrence.  Moderate inflammatory  enlarge-
 ment of the  glands  ends, as a rule, in resolution; while if they
 are very much  inflamed and enlarged, it is almost impossible to
 prevent suppuration, which event, however, in some cases, takes
 place very slowly; it will also frequently be found that glands
 which have at first  only been moderately enlarged,  and which
 have remained in that condition for several weeks, will suddenly
 increase  in size and suppurate, sometimes  on both  sides and
 again only on one side.  Most of these abscesses, after they have
 been evacuated, heal  slowly, but  some of them very rapidly;
 sometimes the  pus burrows to  a dangerous extent, perhaps  as
 far down as  the  thorax, and pyaemia may ensue.  A still more
 unfavorable result is where the inflammatory engorgement ends
 in sloughing, which  is most likely to occur when there is a gan-
 grenous or diphtheritic angina.  In this case, when the abscess
 breaks or is opened, the discharge is found to be a poor thin pus,
 which  soon changes  to an ichorous fluid ; at the same time the
 opening grows  larger and larger, its  edges become thinner and
 keep steadily receding, until finally there is an opening the size
 of a silver thaler,  and, the cellular tissue having been completely
 destroyed, the denuded muscles and vessels form the bottom of
 the  ulcer.   Fatal  hemorrhages not  unfrequently occur from
 erosion of the vessels, though blood-poisoning is the most fre-
 quent  cause  of death; now  and then, even in this  state,  the
gangrenous process stops, the dead tissues are thrown off,  the
ulcer becomes a healthy one, and recovery takes place.   The
gangrenous process may even extend up on to the face  (Hey-
felder).
   As regards the anatomical conditions of the affected cervical
glands,  Barthez and  Rilliet found  the  submaxillary glands
enlarged, hyperaemic,  and  softened, or, in a later stage, grayish, 
ANATOMICAL CHANGES.
225
very compressible, and the seat of considerable purulent infiltra-
tion, and in their interior, little abscesses full of thick, creamy
pus.  The affection of the cellular tissue is undoubtedly of an
inflammatory  nature,  and does  not involve  the parotid gland;
hence the name of parotitis, frequently applied to it, is incorrect.
Nevertheless it is very probable that  the anatomical changes of
the mumps, that is, the isolated affection of the cellular tissue
of the parotid region, commonly known by the name of parotitis,
more correctly paraparotitis, may occur as  a sequel of scarlet
fever, independently of the general inflammatory affection of the
cervical cellular tissue.
   Of  quite a different nature  are  those  enormous swellings
which extend from the chin back to the mastoid process, and up
over the edge of  the  jaw on to the cheek, and far down on the
neck, and are of  a reddish or livid blue color, according as their
cutaneous covering is more or less stretched and distended ; they
occur, as a rule, only on one side, rarely on both sides, and when
cut into are found to contain nearly pure  blood  (according to
Huber,  haematoma scarlatinosum).  They are probably the pro-
duct of a hemorrhagic inflammation  of  the cellular  tissue (per-
haps in consequence of lymphadenitis), and should by no means
be confounded with  those effusions of blood due to  erosion of
large blood-vessels during gangrenous destruction of the connec-
tive tissue of the neck.
   Extensive  infiltration of the cellular  tissue,  with  the forma-
tion of  abscesses, may occur not only on the neck and in con-
nection with inflammation of the lymphatic glands, but also at
all other points and quite independently of the latter.
   In one case I observed  purulent infiltration of the cellular tissue of the right
hand requiring incisions upon the. back and palm, and the extension of which only
ceased with death; in such cases not unfrequently the  periosteum and even the
bones become involved and deep destruction occurs.
   Severe cellulitis is  especially likely to be caused by septic
poisoning, as it  is seen to  occur when  absorption takes place
from points that are the seat of gangrene; from this, as well as
otlier causes, gangrenous decubitus may obtain in an incredibly
short time.   Still another cause of cellulitis are the hemorrhages
into the cellular tissues during hemorrhagic scarlet fever.
        VOL. II.—15 
226
THOMAS. —SCARLATINA.
   Extravasations  may likewise  take place in the  muscular
tissue (Huguenin).
   Very often nothing abnormal is found in those cases which
die early in scarlet fever with  severe brain  symptoms; but in
many of them there is congestion of the cran ial viscera, hyper-
aemia of the brain (studded with red points, and in some portions
uniform  reddening of the white and  darkening of the gray sub-
stance)  and of the pia mater;  the large  veins and sinuses are
frequently gorged  with blood.  Other brain  anomalies and
inflammation of the  meninges are  not  common ; meningitis,
oedema  of the brain, effusion into the ventricles,  are observed
only exceptionally, while apoplexy,  sinus-thrombosis, etc., are
exceedingly rare.  When, however,  after hydrocephalic  symp-
toms, death takes place in the later stages of the disease, oedema
of the brain and  hydrocephalus will be found, and may be
ascribed  as the cause of death  in those cases in which serious
disturbances of  the  nervous system have been the prominent
symptoms.  Nothing certain is known concerning those anatom-
ical  changes of  the spinal  cord which the symptoms in  a few
of the serious cases lead us to suppose may exist.
   There is found in scarlet fever no constant or characteristic
condition of the mucous membrane of the organs of digestion, as
was  found to be true also  of that of the air-passages, and  an
extension of the throat affection into the oesophagus is as rare
as into the larynx, though, according to Canstatt, there is often
more or less hyperaemia of the mucous membrane of the former.
The  mucous membrane of the stomach and  intestines, in cases
which have been most carefully and microscopically examined,
has been found perfectly normal or only affected with some inci-
dental lesion, as for instance, tubercles.  A permanent hyper-
aemia of the  mucous membrane  does  not indicate, as was
formerly erroneously  thought,  an  exanthema of  the mucous
membrane, but  denotes in severe cases, as in other acute exan-
themata, the presence of a catarrh.  In consequence of this, the
mucous membrane of the stomach is hyperaemic and swollen
and  covered with a tenacious mucus, and there is probably an
increased production of epithelial cells both in the interior of
the tubuli and upon the free surface of the mucous membrane, 
ANATOMICAL CHANGES.
227
 and the nuclei  of  these cells  are  found  in greater abundance
 than usual in the mucus.

    According to Fenwick, in the beginning of scarlet fever the tubuli are filled and
 distended with a granular and fatty material, or with granules mixed with small
 cells, which are found in greater numbers than usual in the contents of the stomach,
 and which, according to Hillier, sometimes retain a tubular shape; after the second
 or third week, however, the tubuli are less distended, and only their blind extremi-
 ties are filled  with granular material.

    Hemorrhagic erosions sometimes occur  in the  mucous mem-
 brane of the stomach.  In the small intestine, besides more or
 less injection  of  the mucous membrane,  as  a  rule,  only at
 isolated  portions of greater  or less extent, and in  a few cases
 throughout the whole  intestinal tract, from the duodenum to the
 caecum  and colon,  there is a swollen condition of  the glands,
 partly those of  Brunner and Lieberkulm,  but  especially of the
 solitary follicles  and Peyer's patches, presenting a most striking
 resemblance to the changes found in typhoid fever, particularly
 if the patches are ulcerated,  as was observed by Deiters.  The
 follicular affection, which sometimes causes small extravasations,
 may, when it is not of  an intense  degree, exceptionally and  at
 isolated points of the intestine,  cause little ulcers, but in scarlet
 fever the large ulcerations, as seen  in  typhoid fever,  small-pox,
 or measles, are never met with.  Moreover, small extravasations
 have been found in  the mucous membrane, and especially in its
 villosities,  and Fenwick observed one case  in which  the latter
 condition was very striking.
   Tiingel observed "diphtheritic exudation" on the mucous membrane  of the
 lower portion  of the ileum, in a  case of scarlet  fever, followed by pysemic symptoms.
 E. Wagner found the whole thickness of  the mucous membrane of the jejunum and
 ileum, and particularly the villi of  the former, filled with cells and granules, but
 there was no  trace of any fibrinous formation;  the epithelial cells of the glands
 were opaque and slightly fatty.

   The mesenteric glands are generally found  hyperaemic, and
some of them considerably swollen, and,  when cut  into, their
tissue is found to contain more fluid than usual.
   Fenwick has found  the pancreas in a slightly inflammatory
condition;  many others have found  it quite normal. 
228
THOMAS.—SCARLATINA.
    The changes in the liver consist principally of a  more  or less
 albuminoid infiltration of the  secreting  cells ; substantially the
 same condition in which they are  found in many otlier diseases,
 simply as the result of fever.

   In a very flaccid, exsanguious normal-sized liver of a fatal case, of forty-eight
 hours' duration, and in the same organ,  enlarged by half its size, of a child three
 years of age, who died at the end of three and a half weeks, of diphtheria compli-
 cating scarlet fever, E. Wagner found numerous (here and there one  or two upon
 the surface of an acinus) white granules, for the most part very small,  but some of
 them larger and easily perceptible to the naked eye, which proved to be lymphoid
 new growths, and beside these he observed, by the aid of the microscope,  and par-
 ticularly in the interacinous connective tissue, numerous collections of cells and nuclei.
 The capsule  of the liver  contained similar granules. Huguenin reports  the same
 condition, while Biermer describes a peculiar growth of connective tissue around the
 liver cells.

   Whether such morbid changes are of frequent occurrence  is
 unknown  ; for generally only the size and degree of congestion
 of the liver are reported,  conditions which may easily  vary, and
 which are sometimes normal, sometimes abnormal;  the fact  is,
 no uniform condition of this organ seems to be found  in  scarlet
 fever.    The lymphatic glands  are frequently somewhat  hyper-
 aemic, enlarged,  and softened.  Icterus  has several times  been
 observed as a rare complication of the last stages  of scarlet fever.
 According to Harley, the gall is seldom normal, but very poor in
 its solid constituents, particularly the  biliary salts.
   There is no uniformity in the  morbid anatomy of the spleen,
as the reports of the different observers vary considerably, many
having found this organ of normal size (probably post-mortem ?),
 whether the case died early or late in the disease,  others again
 moderately enlarged, sometimes exsanguious or hyperaemic, of a
firm consistence, and sometimes  softened.    Judging  from  my
 own experience, for the most part among cases that  have recov-
ered, a slight enlargement of the spleen can,  as a rule, be demon-
strated  in severe cases of  scarlet fever, though very frequently,
owing to the  restlessness of the child, a thoroughly satisfactory
examination is not possible.

   Wagner found the neoplasms alluded to in the liver also in the spleen, and  he 
ANATOMICAL CHANGES.
229
 describes the texture of that organ as dark red, somewhat softened and studded
 with numerous exceedingly minute whitish granules, which are distributed along
 the course of the vessels and, when confluent, form pretty firm homogeneous masses.
 These new growths were seen very distinctly upon the walls of the medium-sized
 and minute arteries, as well as upon the corresponding Malpighian bodies, and it is
 probable that these granules were distributed throughout the whole substance of the
 6pleen.  Biermer has observed enormous enlargement of many of the Malpb-hian
 follicles.  Wedl has found hemorrhages under the  capsule of the spleen.  The
 lymphatic glands of the spleen are found  in the same condition as those in the
 liver.


   Morbid conditions of the genitals, in the early  stage of scarlet
 fever,  are most  frequently seen  in women (Cormack), less often
 in young girls.   The condition  most frequently  met with is a
 moderate catarrh  of the vagina, with  hyperaemia  of the  mucous
 membrane without ulceration ; among  boys, a slight balanitis
 may occur, with hyperaemia of the urethral mucous membrane.
 The internal organs  of generation in  the female are especially
 liable  to be affected during pregnancy, and abortion  may take
 place.   Roger found the testes  and the tunica albuginea very
 hyperaemic and somewhat softened, and Weber inflammation of
 both testes in consequence, he thinks (likewise Barach), of scarla-
 tinous parotitis ; in one case it was associated with acute hydro-
 cele.   The formation of  an abscess is extremely rare,  but it has
 been observed in the mammae, the labia majora, etc.
   Next to the  skin  and throat, with their pertinent lymphatic
 glands, the kidneys are the organs most frequently affected by
 scarlet fever. Notwithstanding this, in a great many of the cases
 which recover, they remain entirely normal, as they have fre-
 quently been found in cases which have proved fatal from some
 other  cause,  either  early or  late in the  course  of the disease.
 When they are affected there is found, in the first place, a catar-
 rhal condition, characterized by  a disturbance  of the epithelial
 elements of  the medullary substance, whereby they are  thrown
 off in large  masses  and washed away  (mostly  in  the  early
 stages of scarlet  fever, but exceptionally also  met with in  the
later  stages),  and secondly  an  affection  of  the  parenchyma
of these organs.   In this case  the cortical substance is partic-
ularly the seat  of changes;  the morbid process begins in  the 
230
THOMAS.—SCARLATINA.
Malpighian bodies and then follows the course of the convoluted
tubules.'
   Where there is only a slight  parenchymatous inflammation
causing no symptoms during life, or perhaps only a  slight albu-
minuria, E. Wagner says that  the kidneys  are in a condition of
congestive hyperaemia either without, or accompanied by, a more
or less marked degree of albuminous infiltration.  In the severer
cases with haematuria and albuminuria, the capsules of the kid-
neys are easily detachable, the organs enormously enlarged (Bier-
mer), and their substance very hyperaemic and softened,  and,
as a consequence, the seat  of numerous capillary hemorrhages.
Moreover, at various points the epithelial cells of  the uriniferous
tubules are found more or less clouded, enlarged, and changed in
position, or even entirely destroyed, or frequently, too, pushed
off, so that the tubules,  which beside them contain white and red
blood-corpuscles, as well as various quantities of cylinder-shaped
exudation masses, may  be completely blocked up, and thus give
rise to further disturbances.  Circumscribed inflammatory masses
are found diffused  throughout the  stroma, or  only at certain
points of the same, resembling abscesses and composed of small
round cells, the whole presenting an appearance of interstitial or
purulent  nephritis.   Sometimes during scarlet fever  regular ab-
scesses  form in  the kidneys.  In a few cases Klebs has found the
kidneys hyperaemic, firm in consistence, and not at all or only
slightly enlarged, and studded  with uniform white  points—the
Malpighian bodies—which are the seat of nucleolar growths in
the connective  tissue  between  the capillary loops,  completely
compressing  the calibre of the vessels  and thereby  causing
anuria.   Very exceptionally the severer forms of parenchymatous

   1 According to Taube, in the worst cases the morbid  process affects the membrana
propria both of the Malpighian bodies and of all the tubuli uriniferi, as well in the corti-
cal as in the medullary substance, in such a way that in it are developed fusiform cells,
which enlarge rapidly and completely fill up the interstices between the tubuli uriniferi,
but which, like the cells lining  these tubuli, undergo generally albuminoid, and if the
case be a  long one, fatty degeneration.  Thus is produced that condition described by
Baginsky, who found the external layers of the cortical substance in a state of complete
fatty degeneration, and the uriniferous tubes, the Malpighian bodies, and the interstices
transformed into a single mass of  fat, which even at some points seemed to be formed
into drops. 
ANATOMICAL CHANGES.
231
nephritis are met with, even in the beginning of scarlet fever, but
as a rule not before the end of the second or third week.  They
end in either complete recovery or death, very rarely in chronic
disease of the kidneys.
  In  scarlatina  haemorrhagica, Huguenin has demonstrated  a
diphtheritic affection of the mucous membrane of the pelvis of
the kidney,  which had given rise to copious hemorrhage.
   Dropsical effusion is a very common result of disease of the
kidneys  during scarlet fever, and is most  commonly seen as
anasarca, which, as a rule, is not, but  may  be, associated with
hydrops  of one or more of the serous sacs, or with oedema of the
lungs or brain, or with a condition of general dropsy.   Anasarca
is most frequently seen in the face, genitals, and inferior extrem-
ities, less frequently in the arms and abdomen, and least often in
the neck and heart.  In very severe cases every portion of the
body is  pretty  uniformly affected, while  in less  severe cases  it
may only be local, and it is  not rare to find one-half of the  body
more affected than the other.  The swelling is doughy and shiny,
and where the exudation into the  subcutaneous tissue is  con-
siderable, the impress of the finger remains for some time ;  occa-
sionally  even the  muscles are the seat of the oedema. Where
anasarca is  present, desquamation,  as a rule, apparently ceases,
probably because of the highly moistened condition of the epider-
mic scales, and returns only with the disappearance of the fluid.
There may  be  associated with anasarca a moderate degree of
ascites, which in severe cases may be excessive and accompanied
by hydrothorax and hydropericardium,  or  by oedema of the
lungs and glottis,  while hydrocephalus and oedema of  the brain
may occur without these  symptoms or with only a very slight
oedema.   In the cases of hydrops of the serous sacs, the trans-
uded fluid is, as  a rule,  perfectly clear, or  only very slightly
turbid, and when recovery takes place disappears completely.
   Genuine  inflammations of the serous membranes, with  sero-
plastic or purulent exudation, occur now and then; and although
they are  often observed during the  progress of the  kidney dis-
ease,  they are independent  of it.   Although very rare, menin-
gitis is  the  most  striking of these, covering with its purulent
exudation the whole surface of the brain and its sulci, and  is, as 
232
THOMAS.—SCARLATINA.
a rule, associated with a considerable effusion into the ventricles.
Or there may be a peritonitis, generally of a moderate type, with
a scanty, cloudy exudation, with or without a layer of fibrine.
Pleuritis of one side is  most frequently met with either quite
early or late in the disease, and it may or may not be attended
with pneumonia on the same side.  The exudation may be pretty
clear or clouded, sero-fibrinous,  and  contain  some blood, or it
may be pure pus ; its quantity may be insignificant or sufficient
to fill the pleural sac.  The course and duration of this  pleuritis
are the same as in a primary attack of that disease.  Pericardi-
tis  is less frequent, and its exudation, for the most part, serous
or sero-fibrinous ; it occurs sometimes  with a pleuritis, and some-
times in consequence of endocarditis, or an affection of the joints.
   Inflammation of the synovial membrane of the  joints occurs
most frequently just when desquamation is commencing,  but may
occur at any other period.  The joint affection is  sometimes so
slight that externally there are no  signs of it, the pain being the
only symptom; while again  it is  of  so severe a character that
the whole region is very much swollen, and  the skin over the
joint considerably  reddened.  It has a  serous exudation, and
runs, as a rule, an acute course.   The  smaller  joints of the
extremities are particularly liable to be affected. Still it  is not at
all unusual to meet with cases in which the hip, knee, shoulder,
and elbow-joints suffer, and now and then the sterno-clavicular,
infra-maxillary and vertebral articulations are inflamed.  These
lesions are all included under the general term scarlatinal rheu-
matism of the joints.  Sometimes, though quite rarely,  in place
of a more or less intense synovitis acuta with serous effusion, the
disease results in suppurative inflammation of the joint, and con-
sequent ostitis and periostitis, with  subsequent caries  and necro-
sis ;  or in fungous periostitis, or in inflammation of the ligaments
of the joint, or in relaxation of the joint and  spontaneous luxa-
tion.   As a result of the suppurative inflammation of the joint,
fistulous ulcers  are  formed,  the connective tissue between  the
muscles in the neighborhood of the joints suppurates, the mus-
cles themselves are destroyed, and  death ensues from pyaemia.

   The periosteum and bone become diseased, not only in con- 
ANATOMICAL CHANGES.
233
nection with the  joint affections or the ulcerations of mucous
membranes, as in the nose, throat, and mouth, or in connection
with inflammation of the auditory apparatus, but any part may
become the starting-point of  the disease.  The morbid process
does not attack the periosteum of all the bones at the same time
and to the same degree,  but  at one point it is more, at another
less severe; here it occurs earlier, there later.   So also the pro-
duct of the exudative process varies.  It is by no means uncom-
mon for the periostitis to be suppurative and to  lead to necrosis ;
indeed, some have supposed that most of the  cases of necrosis
occurring in childhood are due to an antecedent scarlet fever.

   In some cases of extensive suppurative periostitis, Betz found the ribs diseased
in numerous places; Hamburger, the metacarpal and metatarsal bones; Kennedy,
separation of epiphyses as a result of scarlatinal ostitis ; Graves, inflammation of the
cervical vertebrae, and v. Hauff, ostitis at the elbow and knee-joints.

    The implication of the muscles is shown by the occurrence of
isolated abscesses among these structures, or by serous infiltra-
tion of single muscles or groups of muscles.  But there are other
slighter affections, such as pain and difficulty in contraction, and
also certain forms of paralysis after scarlet fever, which  are of
more  frequent occurrence than  one  would  suppose from the
apparent condition of the parts.
    Scarlatinal rheumatism is characterized also by derangements
of the vascular system.  Besides pericarditis, which has already
been mentioned,  we meet with endocarditis, resulting sometimes
in valvular changes and chronic heart disease,  sometimes in acute
embolic processes.  Peri- and endocarditis are sometimes present
without a concurrent  or  a  pre-existing affection of  the  joints.
Not unfrequently the cardiac muscle becomes fatty,  and its fibres
exhibit a peculiar granular opacity, partly as a result of the high
fever,  and partly on account of other serious derangements.  Hur-
ley states that fibrinous coagula in the heart and  great vessels
are always found at the autopsy.   This fact readily explains the
presence of emboli in  the peripheral arteries.   The larger veins
often contain thrombi, especially after severe scarlet fever.   Sta-
ger mentions  the occurrence of thrombosis of  the sinuses in scar-
latinal diphtheria. 
234
THOMAS.—SCARLATINA.
   The blood is of a dark red color, thin, and generally contains
an excess of white blood-corpuscles.   The walls of the blood-
vessels often imbibe the coloring  matter, and thus  present  the
appearance of inflammation.

             Different Forms of Scarlet Fever.

   One of the most remarkable peculiarities of this disease is the
great variety of symptoms which it presents ; a variety so great,
in fact, that in consequence of the lack of sufficient  evidence
there is  still some doubt whether some of its forms should be
included under the general designation of scarlet fever.  For-
merly all cases of scarlet fever were divided, for the sake of con-
venience, into groups,  according  to  the general  picture of  the
disease, so to speak; that is, according to the character of  the
reaction  of  the organism;  hence, besides the  usual  and  the
abnormally light forms, a distinction was drawn between erethi-
tic, inflammatory,  nervous,  and septic  scarlet  fever.  More re-
cently  the division of Barthez and  Rilliet has been preferred,
which distinguishes not only between the primary and secondary
symptoms, but  also between the characters of the eruption, and
thus divides all the cases into those with a normal and those with
an abnormal eruption, all other details being referred to the chap-
ter on  " Complications."  This method has the merit of simpli-
city, but it necessitates a great many artificial subdivisions of no
special value.   Not only is  it often difficult to say whether  the
eruption is normal or abnormal, primary or secondary, perhaps,
also, whether simple or complicated, for the distinction is not
always easy, but it is by no means certain that we do not ascribe
too much importance to the  affection of  the skin.  It cannot be
denied that  the eruption occupies a prominent place among the
lesions of scarlet fever, not  only on account of its conspicuous
appearance and quite regular occurrence, but also because it is
one of the earliest signs  of the  disease,  and consequently an
important aid in the diagnosis. And yet, we have no  right to
attach extraordinary significance to the eruption alone, and to
regard  the changes  in all  the other  organs as  complications.
Certainly the fact that the affections  of  the throat, lymphatic 
FORMS OF SCARLATINA.
235
glands, etc., sometimes occur as a result of infection by them-
selves without a trace of scarlatinal eruption, shows conclusively
that they have essentially the same  pathological significance as
the cutaneous lesion.
   A clear view of the disease is possible only when we know
the fundamental anatomical conditions, and not only those of a
general character, but  also those which underlie the affections of
particular organs.  Other  principles of distinction, such as  the
peculiar  disposition of the individual, the  composition of  the
blood, etc., may  perhaps  satisfy the demands of science better
than a purely anatomical  principle, but they have as yet been
so little  investigated  that they  are not available as guides in
classifying the numerous varieties of the disease.
   Besides the classes of  cases characterized by marked local
lesions, there are other cases, in which no local symptoms are
present, but simply a fever of greater or less  severity, sometimes
lasting only a few hours.  When the fever is intense, death speed-
ily follows; in  other cases recovery; and the symptoms can be
best explained by & poisoning of the blood.   As a subdivision of
this, which is the most common form of scarlet fever, we have
those cases, in which, besides symptoms of blood poisoning, there
is also a hemorrhagic diathesis.  It is probable, but yet not satis-
factorily proved  by observation, that symptoms  of severe infec-
tion may occur and rapidly cause death,  with signs of primary
collapse, and yet without any fever.
   Finally, as  forms  transitional to the groups about to be
described, we occasionally have cases in  which the scarlatinal
poison excites  fever, which is for some time the only symptom,
but is afterwards, either during its course, or after its cessation,
followed by local lesions.
   The existence of local affections  gives rise  to two further
classes, viz. : (1.) those in which the local affections are single or
isolated, and (2.)  those in which they are numerous or combined.
   In the first of these classes are included cases in which, under
the influence of the scarlatinal poison, a single organ is affected,
either with fever, or  exceptionally without—the  local  disease
being the only sign of the infection.   The parts most frequently
affected are the skin  and  the mucous membrane of  the throat, 
236
THOMAS.—SCARLATINA.
the lesions of which are characteristic of the disease.  In rarer
instances  the parenchyma  of  the kidneys,  or  the lymphatic
glands especially  of the neck,  or the connective tissue  of  the
neck, may each become diseased as a  primary and isolated affec-
tion.  The same thing is true of  the parotid gland, the  joints,
perhaps also some of  the serous  membranes, and  the mucous
membrane of the alimentary canal,   v.  Ammon states that he
has seen  abscesses produced by  scarlatinal poisoning without
the occurrence of disease in any other part.
   To group together into  distinct classes those cases in which
several organs are affected is by no means an easy task, because
it  is not  yet satisfactorily  settled which lesions should  be re-
garded as the original localizations of the scarlatinal poison, and
which as  merely complications.   If  no  distinction  were  made,
and I admit that such a view has much in its favor, the number
of separate  groups would be very large,  on account of the num-
ber of combinations possible.   Until this question is settled, it
is better to consider as original localizations only those forms of
disease  which are  known  to occur  by themselves when  the
patient  has been  exposed  to  the scarlatinal poison ;  as,  'for
instance, the above-mentioned lesions of the skin, throat, cervi-
cal lymphatic glands, kidneys, also scarlatinal rheumatism, and
perhaps also the so-called parotitis.  The lesions of all the other
organs are complications.
   There  is  still another series of groups, which for the sake of
clearness  deserve  to be distinguished from each  other.  The
basis of distinction is the nature  of the individual  lesions, and
whether they occur together or succeed each other.  The line of
demarcation cannot be sharply drawn, because in a given case the
severity of the diseases of the different organs is very variable.
   The following forms of scarlet fever are those which deserve
special notice :
   The usual forms, characterized  by the simultaneous affection
of the skin and throat, which may be the  only symptoms, or may
be accompanied by disease of the cervical lymphatic glands, or
of some of the joints, or of the kidneys ; in  fact, by disease of
any one of these parts  alone or in succession, and  generally in
the above order; 
USUAL FORMS.                    237
   The cases of scarlatina without eruption.   These attacks, it
should be noted, are sometimes followed by a more or less well-
marked and extensive desquamation.  The  throat affection may
be very light or very severe,  and may be  accompanied or fol-
lowed by a great variety of affections  of the lymphatic glands,
cervical connective tissue,  joints, and kidneys ;
   The  rare  cases  of  scarlatina without angina,  and yet with
rheumatism,  kidney disease,  parotitis, and infiltration of the
cervical connective tissue in every possible order of succession ;
   The cases of nephritis,  or rheumatism, or parotitis, or disease
of the cervical connective tissue,  with or without angina,  and
with a subsequent eruption in all its degrees of development ;
   The  cases of opposite  combinations of  the above-mentioned
local affections without eruption or angina; e.g.,  disease of the
lymphatic  glands,  and   subsequent   nephritis  (Hamburger);
rheumatism,  and subsequent disease of the lymphatic glands,
followed later by nephritis (Zehnder); dropsy, and afterwards
disease of the lymphatic glands (Hamburger), etc.
   If now we consider that all  these different varieties may be
combined in the most complicated manner, and may appear early
or late, as severe or as trivial affections, we can easily understand
that the scarlatinal poison in its action upon the body, may pro-
duce a disease of an extraordinarily varied character.  In order
to give an accurate description of the rarer forms, it would be
necessary to enter more fully into details and nice distinctions
than would be justifiable  in an article of this kind, and I  shall
therefore refer to them only in a general way.

       The Course of  the Disease in  its Usual Forms.

  After a period of incubation, which  is usually entirely latent,
but sometimes presents transitory symptoms  of  slight import-
ance, scarlet fever begins, in normal cases,  with fever, followed
very soon by cerebral  and digestive disturbances, and also by
pain in the throat,  In many cases the initial fever is not to be
distinguished  from that of otlier diseases, but generally it may
be recognized by its unusual intensity.  Not unfrequently there
is more or less prostration; in cases of moderate severity the ex- 
238
THOMAS. —SCARLATINA.
tremities, and in fact the whole skin, become cold, and in severe
cases a rigor of variable duration occurs.  In children convulsions
often occur.  Then follow immediately excessive exhaustion and
heaviness in  the limbs, with extreme malaise and a considerable
elevation of temperature, which in a child, who but a few hours
previously was entirely healthy, may reach 104° and upwards,
together with other symptoms of intense fever.   The cerebral
symptoms  which occur at the outset of the disease are corre-
spondingly severe; sometimes, however, of little importance.
There is severe headache, at least in the older  children,  with
giddiness and dulness of the mind, sleeplessness,  or drowsiness,
or restless sleep.  Urgent vomiting with exhaustion and convul-
sions occurs more frequently as an initial symptom  of this dis-
ease than of any other in childhood, except small-pox and pneu-
monia.  It often makes its appearance quite  unexpectedly as an
initial  symptom without  other  evidence of disease.  In  mild
cases the symptom  is  generally  not  of an urgent  character.
Diarrhoea sometimes occurs, but usually it  is not troublesome.
The tongue is thickly coated, and the appetite entirely lost. All
of these symptoms, however, attract but little attention in  com-
parison with the fever, when it has been rapidly developed.
   The throat symptoms are very characteristic. Many patients,
especially older children and adults,  complain of pain in swal-
lowing,  or at least of a pricking sensation in the region of the ton-
sils as the first symptom.  Soon after this the tonsils, uvula, and
soft palate become reddened.  But there are cases in which the
angina is entirely absent, or is developed subsequently; and, on
the otlier hand, the same symptoms may be  produced by simple
tonsillitis without scarlet fever.
   All the other morbid phenomena which occur at this time,
such as pain in various parts, especially in the loins, or as symp-
toms on the part of other mucous  membranes, etc., are either of
a quite  subordinate character or belong not to normal scarlatina
but to the beginning of irregular varieties of the disease, or  to
complications.
   With the chill,  which in older children and adults, occasion-
ally lasts for some time, and with the more or less complete and
serious  attack of convulsions in the younger children, the tern- 
USUAL FORMS.
239
perature, at the very outset of scarlet fever, generally rises rap-
idly to a considerable height; in rarer instances it rises slowly
with progressive exacerbations and remissions, or remains at a
low point.   This intense beginning of the  disease characterizes
the normal cases.  A different course of the initial stage does not
exclude a  normal course, but is often an early  indication of
the commencement of an  abnormal development of the disease.
On the evening of the first day the temperature often reaches the
height of 104° to 105.8°; the pulse increases in frequency corre-
spondingly, but sometimes  becomes disproportionately rapid,
reaching 160 beats per minute, or more ; there is urgent thirst;
the skin is dry and hot;  the eyes congested ;  the  malaise most
distressing. By this time there are often marked cerebral symp-
toms, such as restlessness, severe headache, somnolency,  scream-
ing, tossing about  in the bed, talking in sleep, and delirium.
   In the meantime, even at this early period, the local symp-
toms have  begun to assume prominence.  Not  only  are the
throat symptoms more severe, as is shown by the extension of
the redness over the soft palate and by the tumefaction of the
tonsils, but the skin also begins to present lesions.  According
to my observations, the eruption, as a rule,  makes its  appear-
ance  on the first day of the disease, in a decided minority of
the cases  on the second day, and in rarer instances at a later
period.  Generally it is recognized at about the same time on the
neck, chest, and lateral parts of the face and forehead, but espe-
cially  on  the parts  first  mentioned, in the shape  of numerous
red points situated close to each other, and spreading  rapidly
over  the  rest  of  the body.  On the face  and  forehead the
eruption may be confounded with the flush produced by fever.
When the cheeks  are much reddened by the eruption, the very
pale color of the  region of the mouth presents a striking con-
trast.  It is only exceptionally that the face is entirely free from
the eruption.   The skin  has often a tense  or turgescent  appear-
ance, and sometimes the eruption is preceded by a slightly erythe-
matous coloration of the skin over a greater or smaller  surface.
As a rule,  the extension of the eruption  over the whole body
occupies scarcely  half a day.  The rapidity of its progress is
greater than in other acute eruptive diseases. 
240
THOMAS.—SCARLATINA.
  The  time required for the  full development of  the eruption is
very variable ;  in mild cases the eruption occasionally reaches
its height on the evening of the first day ; in moderate on the
second ; and in severe cases on  the third or fourth day ; in rare
instances even later.  When the maximum occurs  early the erup-
tion is punctiform, each minute point being surrounded by pale
skin;  when the  maximum occurs later the eruption becomes
more and more confluent,' until finally,  when it reaches its full
development, the neck and body, as well as the greater part of
the face  and extremities, present an  intense uniform scarlet red
color, with here and there isolated points of a darker appearance.
At the same time the  skin is very hot, generally dry, sensitive
to the touch, tense, swollen, and the subcutaneous cellular tissue
in various places, especially the cheeks and eyelids,  oedematous.
In cases of moderate  severity  these symptoms are  not  well
marked, and in  mild cases the  skin may be normal,  with the
exception of redness and a moderate increase of temperature.
Sudamina often make  their appearance at this time ; in some
cases the vesicles are numerous, in  others scanty, while in the
milder forms of the disease they are generally absent.  In severe
cases, where the eruption is copious, small extravasations may
be seen in some places, especially about the mouths of the hair
follicles.
   As  the eruption progresses to its  full development, the other
symptoms increase or remain unchanged ;  the tip of the tongue
becomes very red, and the coating thicker ; the latter often now
peels off in  places, but does not usually disappear completely
before  the fourth day, after which time the tongue  presents for
several days a characteristic appearance.   It is red, smooth,
dotted with warty swollen  papillae, and is often somewhat dry,
as are also the lips ; the affection of the  throat increases, and the
tonsils, which are enlarged, are covered with a yellowish-white
layer of  thick pus, or  even with a small amount of true diph-
theritic membrane.  The appetite is now quite gone, the vomit-
ing has by this time generally ceased, the bowels are constipated,
but  occasionally there  is  slight diarrhoea with  colicky pains.
The fever increases, if it have not attained its height at the out-
set of the disease, and  now reaches the  neighborhood of  105.8°, 
USUAL FORMS.
241
keeping at this point with slight variations in severe cases, and
with greater variations in  the mild ones.   In some instances, on
the morning of the  second day of the disease, before the full
development of the  eruption, the temperature  shows a consid-
erable remission,  or  even a complete intermission, and  this
although the case is  otherwise of the usual severity.  The pulse
is usually very frequent, and may become so rapid that it can-
not be counted ; now and then, however, without any  obvious
cause the frequency is  only moderate.  Occasionally there are
chest symptoms, such as  cough, pain, etc.; these are generally
indications of the beginning of  some  complication.  The mod-
erate dyspnoea, which is present, is often due to the fever.  In
the same way are to be  explained certain cerebral  symptoms,
such as more or less  severe headache, restlessness and mild deli-
rium at  night,  sometimes wandering of  the mind by day, but
more commonly somnolence.  The urine at this period is scanty
and concentrated, and contains a very small quantity of blood,
or is albuminous, especially if the fever be  high.   This shows
that even at the outset of the disease the kidneys are unmistak-
ably  involved, although only in the form of a catarrh of the
renal tubules.
   The eruption continues at its maximum only a short time—
from a few hours to half a day, or a whole day—and then begins
to fade,  first upon the  upper part of  the body, and afterwards
gradually, but still with some rapidity, upon the lower portions.
The last traces of it are  to be  seen in the broad and  slightly
infiltrated  roseolae on the back of the hands and feet, and in the
sudamina, if there have been any.   In normal cases the period
of decline occupies from two to three, or even four days, making
the whole duration  of  the eruption from three to seven days.
During this period desquamation commences.   The earliest, but
not the usual form of it,  is the furfuraceous ; the more common
form is the lamellar,  which occurs somewhat later and follows as
a rule the other variety.   In normal cases, while the eruption is
fading the general symptoms subside ; the fever moderates, but
not  so rapidly as to  constitute a crisis.  The defervescence takes
place generally in the form of lysis,  with gradually lengthening
remissions, and  afterwards  shortening  exacerbations,  so that
           VOL.  II.—16 
242
THOMAS.—SCARLATINA.
it takes several days before the normal temperature is reached.
The frequency of the pulse falls to the normal, following the
course of the temperature, the skin becomes moister, loses its tur-
gescence, and at this time sudamina are very apt to form.  The
swallowing becomes gradually easier  and less  painful, the red-
ness and swelling of the tonsils subside, and the membranes, if
there are any, become detached ; the tongue becomes more moist,
and by the end of this period the superficial layer of epithelium
is regenerated.  Rhagades now heal, the  appetite  continues to
improve, digestion becomes  normal, the urine more abundant
and clearer, the extraneous  substances from the renal tubules
and the albumen disappear.  With the fall of the temperature
the cerebral  symptoms  gradually subside, the sleep becomes
quiet and  refreshing, and the  patient consequently regains his
strength.  A week after the height of the eruption, or a week and
a half after the beginning of  the disease, convalescence is gener-
ally complete, if the case have been  of moderate  severity and
uncomplicated;  but caution  is necessary for a long time  after
this.
   The greatest care, however, will not always prevent the occur-
rence of farther troubles, which may arise both during the attack
and during convalescence, and may affect different parts of the
body;  I  refer  to  the other  localizations  of  the   scarlatinal
poison, the affections of the lymphatic glands and the joints, and
the disease of the kidneys.   Even when the scarlatina has run a
perfectly normal course  in respect to the eruption, angina, and
fever, our hopes of  a  favorable convalescence may  be dashed at
any time and under any treatment by the occurrence of one of
the above-mentioned  complications,  or  by several of   them
appearing together or following each other.
   In the majority of cases of scarlet fever most of  the lympha-
tic  glands, which are accessible  to examination, especially the
cervical, i.e., the submaxillary  and jugular  glands, are more or
less swollen and painful. It is  altogether probable  that this
swelling is due to the special  influence of  the throat affection,
yet it is to be noticed that there does not appear to be a definite
proportion between  the two lesions ; there may be,  for instance,
severe  angina with  slight glandular affection, or, on the  other 
    AFFECTIONS OF  THE LYMPHATIC GLANDS AND JOINTS.  243

hand, considerable lymphadenitis, with a trifling  amount of
angina.   When the course of the eruption and angina is normal,
the moderate  enlargement of the lymphatic glands disappears
imperceptibly ; in  other cases, just as these symptoms are begin-
ning to subside, or when they have already vanished, and desqua-
mation is in full progress, about the middle or the end  of the
second week  there occurs a  more or less rapid proliferation of
the cervical glands,  sometimes equally on both sides, sometimes
more  on one  side than on the other, and at other times only on
one side, with, perhaps after several weeks, an extension to the
other.  The fever, which may have already disappeared,  now
generally returns in greater or less force, or if it had only begun
to subside it becomes more intense ; the restoration of the appe-
tite and health is interrupted, and possibly further derangements
or actual complications may be produced.
   The affection of the joints in  scarlet fever usually takes place
during the decline  of the  eruption, when desquamation com-
mences ;  and this  is the case whether the  course of the disease
has been mild or severe; it generally lasts only a few days.
With or  without increase of the fever, pains occur in one or more
joints, sometimes only in  the small joints of the hands and feet,
at others also in the larger joints.  The affection usually runs
much the  same course as  ordinary rheumatism  of the  joints,
except  that   ordinarily  it  does not last  so  long;  the pain
increases rapidly,  but disappears  after  a few hours,  to reappear
in other  joints, so that within a few days all the joints of the
body may be affected once.  Although the anatomical changes
are so slight  as to  be scarcely noticeable, the pains are very
severe, at  least children often  complain  bitterly.  Scarlatinal
rheumatism  is  not always of  short  duration;  sometimes it
fastens itself upon one or more joints, particularly the larger
ones,  and  gives rise to  intense synovitis, with  more  or  less
considerable fluid  accumulation, in fact even  to more  serious
chronic  lesions.   In such cases the fever generally runs high
without  pursuing a definite  course, but  rather  varying as it
does in ordinary polyarthritis.   The other symptoms are similar
to those  of this  latter  affection,  especially  the perspiration,
which  in  scarlatina  leads   to  the formation  of  numerous 
244
THOMAS.—SCARLATINA.
sudamina.   The same resemblance holds in regard  to the com-
plications.
   Nephritis occurs in scarlatina at various periods, with differ-
ent symptoms, and probably depends upon a variety of causes.
In some cases its existence can be ascertained only by the exam-
ination of the urine, since the normal  course of the  scarlatina
terminates  in recovery; the most certain evidence is, of course,
to be  obtained by direct  examination of the kidneys, if  death
occur  suddenly during the normal course of  the disease through
an unexpected accident.   Up  to the present  time there has been
no record of such a case, and in the absence of any or at least of
characteristic signs of disease as revealed by  the urine  (and they
certainly are absent in very many normal cases), we cannot  tell
whether there may not be more or  less  marked  pathological
changes in the kidneys notwithstanding the lack of symptoms.
The urine in hydrops scarlatinosus (always a result of nephritis)
is scanty, and so loaded with  urates  as to  make the microscopi-
cal examination very difficult.  In rare instances the urine has
been found to be free  from albumen and  casts ; we are conse-
quently not to infer that the kidneys  are healthy because the
secretion is abundant and  apparently healthy, with no uric acid
deposit, as is the case at the beginning  of  the eruption,  and
when the course of the scarlatina is normal.
   It is different,  however,  in those irregular  cases which  fre-
quently prove fatal at an early period of the disease ; here the
autopsy often reveals disease of the kidneys.

  Steiner found as a result, he says, of numerous careful observations, that  in scar-
latinal patients, who died early, there was always  more or less hyperaemia of the
kidneys, and that in other cases, besides the hyperaemia of the kidneys, there was
catarrh of the renal tubules to such an extent as to present the signs of diffuse neph-
ritis in its various stages; in one form or the other the kidneys were always diseased.
In the children who died of scarlatina on the second or third day, and whose kid-
neys were found to be hyperaemic and enlarged, with cloudiness of the epithelium
of the renal tubules, the urine, so Steiner states, gave no evidence during life of kid-
ney disease.  In another place he expresses the opinion that in the slight catarrhal
affection of the renal tubules, which remains as a mere  catarrh without progressing
to its further development, the urine is either normal  or contains merely traces of
albumen and desquamated epithelium; while the diffuse catarrhal form of  the dis-
ease manifests itself at an early period by larger quantities of  albumen and 
                      SCARLATINAL  NEPHRITIS.                    245

 epithelium.   A catarrh  of the renal tubules  which reaches this extent generally
 terminates sooner or later (as a rule between  the thirteenth and twenty-first days
 of the disease) in "Morbus Brightii" (croupous or parenchymatous  nephritis);
 the urine is  not only diminished in quantity, but contains albumen, desquamated
 epithelium, fibrine from the blood, and disintegrated casts, the  quantity of these
.ingredients varying with  the extent of the parenchyma involved.  The develop
 ment of the nephritis out of the catarrh of the renal tubules, resulting partly from
 mechanical obstruction, by means of the abundant desquamation of  epithelium
 and the consequent stasis of the blood in  the kidneys, coincides generally with the
 desquamation of the epidermis; and this fact has led to the erroneous opinion that
 the affection of the kidneys is  a  complication of  the stage of desquamation,
 whereas the careful early examination of the urine shows that this is not the case.
 Croupous nephritis, in rare instances, may  arise suddenly without being preceded or
 ushered in by a catarrh, and is then generally fatal.   In  regard to this question  of
 the development of parenchymatous nephritis, I wish to again call  attention to the
 fact, that in normal cases up to from the thirteenth to the twenty-first day the proof
 of the existence of a renal catarrh  is generally obtained only accidentally, and that in
 the absence of morbid signs on the part of the urine, it is probable that there is no
 catarrh, but  merely a partial derangement so trifling as not to present any symp-
 toms.  Even  in severe  cases, as long as  the  affection runs a normal course, the
 symptoms which, during the eruption and  height of the fever, indicate a renal
 catarrh, usually disappear entirely when the severe symptoms of the disease subside,
 and they may disappear also even when renal symptoms due  to parenchymatous
 nephritis arise between the thirteenth and twenty-first days.  This explanation of
 the origin and  genesis of parenchymatous nephritis in scarlet fever,  however
 interesting it  may be, is still not entirely  satisfactory; and  from the  mere fact of
 the existence  of insignificant changes in the  urine, such as the small amount  of
 albumen and  desquamated epithelium, which are often seen at the outset of severe
 cases,  whether normal or abnormal, we are not justified in concluding that they are
 due to a specificness of the disease, and not rather to the fever.  It is a matter  of
 common observation that in other infectious diseases, as well as in those which are
 non-specific, such changes  are undoubtedly produced by the febrile condition.   It
 is probably safe, therefore,  to infer that many of the lesions of the  kidney occurring
 in rapidly fatal abnormal  cases with symptoms of intense fever, are the result of
 the fever, and not  of the  scarlatina; but this is a theory more difficult of proof
 than the one first mentioned.

    The examination  of the urine gives, according to my  experi-
ence, the  following  result:  At  the beginning of the disease,
especially during the development  and height  of the  eruption,
the character of the urine varies considerably.   It may not only
be free  from  albumen, but very  often exhibits  no  indication of
catarrh  of  the renal   tubules.   Not  unfrequently,  however, the 
246
THOMAS.—SCARLATINA.
urine, although  in other respects clear and free from albumen,
soon begins to  show  a mucous cloud,  which is  composed  of
more or less abundant cloudy and degenerated epithelium, and,
sooner  or  later, cylindroidal, in rare  instances  epithelial,  and
still more rarely hyaline casts.   The cylindroidal  casts are very
long, and look like cylinders;  sometimes  like smooth, narrow
bands ;  sometimes quite broad bands with longitudinal striae and
fringed  extremities ;  at other  times  the casts  are  narrower,
cracked transversely, split up, in fact present the appearance of
casts which have collapsed;  sometimes they look as if composed
of minute fibres.  At this period albuminuria occurs only excep-
tionally, and then only to a  slight amount  and for a short time.
When  it does occur the urine generally contains  red  and white
blood-corpuscles in addition to the epithelium and cylindroidal,
epithelial,  and hyaline casts.  Catarrh of the renal tubules is a
frequent, but by no means constant accompaniment of the erup-
tion, and when it does occur its symptoms are generally of the
mildest character, and  rarely of a serious nature at this period
of the  disease.  In no case does the kidney affection,  when at
all severe,  develop at once  into its  full  intensity, as is  some-
times the case with the eruption ; on the contrary, it is  scarcely
noticeable  on the first  day, and gains headway gradually, first
during  the progress of the eruption.   When the eruption fades
and the fever subsides, the renal catarrh generally  declines also,
so that in  the second week it may have entirely  disappeared;
but it may continue in diminished intensity up to the time when
the more serious lesions of the kidney are apt to occur.
   It is thus apparent that the relation of  the catarrh of the renal tubules to scarlet
fever is quite different from that of the bronchial catarrh to measles.  In the latter
case the two affections correspond to each other, but between measles and scarlatina
there seems to  be no correspondence, either in respect to the  regularity of the
catarrh or in respect to the occurrence of this symptom in connection with the
initial fever, the eruption, or the decline of the eruption.
   The renal  catarrh, which occurs at the outset of  scarlet fever, is  certainly not
completely identical with those special forms of like character which occur more or
less uniformly in other infectious diseases, such as cholera, typhoid fever, petechial
fever, and relapsing fever.  Each of these diseases has its peculiarities, especially
in the situation of the local affection, which is sometimes in the parenchyma, at
other times in the tubules of the kidney. 
CHARACTER OF THE URINE.
247
   On the other hand, the condition of the urine in various other acute febrile
diseases is in the  highest degree similar to what is found in scarlet fever.  In
croupous pneumonia, measles, meningitis, intestinal catarrh, in short, in a great
variety of affections, I have often found the same cloudy epithelium and the same
epithelial, hyaline,  and cylindroidal casts as are found at the beginning of scarlet
fever.  In these diseases renal catarrh does not occur so frequently, and this fact
seems to justify the conclusion that the catarrh of scarlet fever is due to a specific
irritation, as well as to the febrile condition.  In a given case sometimes one cause
seems to be more active, sometimes the other.

   In  those cases  of scarlet fever  which present symptoms of
parenchymatous nephritis at the usual time, i.e., after the  con-
clusion of the eruptive  stage, towards the end of the second
week at the earliest, generally during the third or at the begin-
ning of the fourth week, the changes in the urine are much more
striking than at the beginning  of the disease.  During the first
few days, in the most favorable cases, the abnormal constituents
are trifling in  amount, or perhaps entirely absent ; then cylin-
drical casts gradually make their appearance, and afterwards an
abundance of  more or less  cloudy and degenerated, or perhaps
merely  swollen or quite  normal  epithelium,  with granular
detritus, and red and white blood-corpuscles.  These admixtures
make the secretion turbid, and produce  sediments of a  grayish
white or dark  color.  At this time hemorrhage from the paren-
chyma of the  kidneys is a common occurrence, and the urine
consequently becomes  more or less reddish-brown and very tur-
bid, and usually contains an abundance of epithelium and casts.
The secretion now becomes much diminished, sometimes  almost
suppressed.    Baginksky states that sometimes,  though  rarely,
the  stage  of diminished  secretion is preceded by a temporary
diuresis.   Usually the urine is very concentrated and deposits
urates in such  quantity as to interfere with  a satisfactory micro-
scopical examination.   The chemical examination, which up to
the middle or end of the second week, has perhaps entirely failed
to disclose any abnormality, now shows the presence of albumen
in quantities which increase from day to day.  In my experience
the quantity generally remains small if it makes its  appearance
first at the end of  the third or early in  the fourth week, but is
more abundant if the renal  affection occur earlier.  The  amount 
248
THOMAS.—SCARLATINA.
of albumen does not always correspond to the quantity of blood
and casts, yet this is the general rule.   Exceptions, however, do
sometimes occur; occasionally, though rarely,  numerous  casts
may be seen, and yet for days together no trace of albumen ; on
the other hand, a considerable albuminuria may be present while
the urine is perfectly clear and free from sediments, and even the
filtrate shows nothing abnormal.  The examination of the urine,
when the renal lesion is trifling,  is thus evidently untrustworthy,
and it is consequently impossible to date the beginning of the
parenchymatous nephritis.
   Very often individual peculiarities may be noticed in respect
to the quantity and quality of the abnormal ingredients of the
urine ; for instance, in one patient the urine up to the beginning
of the third week is clear, in others it is for a long time uniformly
turbid, and contains cylindroidal casts.  In  the  first  case, when
the parenchymatous  nephritis  sets in, numerous epithelial and
hyaline  casts may be seen ; in the  second case,  besides these
abnormalities there are  also the transitional  form of the cylin-
droidal and a few epithelial casts ; but in the third case the cyl-
indroidal casts disappear at once and permanently.   Sometimes
the casts  are  studded with detritus ;  sometimes they also con-
tain cells of every variety imbedded  in them, and at  other times
they are entirely free from formed  elements, etc.   The  renal
symptoms are as varied in character as are those of the eruption
and other organic affections.

   Eisenschitz and Steiner dissent from my account of the origin of  nephritis scar-
latinosa in important particulars.  The former  believes  that scarlet  fever does not
occur without catarrh of the renal tubules, any more  than measles without catarrh
of the respiratory passages.  He claims to have discovered the renal affection when
the eruption has existed less than twelve hours, and  insists that cases without
catarrh, and especially albuminuria, are very rare. The renal catarrh may continue
as such during the whole course of the scarlet fever, varying only in intensity, or it
may become the starting-point for other more serious lesions of the kidneys, such as
chronic Blight's disease, in which the urine is clear, abundant, and contains but lit-
tle albumen, and acute Bright's disease, in which  the  urine is reddish-brown, turbid,
very albuminous, and scanty.  The latter variety, he  says, may arise either directly
from the catarrh or from the " chronic " affection.  The difference between us is this:
it is only rarely that I am able to find any symptoms  of  catarrh at the outset of the
disease, and when they do occur, I see them generally diminish with the decline  of 
NEPHRITIS.
249
the fever in the second week, or disappear entirely ;  and finally, without any con-
nection with such symptoms at the beginning of the disease, I see a new affection of
the kidneys  breaking out with more or less suddenness, while Eisenschitz always
finds a catarrh from the beginning to the termination of the disease.  It is certainlv
singular that he gives us no detailed description of the symptoms which occur dur-
ing the transition from catarrh to nephritis.
  It is possible that these differences may depend upon local and epidemic pecu-
liarities.

   Although the alterations in the urine are the most important
indications of  scarlatinal nephritis, there are other symptoms
which are quite significant.  The patient complains of pain  in
the region of the kidneys, voluntarily, if  he be old enough, but
only on pressure if a young child ; the appetite diminishes ; the
abdomen  becomes  tense  and swollen,  perhaps even painful,  or
there is at least a feeling of fulness, and not unfrequently also
vomiting, constipation, nausea, headache, sleeplessness, restless-
ness, and peevishness.   In the second week, when the  fever has
moderated considerably,  or  has quite disappeared, it may return
in variable intensity with the occurrence of the  symptoms  of
renal disease.  In mild  cases  this relapse  does not occur,  or  is
limited to slight  exacerbations in the evening; and even in severe
cases with high  temperature,  the fever is short or quite epheme-
ral.  At this time a moderate amount  of oedema also makes its
appearance, generally only on the face, particularly in the eye-
lids, producing more or less bloating, also about the ankles  and
on the buttocks,  sometimes  only on one side.
   These  initial  symptoms, as  a rule,  continue in  the same
intensity  for a variable  length  of  time ;  sometimes,  however,
they diminish somewhat in  severity, and  in rare instances, even
when the  case is  otherwise normal, they become aggravated.  In
the latter case the urine becomes scanty, very albuminous  or
bloody ;   there is pain  in the region of  the kidneys and  on
micturition; the oedema increases  to a  moderate extent, the
slight fever, cerebral disturbance,  and  vomiting continue;  a
more or less severe diarrhoea sets in, and pulmonary symptoms
make their appearance,  such as catarrh, especially  over the
lower lobes, distressing  cough with a  moderate amount   of
dyspnoea  and laryngeal affection.  Although  there is some fever 
250
THOMAS.—SCARLATINA.
the pulse very commonly at this time becomes remarkably slow,
from fifty to sixty beats per minute in children, and under fifty
in adults,  soft, and often irregular ; the first sound of the heart
is diffuse  or replaced by a slight murmur.  After  these severe
symptoms have lasted for several days  improvement  is indi-
cated by the cessation of the fever, return of the appetite, and
especially by the increase in the amount of urine, which now
becomes clearer and of lighter specific gravity ; it loses its dark
color, no longer contains blood or precipitates sediments, and the
albumen steadily diminishes in quantity from day to day.  The
desquamation of epithelium in the renal tubules also gradually
ceases,  the casts lose the imbedded cells,  detritus masses, etc.,
and become less numerous, and at the same time the amount  of
grayish-white sediment in the urine decreases.   Sometimes the
oedema now disappears entirely, the  pulse  regains its normal
frequency, the  heart's action becomes  more vigorous,  and the
patient, enfeebled by long disease, recovers  his strength.  The des-
quamation of the skin, which had remained up to this time more
or less  incomplete, often now goes on with  renewed activity.
   It is difficult to ascertain with accuracy the duration of the
nephritis in normal cases, partly because it is  not easy to distin-
guish between normal and abnormal  cases, but  principally be-
cause in tolerably severe cases the morbid microscopical elements
in the urine continue to appear a long time after the albuminuria
has ceased.  Weeks after the disappearance of the last  trace of
albumen we find single or even moderately numerous  hyaline
casts, with or without cloudy epithelium,  detritus,  and red and
white blood-corpuscles ;  showing that, at least, in some parts of
the kidneys the inflammatory process still  continues. As a rule,
it is safe to say that the normal duration  of the albuminuria is
about two or  three weeks, and that casts  are  discharged for
about one month. Besides these  severe  cases with prolonged
albuminuria, mild cases  of nephritis very often occur, in which
the morbid symptoms last only a few days, and also abortive
cases, in which the renal affection disappears still more rapidly.

             Irregular Course of Scarlet Fever.
    Scarlet fever in its irregular forms may terminate favorably 
IRREGULAR FORMS OF SCARLATINA.
251
or unfavorably, and its  symptoms in such  cases may present
every variety from the mildest to the most severe  character.
Following  the  excellent division of Wunderlich I divide the
irregular forms of scarlet fever into those with rudimentary and
those with fully developed localizations.
   Of  the rudimentary, and  therefore  mild  and  favorable
forms, the most frequent is simple scarlatinal angina.  A slight
or moderately  severe fever of  short  duration, accompanied by
some pain in the neck and enlargement of the cervical glands, is
not  an uncommon occurrence in persons who  have but  little
predisposition  to  the  disease,  especially  if they be  of mature
years, and also in those who  have already had scarlet fever in
childhood.  These symptoms are the more  suspicious if scarlet
fever have occurred in the family, or if the  patient have prob-
ably been exposed to the poison.  If the throat be  examined,
the characteristic redness is seen in a mild form,  with or without
a moderate enlargement of the tonsils ; perhaps also the tongue
presents the appearance  of  the scarlet-fever tongue.   There are
also malaise, anorexia, headache, and other symptoms of slight
importance.   Such attacks generally disappear in a few days,
but they should receive the same attention which is paid to the
unmistakable disease; every  throat  affection during a scarlet-
fever epidemic is suspicious !
   In  other  cases the angina is absent, or so trifling that it does
not  account for  the existing fever.  When present it lasts only
a few days, with  the symptoms  of a slight febricula.  That it
depends upon infection with the scarlatinal poison, is evident
from the above-mentioned circumstances ; but at other times the
diagnosis is confirmed by a simultaneous enlargement of the cer-
vical lymphatic glands,  by a suspicious redness of the skin, a
slight affection of the joints, albuminuria, and other renal symp-
toms.   The redness of the skin is generally too uncharacteristic
to warrant a positive  diagnosis ; on the face it may be mistaken
for an unusually marked flush from fever, in other parts for an
accidental result of pressure,  etc; in many cases it is merely  a
scattered roseolar eruption, which looks  like measles and lasts
only a short time, sometimes merely a few hours.
   All these varieties of the disease are frequently  of such short 
252
THOMAS.—SCARLATINA.
duration, and apparently of such  trifling importance, that the
patient  pays but  little attention to them, and often entirely
overlooks them.  But in  other  cases the fever and  local symp-
toms  are more serious, and continue so long as to  constitute a
sort of  transition to the usual forms of the disease, the eruption
only being absent.   In the  absence of satisfactory  aetiological
evidence, the scarlatinal  nature  of the attack is proved by the
subsequent occurrence of the characteristic desquamation, even
when there has been no previous  trace of an eruption, and by
the appearance of a  moderate amount of dropsy and albumi-
nuria.  These cases may be designated as Angina scarlatinosa,
Nephritis scarlatinosa, Febris  scarlatinosa sine exanthemate sive
sine scarlatina.
   There  is also an  unusually mild course of the disease, in
which the eruption  is very scanty, poorly developed,  and con-
fined to certain parts of  the body.  In these cases the angina
may be absent, or so  trifling  in amount  as to  be readily over-
looked.  After a slight fever lasting  for several days, during
which there are some insignificant local affections, these insignifi-
cant symptoms disappear entirely, or are followed by a rudimen-
tary rheumatism or a scarcely noticeable anasarca.
   Finally there are other cases,  in  which, besides the fever,
which in all probability depends upon scarlatinal infection, other
isolated derangements arise, which are not commonly  present in
scarlet fever, and are rather of the nature  of complications ; such
as  gastro-intestinal  catarrh, parotitis,  slight cardiac  affections,
etc.   The diagnosis of this  variety must be based upon aetiologi-
cal considerations.
   For the same reasons we may here include also those cases in
which more  or less  rudimentary scarlatinal symptoms occur in
the course of  other  diseases ; according to Wunderlich, local
hyperaemias of the skin, especially of the palms  of the  hands and
the  chest, with subsequent desquamation; angina in patients
who are rarely affected with it;  a peculiar redness of the tongue
under the same circumstances, etc.; and also  other  symptoms
which are more fully developed but still rudimentary.
    Rudimentary affections  sometimes occur which are of a more
serious nature.  They are characterized by essentially the same 
IRREGULAR FORMS OF SCARLATINA.
253
 symptoms as the favorable varieties  of  the disease ;  by a rudi-
 mentary eruption without angina, angina without eruption,  but
 also by severe cerebral  disturbance  with very high  fever  and
 often collapse.  Sometimes these malignant cases begin in a mild
 or normal manner, and then, after the disease has progressed for
 a time, without the slightest occasion for alarm, symptoms sud-
 denly arise of the most dangerous character, and death speedily
 ensues.  Usually, however,  severe symptoms  are present from
 the  start; intense headache,  very great restlessness,  marked
 drowsiness or actual coma, profound malaise, severe  convulsions,
 which do  not appear to depend  upon the intensity of the fever
 nor  upon local disease; even severe  tetanus, trismus, and otlier
 local tonic and  clonic convulsive movements, persistent vomit-
 ing and diarrhoea, severe dyspnoea, which seems unwarranted by
 the condition of the  respiratory organs,  troublesome rheuma-
 toid pains over the whole body, extreme rapidity of the pulse,
 which is small and scarcely perceptible to the  touch, and symp-
 toms of collapse.  Before the disease  has fairly developed itself
 and exhibited its scarlatinal origin by characteristic local symp-
 toms, death often occurs on the very first day,  either in an inter-
 current fit of  convulsions of unusual severity,  or,  in the absence
 of these, with the signs  of intense fever or profound  collapse.
 Glaser  describes  such a case  which proved fatal within eight
 hours, Bohn and Hambursin one within ten hours, Trousseau in
 eleven hours,  Stiebel two cases in twelve  hours, Epting one in
 fifteen hours.  The autopsy in these cases usually reveals lesions
 which are quite insignificant; the blood within the vessels is thin
 and  of  a  bright  or  dark red color, capillary  hemorrhages  are
 seen scattered in more or less numerous places over the whole
 body, the brain is hyperaemic,  and the sinuses distended with
 blood;  there are also commencing meningitis, a flabby heart,
 enlarged spleen,  and  some congestion  of  the kidneys.  The
alarming symptoms which occur during life  are to be explained
by the severity of the infection, and should be regarded as indi-
cations  of intense  "blood-poisoning."   In such cases the  diag-
nosis  is often doubtful,  even  after the  autopsy, and  we  are
obliged to rely upon the evidence of previous exposure.  In some
instances  scarlet  fever proves so rapidly fatal,  with  convulsions 
254                THOMAS.—SCARLATINA.
or other severe cerebral symptoms, only because it happens to
occur at a time when there is already existing brain disease, such
as tuberculosis or chronic hydrocephalus, predisposing to dan-
gerous symptoms of this character.
   Finally there  are other  cases, terminating after a longer or
shorter time in recovery,  which present the following history:
The  eruption  and other characteristic local lesions are  absent,
but  the attack is a severe one on account of certain brain, lung,
stomach, or intestinal symptoms of a suspicious character, or also
on account of the duration and height of the fever,  or, in the
absence  of any  clearly  marked  local  symptoms, merely on
account of the intense fever.  After a longer or  shorter time
recovery takes place,  and  the doubt is  cleared up sometimes
by the fact that the symptoms occur in connection with unmis-
takable cases of scarlet fever, and sometimes by the subsequent
occurrence of affections which are characteristic, such  as  des-
quamation, nephritis,  and dropsy.   They vary in  severity, and
seem to constitute a variety intermediate between the abortive
forms  and the malignant cases with rudimentary local symp-
toms.

   The irregular forms of  scarlet  fever  with fully  developed
local lesions may be divided into two classes ; in  the first, the
course of the disease is at first perfectly normal, and the irregular
symptoms occur at a later period ; in the  second,  the latter arise
at the  outset of the attack.  In both classes the irregularity may
affect either the local  process or the febrile symptoms; if the
former, the irregularity is noticed  only in some  of the  affected
organs, or in  all of them  at the same time, or in one after the
other; if the latter, the fever is more intense than usual,  or more
protracted, or both together.  In the abnormal course true com-
plications  are not necessarily present, but they frequently do
occur,  and then change the  character of the disease still farther.
In some instances they give  rise to  no noticeable symptoms, and
are first recognized, after  the disease has run its course, by the
sequelae or by the fatal termination ; but  even the autopsy often
fails to reveal any complication.   Death is quite  a frequent
result,  occurring at almost any period of the  disease, but  of 
IRREGULAR FORMS OF SCARLATINA.
255
course always later than in the variety with rudimentary local
lesions.  The most malignant epidemics are those in which the
abnormal cases occur the most frequently.
   When the course of the disease begins normally, and becomes
irregular subsequently, the normal period lasts a variable time,
generally at least several days.
   When the fever is irregular it fails to defervesce after the nor-
mal progress  and disappearance of the eruption and angina, but
continues for weeks, sometimes with the same intensity and with
a typhoid  character like that of a variety of scarlet fever to be
presently described, sometimes with increasing intensity, especi-
ally if it is to prove fatal, and at other times it  declines grad-
ually,  as in protracted defervescence.  In such cases the pulse is
often very rapid, the  heart's action  violent,  and the first  sound
of the heart diffuse or even replaced by a distinct murmur.
   This murmur is not necessarily of serious importance;  it may be merely a blood
murmur, but sometimes actual regurgitation occurs for a time, owing to paresis of
the papillary muscles, without valvular lesion (accentuation of the second pulmonary
sound).  Partly in this way, and partly as a result of disease of the whole cardiac
muscle, the heart may become dilated and its area of dulness increased.   True endo-
carditis at this period of the disease, especially of the mitral and aortic valves, and
myocarditis belong to the complications of scarlet fever.

   Iii consequence of the exhaustion resulting from intense fever
there  not unfrequently occurs  with a normal temperature a
severe form of nervous delirium, attended by motor disturbance,
and often  presenting  the character  of melancholia, or delusions
of persecution ; in rarer instances, of extraordinary  gayety and
talkativeness (Steinthal).   These symptoms generally disappear
in the course of a few days, or earlier, after a good sleep procured
artificially or occurring naturally.
   Independently of existing fever,  irregularities may  occur in
the course of a hitherto normal scarlet fever, in  the  shape  of
intercurrent  nervous attacks, which unexpectedly  arise from
some external cause or spontaneously, as, e.g., convulsions of all
kinds, tetanus,  spasm  of the glottis,  hysterical  and  maniacal
symptoms, delirium, jactitation, general  excitability,  dyspnoea
without apparent cause, and extreme rapidity of the pulse.
   Sometimes while the  disease is progressing  normally, the 
256
THOMAS.—SCARLATINA.
 patient suddenly sinks  into collapse without known cause, or
 apparently after exposure to cold or after a purge ; the skin
 becomes pale and cold,  the eruption disappears, the pulse be-
 comes thready and uncountable, and death ensues.
    Finally, after a normal course of the first local symptoms, and
 even of the fever, there may occur at any time in severe cases a
 hemorrhagic diathesis terminating either in recovery or death.
    Irregularities may  arise, moreover,  in connection with the
 local lesion.  Under this head the following varieties are  worthy
 of attention:
    Irregularities in the eruption.  This may become hemorrhagic
 when its development is intense ; or, upon the surface of the skin
 occupied by it other eruptions may arise, vesicles, pustules, etc.;
 or  the mode of desquamation may be irregular, too  abundant,
 repeated, etc.
    Irregularities of the angina.  Instead of declining with the
 eruption, it may increase considerably ;  the tonsils may become
 much swollen, and may suppurate or become gangrenous ; diph-
 theria  may set in at  any time, either upon the much inflamed
 parts of the throat, or after the original angina has partially or
 wholly disappeared.
   Irregularities in the course of the disease of the cervical lym-
phatic glands.   In the ordinary course of  this affection the usu-
 ally moderate swelling subsides, but sometimes the inflammation
 extends to infiltration of the cellular tissue of the surrounding
 parts,  and abscess results.  Abscesses may occur upon  one or
 both sides of the neck, at the same time or in succession.   They
 seldom heal rapidly, but generally slowly, as glandular suppura-
 tions ordinarily do.   Death in rare  instances results from  the
 exhaustion of suppuration.  Sometimes  the glandular affection
 terminates in chronic induration and its results.
  Rheumatism of the joints sometimes runs an abnormal course
 terminating in considerable synovitis.
   The most important irregularities are those which are  caused
by renal inflammation, which may occur in any case, the mildest
as well as the most severe, and without any connection with  the
mode of desquamation or the condition or functional activity of
the skin.   It appears  at the same time as  under normal condi- 
IRREGULAR FORMS OF SCARLATINA.
257
tions, sometimes during convalescence, sometimes during the con-
tinuance of the fever or just before its complete  disappearance
when it has been prolonged by one of the above-mentioned nor-
mally  developed localizations.   The  initial  symptoms of  the
nephritis may  be  the same as those described in the normal
course of scarlatina, but their irregular character may sometimes
be disclosed by the greater severity of some or all of them, by the
fever, the scantiness  and character  of the urine,  especially  the
dark color produced by various coloring matters, e.g., bile pig-
ment and haematine.  At this time there gradually occur marked
dropsical symptoms,  which  may sometimes be predicted by the
increase of weight which is apparent even to the attendants upon
the patient, and is not to be  accounted for by increased nutrition.
Except in cases where there  is a certain amount of oedema from
profound anaemia after a very  severe course of the disease, there
will always be found to be kidney disease; in fact, there is no
scarlatinal dropsy without nephritis.  Moreover, the dropsy need
not necessarily be preceded by albuminuria ; the latter may be
entirely absent or exist  in  a very different  degree of intensity
from the intensity of the dropsy.  It is evident that the dropsy
is connected with  some  affection  of the vaso-motor nerves, and
not  dependent alone upon  changes in the kidneys  and loss of
albumen.   With the diminution  in the quantity of urine, the
dropsy soon spreads  over the  entire surface of the skin,  or a
great portion  of it, especially  over the lower  extremities, the
genitals, and the face, where it often reaches the highest grade.
Thus the anasarca  often  develops so rapidly that a  miserable
and badly nourished child may  in a single day present the
appearance  of  an  excessively fat one.  During its continuance
the oedema is  subject to frequent changes.   At the  same time
with or after the anasarca, further effusions generally make their
appearance, such as organic  cedemas and infiltration of the sub-
mucous cellular tissue, but especially effusion into the serous sacs
and into the ventricles of the brain.  The most common of these
lesions is ascites, which is accompanied by excessive and painful
distention of  the  abdomen;   it  often reaches a considerable
degree, and then causes important  functional disturbance,  for
instance by compression  of  the  intestines,  and interference with
         VOL. II.—17. 
258
THOMAS. —SCARLATINA.
the respiration by pressure upon the diaphragm.   In fatal cases
the collection of serum is generally of a pale yellowish color,
clear, and contains much albumen ; the peritoneum is  not in-
jected.  Hydrothorax is less common, but sometimes makes its
appearance at a very early period, with considerable anarsarca,
and sometimes also at a late period, as a rapidly fatal complica-
tion, accompanjting excessive dropsy with ascites.  Both  pleural
cavities are not always attacked, but often only one.  (Edema of
the lungs is often present at the same time ; it sometimes comes
on at the beginning of the nephritis, unnoticed and  gradually ;
sometimes suddenly at the height of the disease, and then gene-
rally as a sign of impending death,  and as its immediate cause.
Hydropericardium seldom occurs isolated, but  is rather  a local
manifestation  of the general dropsy ; when it reaches  a high
degree it causes marked dyspnoea  and quickening of the pulse,
but no other special symptoms.   The oedema extends also to the
uninflamed mucous membranes ; for instance, to the soft  palate,
the uvula, the  neighborhood of the  ligamenta  aryepiglottica
(oedema glottidis) ;  in the latter case, speedy death by suffoca-
tion is almost certain.  In the cranial cavity the serous effusion
manifests itself  sometimes by true oedema of the brain,  some-
times by hydrocephalus  externus, more rarely and in  a low
grade  by hydrocephalus  internus, or  hydrops ventriculorum.
These several lesions are generally only partial symptoms of a
general anasarca;  sometimes, however, they occur  as isolated
symptoms in the form of hydrothorax or slight ascites, but per-
haps more often as oedema of the brain.  Frequently the serous
effusions all take place simultaneously ; generally they  follow,
or, to a certain  extent, complicate each other;  in reality, how-
ever,  they are  only an  expression  of  the advance  and   severe
course of the disease.
   The frequency of dropsy and albuminuria in epidemics of scar-
let fever  is very variable ;  some writers affirm that nearly all the
patients are dropsical,  others that such cases  are very  excep-
tional.  According to Steiner, the frequency of nephritis paren-
chymatosa in the several epidemics varies between five and sev-
enty per cent. ; according to others it may appear less often, but
also even more frequently. Dropsy does not often occur before 
              IRREGULAR FORMS OF SCARLATINA.           259

the middle of the second, and sometimes not until the end of the
fourth week; still more rarely at even a later period (according to
Russegger, once in the ninth week), but  generally in the third
week.  It is said that the dropsy  of  scarlatina may make its
appearance even after several months have elapsed.
   During the continuation of the dropsy the urine is generally
rather scanty, of  high  specific gravity (1.025-1.040), more or less
turbid, rich in albumen and casts, sometimes also quite bloody;
less often cases occur where the urine remains normal, or at least
clear and free of  albumen.  In regard to  such  cases it has been
remarked not only that albuminuria is absent in certain patients
at a particular time of day, or during several days, but also that
this may be the case in a large number of patients in an epidemic,
and there have even been epidemics of scarlet fever in which all
the dropsical patients were free from albuminuria.   But in most
epidemics dropsy, without albuminuria, is a rare occurrence.
   Among the other symptoms of dropsical patients the following
are worthy of notice: anorexia, frequent vomiting and diarrhoea,
and other gastro-intestinal derangements.   Not infrequently the
irritability of the mucous membrane of the digestive organs out-
lasts  the dropsy.  The  patients complain of cough, pain in the
side, and dyspnoea, which are due  to bronchial catarrh or more
serious chest lesions ; there is headache, sometimes drowsiness, or
insomnia and excitement;  the liver and spleen become swollen ;
in addition  to the early dropsy  there are  generally to be found
the usual affections of the lymphatic glands and auditory appa-
ratus.  The skin, in consequence of the anaemia and infiltration
with  serum, presents a  peculiar waxy paleness and a somewhat
transparent appearance; at the time of fever it is dry and brittle,
later it is often moist and covered witli miliaria.  The heat of the
body  varies;  sometimes it is entirely normal, even when the
course of the nephritis is  abnormal; more often it is  elevated
during the whole evening, and returns to the normal by morning.
Sometimes,  especially  at the outset, there  is  a distinct eleva-
tion ;  in other cases there are marked intercurrent exacerbations,
of short  duration, in the midst of a normal or  slightly elevated
course of the temperature, and in rare instances the temperature
remains high for a considerable  time.  A notable peculiarity of 
260
THOMAS.—SCARLATINA.
 scarlatinal nephritis, namely, the retardation and moderate irreg-
 ularity of the pulse,  is often observed in the dropsical cases,
 even when there is considerable fever, provided the pulse be not
 quickened by the approach  of  death, or  by some accidental
 cause.  The  scarlatinal dropsy is often fatal;  when it runs the
 course above described the fatal  result  is generally due to anae-
 mia, in consequence of gastro-intestinal disturbances, or to severe
 affections of the respiratory organs.
   In  the most severe  cases—especially  in those where  the secre-
 tion of urine is very scanty, or entirely or almost entirely sup-
 pressed for several days, or even  exceptionally for a week or ten
 days—uraemic symptoms  often occur, sometimes with  the pres-
 ence  of  considerable  dropsy, sometimes  with  only  a slight
 amount, or none at all.  When there is much anasarca the uraemic
 symptoms may display themselves in the form of stupor, with
 headache  lasting  for some  time  — fourteen days, according to
 Zehnder ; but at other times convulsions break out, preceded by
 such serious  symptoms  as very intense  headache, vomiting,
 amblyopia, and  even complete blindness, tinnitus  aurium,  per-
 haps even delirium and coma, and this  after transient improve-
 ment had taken place and given rise to false  hopes.  The convul-
 sions sometimes attack only certain groups of muscles (trismus);
 sometimes in an exceedingly varied way the trunk and extremi-
 ties ;  sometimes  only  one-half the  body ;  they may  also be
 perfectly  epileptiform,  or tonic and clonic  spasms may alter-
 nate at one and the same place  during the attack; sometimes
 there may be only a  single attack, which  may last from five
 minutes to several hours ; but not unfrequently several attacks
 follow each other in the course  of a few days ; exceptionally,
 numerous slight attacks occur on a single  day after intervals
 of varying,  generally  short, duration.  During severe  uraemic
 attacks death suddenly supervenes  from oedema  of the lungs,
 stoppage of respiration, exhaustion from too long-continued and
 too oft-repeated severe convulsions, cerebral hemorrhages, etc.; or
after the  convulsions have ceased death may occur gradually in
 otlier ways by collapse  from paralysis of the heart, by oedema of
the brain,  or by hydrocephalus.  But if at this period the disease
incline to recovery, the convulsions cease, and the profound stupor 
IRREGULAR FORMS OF SCARLATINA.
261
and severe brain symptoms which existed during their continu-
ance disappear more or less rapidly (Townsend, in a case accom-
panied by right hemiplegia and uraemia,  saw these  symptoms
disappear after lasting for weeks); the amblyopia disappears, the
vomiting ceases,  the urine  becomes  more abundant,  and the
patient regains more or less appetite.  Usually there is no return
of the urgent symptoms, and as the secretion of urine increases
the anasarca and serous effusions disappear, the brain and lungs
are relieved,  the appetite  and the  temperature of  the  body
become normal.  Under such circumstances the last symptoms
to disappear are those on the part of the urine, which, however,
become every day clearer,  more free from albumen, and less
turbid.   After a while the albuminuria disappears entirely, and
there remains only a scanty grayish white sediment, containing a
few hyaline casts and a small amount of epithelium, to remind
us  of the  past  serious  lesions of the kidney.   Finally,  even
these vanish,  and  complete convalescence is  established.  For
the first time  there now takes  place an intense general desqua-
mation.
   The form of  scarlatinal nephritis which is  characterized by
general anasarca and dropsical effusions lasts, in favorable cases,
from  one to several  months ; recovery follows immediately,  or
soon  after the disappearance of the dropsy.   Occasionally the
nephritis  becomes  chronic, or  months  after  the  apparent
recovery a relapse occurs, with albuminuria or dropsy after some
new exciting cause.  Death often ensues even in the first, gener-
ally in the second or third, occasionally  in  the  sixth week of the
dropsy, or  even later, partly as a direct result of the nephritis
and partly as a result of other affections.
   With the disappearance of the dropsy the series of scarlatinal
symptoms generally ends.  The normal course of the disease,
when the kidneys are not involved, lasts from one to two weeks,
the desquamation being generally completed  at the end of the
third  week ; but when nephritis with dropsy occurs, the affection
may easily continue for six or eight weeks and in severe cases
much longer.
   Scarlatina,  when  it runs an irregular course from  the start,
presents such a great variety of  symptoms, that it is impossible 
262
THOMAS.—SCARLATINA.
 to give a general description which will answer for the several
 forms of the disease.   The following, therefore, claims to  be of
 service only as a general sketch.
   Those cases which  are irregular from the start are  generally
 characterized by severe nervous symptoms with intense fever,
 and also by  gastro-intestinal disturbance  of unusual violence.
 After a period of incubation, in which there are no symptoms at
 all, or only a slight malaise, the attack is ushered in with intense
 headache and stupor, or with faintness, profound malaise, and
 repeated  copious vomiting of a mucous or bilious  character.
 Then rapidly follow more or less prolonged and  severe convul-
 sions, delirium,  and a marked elevation of temperature.  These
 symptoms may  doubtless be present in normal cases, but never
 with  the same  extraordinary severity.   The pulse  very  soon
 exhibits a rapidity which is seldom seen in other diseases ; it is
 often intermittent or irregular, but never abnormally slow ; at the
 same time it  is  generally full and hard, but, in rare instances,
 small.   The skin, after the period of prostration,  is turgescent
 and hot, the face bright red with actively pulsating arteries, the
 eyes are injected, and the patient complains of the light.  There
 may also be other symptoms, such as increased dyspnoea, palpi-
 tation, tinnitus aurium, giddiness, grinding of the teeth, uneasi-
 ness, and sleeplessness.   The throat is seriously affected from the
 beginning of the disease, and the  intense injection extends over
 the whole oral cavity; the throat is swollen, and even  at this
 early period is covered with diphtheritic deposits.   The  tongue
 is bright red, and soon becomes dry, and there is intense thirst.
 Sooner or later, usually at the  end of the first day, or at the
 beginning of the second, but  sometimes one or two days later,
 and in rare instances after a prodromal fever lasting for weeks,
 the eruption makes its appearance.  It is  sometimes, especially
 when it appears early, intensely red and accompanied  by much
general swelling and tenderness of the  skin with excessive  itch-
ing ; at other times it  is of a more dusky red color with a tinge
of violet, or it may be livid, and then does not entirely disappear
under the pressure of the finger ; in rarer cases it is abnormally
pale, and  then is usually very transient.  When the eruption is
very abundant the skin is often infiltrated and has the appear- 
IRREGULAR FORMS OF SCARLATINA.
263
ance of leather.   Sometimes, instead of beginning upon the face
and neck, it makes its first appearance upon the abdomen, back,
and  limbs, or suddenly breaks out over the whole body at the
same time.   Less frequently the  face or  other  parts  remain
wholly or almost entirely free from the eruption, and the only
situations affected to any considerable extent are one side of the
body, or the upper or lower half of  the body, or the extremities.
Sometimes the eruption is still more  scanty.  Glaser, for exam-
ple,  describes a form of the eruption in which it appears as a
broad ring around the neck, or at the same time as a semicircle
or half-moon on the  forehead, or as  a circle surrounding each
elbow-joint ; Wildberg  found it occurring  only on  the joints,
Zehnder as red spots scattered over the body, and Geissler as a
redness on the abdomen, simulating the erythema produced  by
a mustard plaster.
   After the appearance  of the eruption the fever continues
with scarcely any abatement;  the febrile reaction is so con-
tinuous that it  is difficult to  discover any morning  remissions,
or, at  any rate, only such as  are unimportant.   During  the
next few  days  the eruption  becomes still more  intense, and
miliaria  make their  appearance in various places, sometimes
vesicles of larger size filled with a turbid, purulent,  or ichorous
bloody fluid, and even bullae as  large as a hazel-nut (scarlatina
pustulosa and pemphigoides).   At this  time not  unfrequently
occur certain lesions which may be  regarded  as unmistakable
irregularities of  the  eruption :  small  petechiae, ecchymoses of
larger size, elevations of the epidermis filled with  blood resem-
bling hemorrhagic miliary vesicles.  These lesions  are,  however,
frequently due  merely to intense  congestion  of the skin and
delicacy  of  its  vessels, and are consequently of less  serious
import when the eruption is abundant than when it is scanty
and  pale.  The  throat affection also  very  frequently presents
irregularities in its  course.  As a rule,  we may consider  the
course  of scarlatina as irregular whenever the throat  affection
is very severe; but it is,  of course, difficult to place the limit
beyond which the angina is to be regarded as abnormal.   In
these irregular cases the tonsils become so enlarged that they
nearly  or quite  touch each other,  and interfere seriously with 
264
THOMAS. —SCARLATINA.
       deglutition; the arches of the palate are very oedematous and
       of a bright red color, and the throat is often covered in various
       places with  pseudomembranous  deposits ;  the  mucous mem-
       brane  is often discolored and livid, excoriations occur,  which
       often terminate in ulcerations or even in gangrene, and may give
       rise to serious  hemorrhages  and  considerable  sloughing, for
       example,  of almost the whole tonsil.   The  cervical lymphatic
       glands in  all these cases become  much enlarged, and form
       thick bunches along the lower jaw ; not unfrequently the entire
       cellular tissue of the upper cervical region becomes so swollen
       and indurated in the form  of a semicircular tumor that the
       inferior maxilla is  almost anchylosed.  The return of  venous
       blood  is thus obstructed, and the  face presents an unsightly
       deformity, particularly  in  the  parotid  region.   Respiration,
       speech, and swallowing become very difficult, the latter almost
       impossible.  The severe inflammation of the throat often extends
       to the nasal mucous membrane, presenting either a  suppurative
       or diphtheritic character, with a copious, acrid, almost corrosive
       discharge, which produces excoriations and  ulcers both within
       the nares and at their orifices.   Under these circumstances respi-
       ration is carried on almost exclusively through the mouth, which
       consequently becomes dry, chapped, and fuliginous.  Epistaxis
       in considerable amount may also  occur at this time, and severe
        disease of the auditory apparatus  resulting in  complete deaf-
       ness may be rapidly developed.   Serious disease of the eye may
       also result from extension of the morbid  process through the
,      lachrymal ducts to the conjunctiva.  In severe cases the appe-
       tite entirely disappears,  there is often considerable pain  in the
       stomach, and the vomiting continues or returns upon slight pro-
       vocation.   There is also often  a persistent diarrhoea, with green-
       ish and perhaps bloody stools of  a most offensive odor, indicat-
       ing serious intestinal lesions, and accompanied by tenesmus and
       tormina.   Schonlein describes very  severe colicky pains  occur-
       ring periodically in the umbilical region, and designates them
       neuralgia coeliaca.   The kidneys also are often affected at this
       time in the irregular cases, the urine becomes more scanty, turbid,
       and albuminous, and contains sometimes only the products of  a
       catarrhal, less frequently of a  parenchymatous nephritis, some- 
IRREGULAR FORMS OF SCARLATINA.
265
times also blood in large quantities.  The further symptoms of
kidney disease are not usually developed at this  time, and  if
there be any slight swellings they are generally due to congestion
of the skin.   The severe cerebral symptoms,  which are usually
present in these cases, and which were formerly for a long time
regarded as signs of  disturbance in the secretion  of urine, are
now more properly attributed to the blood-poisoning, high fever,
or to other lesions, such as hyperaemia of the brain with capillary
extravasations, hydrocephalus, partial  softening and beginning
meningitis.  According to Wunderlich, we may gain a  more
comprehensive idea of the great variety of these symptoms if we
compare  them with other  groups of symptoms depending upon
definite lesions to which  they present  a striking  resemblance.
Not unfrequently the patient becomes suddenly paralyzed,  as in
apoplexy, and dies in a few hours, or even sooner.  In such cases
the paralysis rarely takes the form of hemiplegia, but generally
affects the  whole body, and is accompanied by a rapidly devel-
oped and profound coma with dilated pupils.  In many cases the
symptoms are those of severe cerebral irritation, either with deli-
rium of a garrulous or furious character, or with epileptiform or
tetanic convulsions,  or trismus.  These attacks  may cease, or,
more commonly, end in death, with coma, collapse, and paralysis,
or  they  may even  change their character.   Sometimes these
symptoms of  irritation are intermittent with irregularly occur-
ring paroxysms;  during the  remission the amount of cerebral
disturbance may be very slight, or  the affection may assume an
entirely different form.  The sudden and total change which takes
place in  such cases,  after a longer or shorter period of repose,
is often very striking.   Wunderlich states that not  unfrequently
symptoms occur which resemble profound toxicaemia or a severe
typhus fever,  apoplexy (hemiplegia  and paraplegia), encepha-
litis,  meningitis, very  acute  or subacute  hydrocephalus,  and
which are accompanied by retardation of the pulse and by the
so-called Cheyne-Stokes respiratory symptom ; much  more un-
common  are various local disturbances of sensation (paraesthesia,
sleeping  of  the feet,  hyperaesthesia, and anaesthesia), neuralgiae,
especially of the upper half of the body, local spasms (contrac-
tions of  the neck, torticollis, spasm of the glottis, retention  of 
266
THOMAS. —SCARLATINA.
urine, nystagmus, reflex cramps of various kinds), and local paral-
yses, such as aphasia and amblyopia, or paraplegia of the lower
extremities, or, in addition to the latter, retention of urine and
faeces,  rigidity of  the back, difficult deglutition,  etc.   In some
cases, in connection with the severe and fatal cerebral symptoms,
Paul found sugar in the urine.  The  form of the pathological
changes corresponds only imperfectly with the symptoms, and it
is never possible to diagnosticate from the latter the exact nature
of the anatomical lesion.  Sometimes, even when the cerebral and
spinal  symptoms  are most severe, no  abnormal  change can be
detected.  Very rarely (at least such cases  are rare in Leipzig),
even during the first few days of an attack of scarlet fever, severe
rheumatic  affections may  arise, especially  inflammation of the
joints with  rapid  progress to suppuration, and  abscesses may
form between the muscles, in the internal  organs, etc.   Some-
times severe pains are felt in certain  parts,  spontaneously or on
pressure, either over the bones,  as, for example, the spinous pro-
cesses,  the  anterior surface of  the tibia, the  acromion, etc., or
in the muscles when the patient voluntarily makes much muscu-
lar exertion (Betz).  These pains are due to affections of the peri-
osteum (perhaps also of the bones) and muscles, but not to  any
lesion in the joints.   Heim, Joel, Betz, Stiebel, and others have
called attention to a peculiar odor  which  sometimes emanates
from scarlet-fever patients, and reminds one of the odor of old
cheese  or of a menagerie.  It is so  penetrating that  it fills the
whole room, and may be regarded as a pathognomonic symptom;
but whether it is present  only in the unmistakably irregular
cases I am unable to say.
   The symptoms above described do not always appear in equal
intensity at the same time, but  in numerous instances those of
some particular organ assume  predominance, while  the others
remain in the background or  may be entirely absent.  This  fact
furnishes a  basis of  distinction between a  number  of the chief
varieties of irregular scarlet fever, which derive their names from
the nature and intensity of their most important symptoms ; e.g.,
angina maligna, angina parotidea, scarlatina with severe nervous,
meningeal, or apoplectic symptoms, or with  rheumatoid or chole-
raic complications, etc.  In all these  various forms the eruption 
IRREGULAR FORMS OF SCARLATINA.
267
may vary extremely, in the time of its occurrence, in its amount,
intensity, and duration;  and this fact, together with the extra-
ordinarily great number of the irregular symptoms  and their
combinations, accounts for the striking  differences  which  are
noticed in individual cases.
   The severe forms of irregular scarlatina sometimes last only a
short time, a few days, a week, or a little longer; when the local
symptoms have become fully developed the farther course of the
disease is often cut short by death, which may occur  in various
ways. Sometimes the fatal result  is due to the severity of  the
fever, which is independent of any intense local symptoms, and
which gradually or suddenly, or even after an antecedent remis-
sion,  produces a very intense,  and conseqently fatal elevation
of temperature (107.6°-109.2°  and upwards), and  an extremely
rapid pulse (200, and even higher).  At other times death results
from the angina and the disease of the cervical lymphatic glands,
through  obstruction of the air-passages,  either by extension of
diphtheria  to the larynx or by oedema glottidis.  Among other
causes of death  may be mentioned  congestion  of the  cranial
viscera, intense fever, pyaemia, septicaemia,  and other  constitu-
tional affections, cerebral  exhaustion from intense excitement,
pathological lesions in the brain or its membranes (inflammations,
hemorrhages, hydrocephalus, etc., or the  rapid  increase  of a
chronic hydrocephalus), tetanus or convulsions occurring unex-
pectedly with a  premature and sudden disappearance  of  the
eruption, rapid collapse with abrupt fall of  temperature, various
complications, and the hemorrhagic diathesis.
   In  favorable  cases, after remaining  well marked for a few
days, a week, or perhaps  longer, the eruption fades, the miliary
vesicles dry up, and desquamation commences.  Irregularities in
the eruption may, however, occur at this time in  the form of a
more or less characteristic return of the scarlatinal redness, or in
the form of other cutaneous lesions, such as  roseolae, erythema
simplex and nodosum, erysipelas, urticaria, herpes, lichen, ecthy-
ma, furuncles, etc., as an immediate result  of the  intense scarla-
tinal dermatitis.  These symptoms are not dangerous, but merely
protract  the convalescence.  The angina may  also now return,
unless it have already advanced to its more  serious lesions, diph- 
268
THOMAS.  -SCARLATINA.
theria, gangrene, etc., in which case the fever may continue for
some  time  longer,  and  delay recovery in various ways.   The
throat affection may be  still farther prolonged by the occurrence
of severe glandular affections or intense inflammation  of the cer-
vical connective tissue, leading to suppuration and gangrene, or
even to alarming hemorrhages from erosions  of  large vessels.
These  hemorrhages may also occur after  the incisions  of an
abscess.  Recovery may be delayed in  rare instances  by disease
of the joints or kidneys, or by various other complications.  The
cerebral symptoms, as a rule, abate along  with the fever.  If the
fever be not maintained at a high point by the excessive severity
of the symptoms above described, or by the occurrence of farther
serious complications, it gradually subsides, but more slowly and
with less regularity than in the normal course of the disease ; so
that in an  attack, which has been  irregular from the start, but
which  is still benign in character, the normal condition may be
re-established by the end  of  two or three weeks.   Parenchy-
matous nephritis may, and often does occur at this time,  with a
return of the fever and other symptoms, and even in its mildest
form may delay the  convalescence for a considerable time.   In
such cases the course of the renal affection is often of moderate
severity, but more frequently it is severe and attended by dropsy
of the connective tissue and  serous membranes, together with
copious hemorrhages in the renal tubules.
   According to  this  description  the chief  characteristics of
many of the irregular cases of scarlet fever are  the  severity of
the local lesions, the cerebral symptoms, and the intensity of
the initial  fever.    But not unfrequently there occurs  still
another form of the disease in which there are  not only local
affections  of moderate, perhaps even trifling  importance,  but
also a disproportionately severe fever of  long duration,  which
characterizes this variety  as  a  typhoid  scarlatina.   In such
cases the fever is the chief  symptom, and  the local lesion seems
to be of subordinate importance, and yet  sometimes the prolon-
gation of the fever into the fourth week, or longer, is apparently
wholly due to a protracted local affection.   The eruption  in this
form of scarlet fever generally makes its appearance only  after a
rapidly developing initial stage, followed by high fever  lasting 
IRREGULAR FORMS OF SCARLATINA.
269
 for several  days, and is then often very scanty, but otherwise
 normal.   The angina, which is the next most  important symp-
 tom,  is  often  imperfectly  developed,  but appears somewhat
 earlier than the eruption.   The brain symptoms and the fever
 are, however, quite severe, especiall yduring the first few days
 of the disease; the patient complains of headache, is delirious
 or drowsy, the facial expression much altered; there is urgent
 thirst, the  tongue tends to become  dry, but cleans off in the
 characteristic manner ; there is some cough, and the skin, which
 desquamates in the usual way after the fading of the eruption,
 remains dry and hot.   At a later period the patient is apathetic
 and very deaf, although the disease  of the auditory apparatus
 appears  to  be  but slight;  the spleen enlarges, hypostatic con-
 gestion occurs  in the lungs, and there is diarrhoea.  The fever
 continues for weeks in a remittent  form, but there is generally
 no other local  affection  except a moderate enlargement of the
 cervical lymphatic glands ;  in the third week signs of renal dis-
 ease may make their appearance in the urine for the first time,
 and the fever is explained by the occurrence of dropsical symp-
 toms.  When the latter occur, the  fever,  which has hitherto
 been regular, now generally changes its character, increasing in
 an  unexpected manner,  and pursuing a course determined by
 the new local  affection, or  the febrile symptoms may abruptly
 cease entirely ; less frequently when  the renal symptoms are mod-
 erate, or  altogether absent,  the daily exacerbations diminish in
 severity and the fever gradually disappears.  At the autopsy,
 when death  occurs in  this typhoid form at a late period, besides
 the usual affections of the  throat,  lymphatic glands, skin, and
 perhaps  kidneys, there may be found also other lesions, such
 as hyperaemia  of the brain, slight cloudiness of the meninges
 (sometimes  with granulations, according to Hebra), catarrh  of
 the respiratory passages,  hypostases of the lungs, effusions into
 the serous cavities, engorgement and enlargement of the liver
 and spleen,  marked disease of the  follicles of  the  small intes- 1
 tine and  infiltration  of the adjacent mesenteric  glands, some-
 times even  a slight  typhoid tumefaction of  Peyers patches.
 This typhoid form of scarlatina occurs without any connection
with typhoid fever, and we may dismiss, therefore, without any 
270
THOMAS.—SCARLATINA.
further consideration, the conjecture that this special course of
the disease is due to such a complication.
   Sometimes after an attack of scarlet  fever which runs  a
typhoid course without special local symptoms, or is attended
by various  local diseases, or  perhaps is uninterrupted by any
complications, a fresh eruption  unexpectedly breaks out over
the whole  body.   In the cases which have come under my own
observation,  it is never  exactly  similar  to the  normal first
scarlatinal  rash, and yet the  resemblance  is so strong, and the
difference  from all  other exanthemata so  marked, that  I have
no hesitation in regarding it as an irregular second scarlatinal
eruption, and shall therefore distinguish it from the true relapse,
which occurs after the normal course of the disease, by calling it
a pseudo-relapse.  The cause  of this anomalous  eruption may
probably be found in  a renewed determination  to the skin
occurring at an unusual time.  Nephritis  appears to have no
influence in producing the pseudo-relapse, at least this is the
experience  of myself and others.
   The pseudo-relapse presents some notable peculiarities.   It is
decidedly more like roseola,  and  has not the finely punctate
appearance  of the first  eruption.  The roseolae, which are very
numerous,  are generally of a dark,  rather scarlet-red color,  at
the same time smaller and less sharply defined, generally  closer
together, and less elevated above the  surrounding pale skin than
is the case in measles.   The eruption spreads over the body in a
perfectly normal manner.  Sometimes the roseolae are developed
everywhere quite uniformly  and simultaneously,  sometimes
they appear only on the face and extremities or upon the latter
alone, and at other times they are confined to the trunk, or even
to certain  portions of it.  On the face the eruption affects also
the region  around the mouth, and there is no such sharp con-
trast shown by this region with the neighboring parts as is seen
in the first  attack even when the  eruption is very copious.  Very
commonly this second eruption  is completely confluent on cer-
tain parts  of  the body, at other times  it  is markedly discrete.
If confluent, it is much more pronounced than in the first attack,
for  the individual roseolae can no longer be distinguished from
each other ; in some cases, besides the confluent portions, there 
IRREGULAR FORMS OF SCARLATINA.
271
 may be present sharply circumscribed roseolae, with no tendency
 to continence.  As  a distinction from measles, the confluence is
 found not so  much on  the  face as on certain other parts,  such
 as the scalp, very  often also the  extremities, and particularly
 flexion-surfaces.  The roseolae do not reach  their full develop-
 ment  in all  parts at nearly the same time, as in the first attack
 and in measles ; but at one place they rapidly become confluent
 as soon as they make their appearance, in others they perhaps
 begin  to form for the first time on the second day, remain  of a
 pale color, and do not coalesce  at  all.   The full development
 may take place at all points within twelve hours,  or the eruption
 may appear  gradually and incompletely only after the lapse of
 several days.  When this second  eruption fades it may disap-
 pear so  slowly and with such interruptions  during the  febrile
 exacerbations that the process of decline may be mistaken for a
 maximum  development of variable severity which has been pro-
 tracted for several  days.  But in other cases an intense conflu-
 ent eruption may arise and fade within little  more than twenty-
 four hours.  The desquamation following the  fading  of  this
 eruption is  always  lamellar, generally copious,  and  follows
 immediately, even in cases where there has been little or no des-
 quamation preceding the second eruption.  The chief character-
 istics of the  pseudo-relapse, such as  the color, the  commingling
 and often actual confluence of the patches, the unequal develop-
 ment  on various  parts  of the body, the simultaneity  of the
 eruption, the rapid  development to  a partial or general maxi-
 mum,  the manner of fading, and the intense lamellar desquama-
 tion—all these resemble  the characters of the normal eruption,
 and yet they may be  distinguished by the distinctness of the
 roseolae and  the intensity of the eruption on the face,  including
 the region about the mouth.  For these reasons I do not hesitate
 to regard the eruption as an irregular form of scarlet fever, and
 not an accidental complication.  Other  kinds of eruption, par-
 ticularly miliaria, are, as a rule,  absent.
   During the continuance of the second  exanthem the course of
 the body-temperature is by no means  regular and characteristic.
This fact may  perhaps  by itself enable us to distinguish the
nature of the new process.  I have noticed particularly that the 
272
THOMAS.—SCARLATINA.
maximum of the pseudo-relapse never coincides with the maxi-
mum of the temperature.  According to certain observations,
however, the new eruption appears to have a slight influence in
elevating the body-temperature.   There is always a moderate
amount of renewed injection of the mucous membrane of the
throat and  parts of the mouth, the  tongue also presents  the
same appearance as in the first eruption (redness, enlargement of
the papillae), and the  cervical lymphatic glands undergo a mod-
erate increase in size. Slight conjunctivitis, nasal catarrh, hoarse-
ness,  cough, and the  symptoms of a slight bronchial catarrh
may sometimes be noticed even before  the breaking out of the
second  eruption.  The  mucous membrane of the  alimentary
canal is not much deranged, the liver is of normal size, but the
spleen  generally remains  moderately enlarged.  The  nervous
symptoms, if any be present, may be  considered as the result of
the febrile condition.
   In general terms it may be said that the course of the scarlet
fever is not much altered for the worse, at least not in any strik-
ing degree, by this very irregular outbreak of a second eruption;
most  of the cases recover.  The  cause  of this  abnormality is
unknown ; but the regularity of the  interval which intervenes
between the first and the  second eruption makes it highly prob-
able that there is a close relation  between them.  Perhaps the
explanation lies in a peculiar phase of the development of the
scarlatinal poison.
   Among  the irregular  varieties  of  scarlet fever  the hemor-
rhagic form also deserves a special notice.  As a rule, the condi-
tion of the patient is alarming from the  start, and is character-
ized by intense fever  and cerebral symptoms.  The eruption is
generally but very imperfectly  developed; spots as  large as a
millet  or hemp seed,  with a clearly  marked margin, and of a
crimson or  dark purple  red color, and  finally  ecchymoses of
larger size,  make their appearance all over the body; the skin,
which is at first erythematous, subsequently becomes flabby and
wrinkled, and the face bloated.  In  all  the more severe cases
there is considerable angina, sometimes of a diphtheritic or gan-
grenous character, the  lymphatic glands and connective tissue
of the neck usually present serious lesions, and when gangrene 
              IRREGULAR FORMS OF SCARLATINA.           27'3

or diphtheria  occurs the result is almost always fatal.   Hemor-
rhages frequently take place in the cavities of  the body or from
the mucous membranes, especially the latter, if, as is often the
case, they are much diseased  or ulcerated.   Hemorrhages occur
most  frequently from the mucous membrane of the nose and
colon, and may  produce the most profound exhaustion.   Severe
hemorrhage may occur also from a tooth-cavity, or from slight
wounds such as  leech-bites,  or the scarification for cupping.  It
may also take  place from  the urinary passages, usually from
the substance of the kidney,  and in rare cases from the pelvis
or the lower  portions of the urinary passages.   In these cases
the urine is  of an almost blackish color.  In  women hemor-
rhages occur from the genital organs, either with or without the
presence of vaginal diphtheria.  The internal organs, especially
the brain, heart, liver, spleen, stomach, and lungs,  may also be
the seat of hemorrhage; so also the subcutaneous cellular tissue,
especially of the neck.  Finally, pleuritic or pericardial exuda-
tions  may occur of a more or less  hemorrhagic character.  In
the hemorrhagic form  of  scarlatina death is  by far the most
frequent termination, and sometimes depends  upon the intense
fever;  sometimes upon prostration from hemorrhages and diar-
rhoea ; sometimes upon  cardiac  exhaustion or  serious  organic
affections, such  as pneumonia, meningitis, nephritis,  colitis,
pleuritis, etc., and finally, upon the severity  of the constitutional
disturbance,  either directly from the  scarlatinal poisoning or
from secondary affections,  such as diphtheria,  gangrene,  etc.
Recovery is possible only in the milder grades of this irregular
form of  the disease, where  the fever is slight, the angina  still
more unimportant, the hemorrhages trifling or of  brief duration,
and when no other serious complications occur.
   Irregularities in the course of scarlet fever may occur at  any
time in consequence  of the  development of  complications.   If,
as a matter of experience, the latter are usually found to have
but a slight effect upon the progress of the disease, the explana-
tion may be found in the fact that the irregularities precede  and
are not caused by the complications.
   It is easy to  see what extraordinarily varied symptoms may
be produced by the combinations of all these numerous  symp-
          VOL. II.—18 
274
THOMAS.—SCARLATINA.
toms, and by the different general types which the course of the
disease presents ; in fact, no other disease exhibits such a variety
of forms, such a dissimilarity of symptoms in cases which depend
upon a common cause.

   When scarlatina occurs in the course of other diseases (which are then generally
irregular) it frequently increases their severity ; according to Rilliet, especially if the
other affection implicate organs which are apt to be affected  by the scarlatinal poi-
son.  Thus, for example; Loschner regards the existence of a previous tuberculosis
of the lymphatic glands as a very bad sign in scarlet fever; the more severe and
extensive this lesion is, the more violent is the course of the disease, the more fre-
quent its complications (meningitis, hydrocephalus, pleuritis, dropsy), and the more
unfavorable its termination.  On the other hand, other diseases which are indifferent
to the scarlatinal poison not only do not change the character  of  the scarlet fever,
or interfere with recovery, but they may even exercise a salutary influence.   Barthez
and Rilliet state that scarlatina  has a favorable influence upon phthisis, an observa-
tion which is approved by Deiters, but rejected by Hebra.  In this category is included
the concurrence of  scarlet fever with small-pox, measles, varicella, typhus, etc.   In
these cases death results only very rarely.  In two cases of chorea  seen  by Thomp-
son, the disease disappeared when the children were attacked with scarlatina; Losch-
ner saw two cases, one of which recovered during  scarlatina ; in the other the dis-
ease was aggravated but suddenly disappeared.  Lumbricoid worms are frequently
discharged during the course of scarlet fever, and cases have been  known in which
the worms have passed into the stomach and  been vomited.  Prevot has seen scrof-
ula in a child cured by the occurrence of scarlatina maligna with formation  of
abscesses. The child afterwards  permanently regained vigorous health. Betz observed
an improvement in the stools in a case of dysentery when a diphtheria of the colon
occurred as one of the symptoms of a complicating scarlatina.  The child died.


                           Complications.

    The complications of scarlatina are very numerous, and at the
same time of a very varied  character; there is scarcely any organ
which  may not  be implicated.   No period of the disease is free
from complications ;  they may occur  during  the  initial stage,
the fastigium, or the decline ; some  at any time, others more par-
ticularly at certain periods ; in normal cases, or in those which
are  irregular from  the  outset, but more especially the latter;
hence  they  are  more frequently observed  in  severe  epidemics
than in those of a milder character.  They occur also in connec-
tion with every form of  development of the eruption, angina,  or 
COMPLICATIONS.
275
fever; whether the eruption be intense, or moderate, or imper-
fectly developed, or entirely absent, or whether it run  a brief
and rapid or  a protracted course.  Nor does the form of  the
angina or the grade of the fever appear to have any influence hi
their production.
   The forms of the development of these complications is  ex-
tremely  various.  Sometimes they occur  suddenly  and most
unexpectedly, or they may be preceded by certain insignificant
and scarcely noticeable symptoms, without any external cause or
other disturbance, or they may perhaps seem to depend upon
the sudden disappearance of the eruption.  In  the latter case
there will always be a doubt whether the complication be  not
due rather to some new internal morbid process.   The complica-
tions may progress more or less rapidly, and sometimes  several
of them may combine in the most varied manner.
   In many cases the occurrence of an important complication is
the immediate cause of death ; in others it merely protracts to a
greater  or less degree the course of the disease,  or gives rise to
sequelae.
   The most frequent complication of scarlet fever is that with
severe cerebral and  spinal symptoms,  and this  for  the reason
that the latter always occur whenever the  disease runs a severe
course, or whenever there are other serious  complications. And
yet in many  instances  it may be a  question  as to what is
the true nature  of  these symptoms,  since  it  is not  easy to
distinguish between  a  merely concomitant  symptom  of   an
uncomplicated case  and  an  actual  complication.   A  positive
discrimination is, however, without much practical importance.
   Severe nervous symptoms  can be traced back to  several
causes :  to the scarlet-fever poison in the blood acting as a
narcotic ; to the high fever; to the extensive areolar  infiltra-
tions  in  the  neck,  which interfere with the return circulation
of the blood ;  and in the latter stages  of the  disease  to  the
anaemia  produced by  the severity of  the  fever ;  to  the blood
alterations  from  pyaemia and  septicaemia, and finally to  the
changes produced in the course of the so-called uraemia.  The
anatomical alterations, which are not, however, invariably found
on examination, are hyperaemia, slight inflammations,  oedema, 
276
THOMAS.—SCARLATINA.
anaemia, and  hydrocephalus—rarely severe  inflammation with
abscesses and extravasations.  In some cases it is impossible,
either at the outset or even in the whole course of the disease,
to trace the cause of the symptoms.   The symptoms themselves
do  not give us the slightest, or at least only the most dubious
indications of the nature of the nerve lesions, although an experi-
enced judgment is of great service in their detection.   The diffi-
culty in the diagnosis  becomes  still more apparent  when  we
consider that each symptom may depend upon a great variety of
lesions.   The nervous disturbances appear at various  periods of
the disease : at the outset, and then generally in connection with
other symptoms, as an indication of  toxicaemia and of the sever-
ity of the fever (headache,  delirium, and coma);  perhaps sud-
denly, in the midst  of an otherwise favorably progressing case,
brain symptoms may arise, as a result of cerebral irritation ; also
when the eruption, fever, and angina are rapidly increasing in
intensity, in the form of febrile delirium and stupor, increased or
modified by the continuance of the poisoning ; also coincidently
with the sudden disappearance of the rash, and then especially
in the form of convulsions during  the  stage of nephritis and
uraemia,  in the same way as when there is no scarlatina ; in fact,
at any time whenever pathological changes occur in the nervous
system.
  Affections of the eye of a mild character, particularly slight
conjunctivitis, with  epiphora  and photophobia, are  not infre-
quently met with at the outset of severe scarlatina,  coincident
with an  abundant  eruption on the face, but never to  the same
degree as in measles.   On the other hand, the later occurring
ophthalmias, which are not infrequently met with in  scrofulous
subjects, are generally very obstinate, and lead often to marked
corneal troubles and even panophthalmitis, with severe and even
permanent impairment of  vision.   The same  symptoms may
result from an intense coryza passing up through the  lachrymal
duct, and thus giving rise to lachrymal fistula and other more or
less severe affections of the tear-passages.   Primary keratitis
occasions frequently perforation of the cornea, with its unfortu-
nate consequences.   From the  scarlatinal  nephritis a  special
form of  retinitis arises,  which,  according to  Schroter, develops 
COMPLICATIONS.
277
itself sometimes within a few days, sometimes in a longer time,
with various degrees of loss  of  sight.  It  occurs  generally in
both  eyes, but not always at the same time nor in the same
degree, and, as a rule, total blindness is not developed.   The
course of the affection is generally protracted, but the prognosis
is generally favorable, more or less complete restoration of vision
being  the usual  result.  Less frequently  the impairment of
vision is due  either to atrophy of  the optic nerve  or  to  a
detachment of the retina.
   The transitory blindness which accompanies uraemia, in con-
nection with other symptoms, is of a far different nature,  and
occurs independently of the  presence or  absence of any retinal
affection.  It shows itself, Schroter says, as a binocular ambly-
opia,  which proceeds in a day or two to complete loss  of per-
ception of light—not unfrequently on awakening from a period
of unconsciousness the patient finds  himself  completely blind.
The pupils are abnormally dilated, they usually still react to
light, but less frequently are  fixed and motionless.  The amau-
rosis disappears as rapidly as  it occurred, and generally in from
two to four days vision  is  completely restored.  Porter  has
observed  in a girl six years of age such a temporary amaurosis,
with exophthalmos from infiltration of the cellular tissue of the
orbit, with other  severe  complications.   Duval, under  similar
circumstances,  found  the  sight  completely restored  after  the
exophthalmos had lasted for ten days.
   The previously described inflammatory  ear affections,  or  a
relapse of the  same if any  occur,  often begin,  according to
Wendt, with very violent pain in  the ear, and a febrile exacerba-
tion which is independent  of  the progress of the  eruption,  etc.
The hearing is always very much impaired by the swelling of the
mucous membrane, also by the closure of the Eustachian tube,
by the filling up of the tympanic cavity with hypersecretion, and
by destructions of moderate extent.   Subjective tinnitus is  sel-
dom met  with.   Sometimes brain symptoms intervene through
the free anastomoses between the dura mate]- and the middle ear
by means of the  middle meningeal artery.   Hynes saw a boy
die  on the twenty-second day of  the  fever from arterial hemor-
rhage from the right ear, and at the same time from the mouth. 
278
THOMAS.—SCARLATINA.
    The affection of  the nasal mucous membranv (coryza scar-
latinosa) begins, as a rule, at the time of the acute angina, less
frequently in  a  subacute  and simple form, and more often as a
severer difficulty, with great swelling and intense  pharyngitis
and diphtheria of the naso-pharynx. It is indicated by the nasal
tone of the speech, but in particular by the more or less abun-
dant  irritating ichorous discharge  from the nostrils, with occa-
sional epistaxis  from the intensely congested mucous membrane,
or  at times from ulcerated  surfaces.    The scarlatinal  coryza
is truly a complication very much to be dreaded, not so much on
its  own account, as on account of the  dangerous forms of pha-
ryngitis associated with it.   It may, however, of itself give rise
to quite grave lesions, especially through the formation of ulcer-
ations, which, in their progress, may excite serious hemorrhages,
and may even lead to periostitis and necrosis of the nasal bones.
    Under similar  circumstances we find, principally in  young
children, severe stomatitis appearing,  with ulceration affecting
the back part of the mouth,  the  cheeks,  gums, and  tongue,
and spreading thence over a considerable portion of  the mucous
membrane of the mouth.  This affection is painful, gives rise to
a very offensive  odor, salivation, and hemorrhages, and interferes
seriously with the nutrition of the patient.
    Pure and simple ptyalism, without parotid or other affections
of the mouth, is  seldom  seen  (Muller); it generally occurs in
connection  with  ulceration of the mouth, and probably from the
use or abuse  of mercury. Zehnder saw it return once after a
cessation of fourteen  days  caused by uraemia.
   The inflammation of the whole or at least the greater part of
the connective tissue of the neck, as well as of the parotid region,
which usually occurs  in  the second week  of  the  disease, but
sometimes earlier, is correctly regarded as an extremely perilous
affection, not only on account of the great danger of suffocation
from compression of  the air-passages and oedema of  the glottis,
but also and principally on account of  the extensive destruction
of the tissues resulting  from the  great suppuration, or from
sloughing.   From the suppuration we  can  have deep burrowing
as far down as the thorax, perforation of the pharynx, so that
the food comes out through the external opening (Cremen), retro- 
COMPLICATIONS.
279
pharyngeal abscess, erosion of the large veins of the neck, as well
as of the carotid and smaller arteries (arteria lingualis), and con-
sequent fatal hemorrhage, and lastly, destruction of important
nerves and muscles.  Gangrene produces still more readily the
same  consequences, and besides these, emphysema of the  skin.
By the destruction of the skin the deeper parts are laid bare
to a large extent, and septic infection often results.   With any
extended destruction of the tissues death is almost inevitable ;  it
ensues sometimes quickly, sometimes more slowly from progres-
sive marasmus.
   Affections of the air-passages and lungs are much more rare
in scarlet fever than  in measles.  The  most  important are:
oedema of the glottis from severe sore throat, inflammation of the
cellular tissue  of the neck,  with  or without ulceration of the
larynx ; croupous laryngitis and  similar disease lower down in
the air-passages, with  or without  broncho-pneumonia, resulting
from pharyngeal diphtheria ; bronchitis, which sometimes occurs
as a complication during the height of the eruption, or immedi-
ately after it; under similar circumstances, and yet more rarely,
croupous pneumonia of greater or less extent, affecting the upper
as well as the lower lobe of the lungs ;  this affection does not
make the prognosis more unfavorable in  the absence of  other
complications ; pneumonia, lobar  as well as lobular, very fatal
in the later stages  of  scarlatinal  nephritis, because  it is  often
conjoined with pleurisy,  and further on gives  rise to pulmonary
oedema and  abscess of  the lung ; it is usually attended by signs
of great constitutional disturbance, such as pain, dyspnoea, dis-
tressing cough, abundant frothy,  bloody sputa, and  augmenta-
tion of fever ;  atelectasis of the lungs in connection with other
severer  symptoms;  pulmonary  apoplexy, especially when  a
hemorrhagic  diathesis  is present.  Fleischmann had a  case of
considerable  hemorrhage into  the posterior mediastinum  from
a cavity of the lung ; in rare cases gangrene of the lung occurs ;
finally, there may be oedema of the lungs, which may unexpect-
edly occur in every stage of the disease, with a fatal issue, and
when  occurring at an  early period of the fever is generally due
to sudden failure of the heart's action from  overstrain  of that
organ. 
280
THOMAS. —SCARLATINA.
   Symptoms sometimes appear, such as  severe gastralgia, per-
sistent and often bilious vomiting, and great sensitiveness of the
stomach to  all ingesta,  denoting a gastric  affection, which,
though intense, is free from danger and of short duration.  In
cases  of  hemorrhagic  scarlet fever  haematemesis  sometimes
occurs.
   The follicular inflammations and partial or general hyper-
aemia of the intestinal mucous membrane, occurring at the time
when the eruption has attained  its fullest development, mani-
fest themselves by a persistent and considerable diarrhoea, with
or without colicky pains and tympanites,  and may perhaps lead
us to  mistake the  disease  for a  typhoid fever.   At the  same
time the tongue is dry, there is considerable thirst;  the urine is
scanty, the  eyeballs are deeply sunken,  and the face has the
expression of a patient suffering  from cholera;  the  stools are
liquid, mucous, yellowish or greenish, even dark green, contain
only a small quantity of  liquid faecal matter, but a large amount
of epithelial cells and pus-corpuscles, sometimes also more or
less blood.  If these symptoms are only of slight intensity, they
do not denote any danger ;  but if they are more severe they are
rapidly followed by collapse.   Joel observed  a case where,
besides the intense fever, the  gastro-intestinal  symptoms  were
the most important phenomena.  The slight angina,  the subse-
quent  desquamation of the epidermis at  different parts of the
body, and the fact that the  sister was also suffering from scarlet
fever, did not leave any doubt about the diagnosis in this case.
Enterocolitis  and coloproctitis,  with violent colic,  painful tenes-
mus,  and catarrhal or dysenteric evacuations, are occasionally
observed  during the course of scarlet fever,  especially in its
later stages.  If sporadic, they generally last only a short  time,
and are not particularly dangerous.
   At the time when the eruption is at its height (and even  later,
according to  Stager) the  liver is sometimes found considerably
enlarged, in consequence of  congestion ; sometimes it is smaller
than natural.  At the autopsy of an adult dying from scarlatina,
Wunderlich found the liver weighing but little more than two
pounds.  Icterus may occur as a result of the slowly progressing
changes in the liver, but becomes  marked only after the disap- 
COMPLICATIONS.
281
pearance of the eruption.  Santlus states that he has frequently
observed icterus as a complication of scarlet fever in an epidemic
distinguished by numerous anomalous cases.   Patients very fre-
quently recover from this complication  (Swiney,  Graves,  etc.),
but a fatal termination is not rare.   Danielssen observed a case
of a girl,  twenty years  of  age, who died  with symptoms of
malignant icterus.  The autopsy showed acute fatty degenera-
tion of the liver, spleen, kidneys, heart, and  considerable ecchy-
mosis of the lungs and kidneys.  But, as a rule, hepatic lesions
are rare.
   Whenever  a careful examination is made,  especially during
the eruptive stage, an enlargement of the spleen is frequently, if
not almost constantly found.   It must be regarded as a compli-
cation  only in those  rare cases where the spleen is unusually
enlarged and  softened; the symptoms produced  by it are not
characteristic.
   Inflammations of  serous membranes  occur generally in con-
nection with  scarlatinal rheumatism of  the  joints.   Meningitis
forms the principal exception to this rule, and occurs most fre-
quently at the beginning of scarlet fever, at the time of the severe
cerebral congestion.   It is marked by a stage of extreme  irrita-
tion (most intense headache, glistening eyes, loud screaming, bor-
ing of the head into the pillow, vomiting, high fever), with early
signs of compression  of the  brain  (sopor,  convulsions).   Those
cases of pleuritis caused by some pulmonary affection also form
exceptions.  All forms of  scarlatinal  pleuritis are characterized
by rapid development and by but slight local disturbance, even
when the affection is very intense.   From some unknown cause,
the effusion is generally unilateral and sometimes purulent, as is
often the  case in many other exudations of  scarlet fever.  The
pericardial effusion possesses these peculiarities  in  a much
lower degree.   It occurs  more rarely, is generally moderate in
amount, gives  rise usually to but  slight subjective symptoms,
and is sometimes further complicated by endocarditis, which
may be followed by  its  usual sequelae,  chronic  valvular dis-
ease, and embolism of peripheral arteries resulting in gangrene,
pyaemia, and septicaemia.  Endocarditis may occur as an isolated
complication  of scarlet fever, or as a result of the rheumatic 
282
THOMAS.—SCARLATINA.
affection.  Peritonitis is  characterized by either  a turbid  or a
more  or less  abundant purulent exudation, and  adhesions of
the intestines  at numerous points.  According  to Hebra, these
lesions are usually the result of tuberculosis of the peritoneum
or mesenteric glands ; and here, as in the ordinary form, there is
very  severe pain, tympanites, and paralysis of the abdominal
muscles.  I have often found similar symptoms present in cases
of commencing  nephritis, and thought that this disease  was
associated with peritonitis.
   Purulent arthritis is  a rare complication.  The joint seems
to be only  slightly affected during the first days,  but subse-
quently it becomes  more painful,  red, and swollen, the fever
increases,  the patient becomes delirious and suffers from other
grave adynamic nervous  symptoms,  finally death  closes the
scene.  Or the inflammation is intense from the beginning, and
the complex symptoms of pyaemia rapidly  manifest themselves,
with  extension of the arthritis to one or more additional joints.
In rare cases  the purulent arthritis terminates in recovery after
the formation  and cure of tedious fistulae.   When the patient is
scrofulous or exhibits some other allied diathesis, granular syno-
vitis  with  chronic  suppuration  (fungous   arthritis) generally
occurs in place of the simple affection.
   As complications  of scarlatina, which occasionally occur  at
any period of  the disease,  the following affections are worthy of
mention :  inflammation of the sheaths of the tendons, which is
very  apt to be suppurative inflammation;  inflammation of the
muscles ;  extensive abscesses  in the muscles of the extremities,
trunk, or  cervical region,  also elsewhere, as in the mamma of  a
girl fourteen years of age, as reported by Weber, or extending
from  the  genitals and forming fistulous openings into the hip-
joint, as in Wood's case ;  periostitis and ostitis in  various places
(the petrous portion of the temporal  bone  in  case of otitis, the
nasal bones in coryza,  the cervical vertebrae in cases of severe
pharyngitis).
   Gangrene  may involve other parts of the body besides the
neck; for instance,  the  genitals (Wood,  Arrigoni) and  peri-
naeum ; the face, from diseases of the eyelids (Zehnder), the eye,
ear, nose, etc. 
SEQUELAE.
283
                          SequeloB.

   Scarlet fever is  sometimes followed, especially under unfa-
vorable surrounding circumstances, by a state of anaemia, sick-
liness,  and  susceptibility to various slight  affections, such  as
local cedemas,  which are generally slight, but  sometimes more
extensive and recurrent.  In Welsch's case, without nephritis,
the oedema  returned every  eight  days for twenty  years, and
sometimes  even threatened  life.   The  oedema  is occasionally
widely diffused and firmer than usual.  The patient may also
suffer  from miliary eruptions, furuncles,  abscesses, glandular
enlargements, the milder forms of neuralgia, digestive  distur-
bances with or without colic, just as after other grave diseases.
Or there may be other derangements resulting from  the various
irregularities and complications which occur  during the course of
the disease.  The following are the most important conditions
following ulceration of the integument:  lesions of the lymphatic
glands, cellular tissue, bones and joints (intense articular pain,
torticollis from inflammation of the cervical vertebrae, caries of
the vertebrae with subsequent kyphosis, chronic purulent syno-
vitis with formation of fistulae,  luxation, etc.), intestines (chronic
diarrhoea, prolapsus ani in little children), the  pharynx, air-pas-
sages, and genitals ; sometimes also loss of hair, various cutane-
ous diseases, enlarged tonsils, chronic nephritis (which, according
to H. Weber, may be found even in cases where no such  disease
existed  during the scarlet fever.   This  is questionable,  for
nephritis scarlatinosa  may run its course for a long time with-
out producing any symptoms); hepatic and splenic affections,
peritonitis, cardiac, especially  valvular  diseases,  thrombosis of
veins, stones in the bladder; likewise affections of the respira-
tory organs, such as chronic laryngitis following oedema glot-
tidis, ulceration, etc., enlargement of the bronchial glands, pneu-
monia and pleuritis ; miliary tuberculosis and phthisis.  Of very
great importance are the affections of organs  of special sense.  In
many cases hearing is  permanently impaired, in consequence of
adhesions, rigidity, or even destruction of parts  of the apparatus
for conducting the sound ;  or  we  may have a sequel which  not 
284                THOMAS.—SCARLATINA.

only endangers the hearing, but also the life, as, for instance,
chronic suppuration of the middle  ear, caries, etc.  Less  dan-
gerous  are  the disturbances of vision,  especially  those which
appear from two to six weeks after scarlet fever, from paralysis
of the muscles of accommodation, and are always binocular and
generally not connected with mydriasis.  In these  cases distant
vision is good, except in the higher degrees of hypermetropia;
the near vision is very poor, but can be perfectly corrected by
strong convex glasses.   These diseases of accommodation are
generally sequelae of  diphtheria, as is shown by the existence
of other signs of diphtheritic paralysis.  They may cause  con-
vergent strabismus, which occurs only periodically in the begin-
ning (during near vision), but ultimately becomes permanent.
The external muscles of the eye are rarely paralyzed.  Finally,
there  not infrequently occur nervous disturbances  of  various
kinds:  motor lesions,  such  as chorea after rheumatism with or
without cardiac disease, hemiplegia, spinal and cerebral para-
plegia, spasmodic contractions (of the trapezius  and sternomas-
toids);  paralysis of  single nerves (the facial with  or  without
disease  of the petrous portion of the temporal bone, the nerves
of special sense,  etc.) ; further, general  hyperesthesia  of the
entire  body  (with  the exception  of the face  and scalp),  or
hyperaesthesia and anaesthesia in various parts, different forms
of neuralgia ; hysteria and epilepsy ; alalia, aphasia, and alexia;
melancholia,  mania, and  other  chronic  mental derangements,
especially in adults.

                         Diagnosis.

   The  diagnosis of a characteristic scarlatina eruption is not dif-
ficult.   The minutely punctate  appearance from the start and
still noticeable even after the eruption has become confluent, the
more  or less uniform development of the eruption over the body,
the absence of the eruption from the face and especially the
region about the mouth, are all so characteristic that it is hardly
possible to make a mistake.  In  difficult cases we ought to
observe whether the individual  spots are sharply defined  and
slightly infiltrated, or  whether they shade off gradually and are 
DIAGNOSIS.
285
 smooth, as is frequently the case in primary erythema, especially
 in young children,  in secondary erythema  after wounds and
 operations, in the suppurative stage of variola, and in eruptions
 produced by the application of tar or creosote.  Erythema is the
 only eruption which presents a close resemblance to a perfectly
 developed scarlatinal  rash.  It may be distinguished, however,
 by the  fact that it  is not widely diffused, being absent on the
 extremities, neck, and portions of the  trunk, and that it spreads
 in a very irregular manner.
   Where doubt  arises  from the scantiness of  the eruption, or
 from other causes, we must bear in mind  that in scarlatina the
 angina is rarely absent  (even in mild cases it is tolerably well
 marked); that the tongue almost always has  the characteristic
 appearance,  and that in most cases  there is  even  at an early
 period  more or less swelling of the  cervical  glands.  In cases
 where an early diagnosis is impossible, the  doubt will be cleared
 up at a later period  by the occurrence  of desquamation, par-
 ticularly  the characteristic  desquamation on  the  palmar and
 plantar regions, or  perhaps by the appearance of  albuminuria
 with or without  dropsy or  other  symptoms  of nephritis.  No
 other disease presents a group of symptoms similar to this.
   In  other cases where there is a suspicious angina, either with
 or without a scanty eruption, the diagnosis may be made from
 the  appearance of the tongue, from  a subsequent  eruption, or
 from the occurrence of a cervical lymphadenitis or a nephritis.
 The scarlatinal poison may excite merely a trifling  catarrhal
 angina, or perhaps only a follicular tonsillitis.
   So also a rheumatic  affection or a nephritis may be regarded
 as suspicious, if they  occur in connection with the characteristic
 scarlatinal tongue, desquamation of the epidermis,  and cervical
 glandular  swellings.  Equally suspicious  is an angina accom-
• panied by fever of  a  typhoid character,  severe gastro-intestinal
 symptoms, or some  other abnormal localization of the scarlatinal
 poison.
   The diagnosis is more difficult when the scarlatinal rash is
 irregular, and presents a roseolar appearance.  In such cases the
 affection is most apt  to  be confounded with measles.  For the
 differential diagnosis,  see page 106. 
286
THOMAS.—SCARLATINA.
   The distinction between rubeola (Rotheln, German measles)
and  scarlatina is still more difficult.   Where the rubeolous an-
gina is quite marked, and the lymphatic glands are enlarged, the
rubeola may be easily mistaken for a slight attack of scarlatina
with  an irregular roseolous eruption, especially if there be no
subsequent desquamation.  We must then be guided by the
short duration of the eruption, its presence on the face—where it
appears as early and as  characteristically  as  on  the neck  and
trunk—by the scarlet tongue, by the form of the affection of the
palate—in scarlatina only the posterior parts, uvula, arches of
the palate, and their vicinity are affected, while in rubeola the
anterior parts are also affected, and both to much the same degree
—and finally by the fact that the glands are more seriously
implicated in scarlatina.
   The differential diagnosis between  a slight  scarlatinal rash,
complicated by numerous sudamina, and a  simple miliary erup-
tion, is based upon the following : The latter is never so generally
diffused over the whole body, as in the case of a scarlatina mili-
aris,  whose papules will  be found more  distinct on the dorsal
surfaces of the hands  and feet, and which  here and there will
show a few characteristic places, with perhaps even confluent
redness.   If other symptoms of scarlatina,  such as angina, the
characteristic  tongue, glandular enlargements, etc., be present,
these will aid us in making the diagnosis.
   Erysipelas may also be sometimes mistaken for an attack of
scarlatina of limited extent.  The distinction lies in the fact that
in scarlatina, besides the other characteristic symptoms, the rash
has a punctate appearance, while in erysipelas the surface of the
eruption is not elevated, there is marked oedema of the connec-
tive  tissue, and vesicles may form.  In scarlatina, desquamation
may occur in  places where there has  been  no antecedent erup-
tion ; in erysipelas this is  never the case.
   Still more  perplexing  are the  cases  which occur without
eruption,  especially  those rudimentary malignant  cases which
rapidly prove  fatal.   In such instances we  must be guided by
the fact that there is an epidemic of scarlatina at the time, or by
the existence of more  or  less angina,  or by the extremely rapid
and  intensely febrile course of  the  disease in  connection  with 
PROGNOSIS.
287
severe nervous  symptoms which cannot be  explained  in any
other way ; in no otlier disease does death take place in so short
a time and with such symptoms.  The whole skin should be
carefully and repeatedly examined in all such cases, inasmuch as
the eruption is sometimes very transient, appearing perhaps only
on the extremities or neck.
   The scarlatinal nature of the dropsy,  at whatever period of
disease it may occur, can  be recognized by its acute, almost
cyclical course, which, in children especially, is  not often seen
from any other cause; perhaps  also by the  occurrence of des-
quamation, or by the retardation of the action of the heart; or
by the fact that the oedema makes its appearance first upon the
face, and changes  its  position from time to  time ; finally, by
effusions into serous cavities, glandular enlargements, etc.

                        Prognosis.

   The prognosis of scarlet fever is uncertain under  all  circum-
stances.  Even when the disease is running a mild and perfectly
normal course  dangerous symptoms may arise,  without special
reason, thus changing at once the entire nature of  the disease,
and even very rapidly hastening death.  The physician, therefore,
should never predict, unconditionally, that the disease will end
favorably, but he should always realize that unexpected contin-
gences may possibly occur.   Apart from such occurrences, which
are far more  frequent in the anomalous forms than in the nor-
mal, the prognosis  is decidedly favorable;  and is positively
unfavorable only in some of  the irregular forms. In forming a
prognosis, therefore, the point of most importance  is to distin-
guish whether the case is normal or abnormal, and if abnormal,
whether the anomalies are of  such a kind as  to justify the  hopes
of a favorable issue or the reverse.
   We may anticipate that scarlet fever will run a normal course
under the following conditions : when the initial symptoms are
mild ; when  the appearance of  the  exanthem is timely; when
the outbreak is not  sudden;  when, in the  main, it has a
general distribution and completes its course rapidly, reaching
its maximum early, that is, on the first or second day, or latest, 
288
THOMAS.—SCARLATINA.
at the  beginning  of the third; when the throat affection  is
inconsiderable, and there is neither great difficulty in swallow-
ing, nor marked swelling, nor any other affection of the tonsils
or cervical lymphatic glands ;  when the fever never exceeds 101°
Fahr., and there is  only moderate frequency of the pulse, and
the cerebral symptoms at most  are slight, and only last a short
time at the above-mentioned height of the disease ;  and, finally,
when the abatement  in the eruption is accompanied by a steady
decrease in the temperature, which after  a few days returns to
the normal;  at least these conditions  furnish some guarantee
that there is no further localization of  the scarlatinous poison.
Should the disease,  however, not end here,  as is quite  possible
in the most typical cases, we may distinguish the following con-
ditions as  also normal and indicative of  a favorable termination:
slight affections of  the  joints ;  a nephritis,  if  it  commences
slowly, is of moderate intensity and of short duration, and  if
the fever and  hematuria disappear about the third week, with
only slight albuminuria, and little diminution in the quantity of
the urine,  as  well as without cerebral  symptoms  and  without
dropsy; finally, an entire absence of any complication betokens
a favorable issue.
   Scarlet fever with an anomalous course is  particularly unfa-
vorable, and the prognosis is at least very uncertain, especially
when the  following  conditions are present: a  continuous rise in
the temperature from 104° Fahr.  upwards,  or hyperpyrexia, with
dyspnoea,  and extreme frequency of the pulse, and  also attacks
resembling collapse,  accompanied by a  cold  surface and small
pulse ; an exanthem of a very intense copper color extensively
diffused, and  lasting several days during its greatest height,
or a  livid  eruption,  or even,  perhaps,  one  that has merely  a
trace  of a blue color, particularly where there  are abundant
hemorrhages in the skin ; angina gangrenosa, and diphtheria of
the pharynx,  especially  when it extends to  the nose,  larynx,
and air-passages ;  a  very dry tongue ; an  intense coryza ; great
infiltration of  the  connective tissue in connection with Lymph-
adenitis of the neck  and periparotitis, chiefly when it terminates
in gangrene, or by the discharge of matter inwardly, as  into the
oesophagus and air-passages, or by extensive burrowing of mat- 
                            PROGNOSIS.                        289

 ter ;  typhoid forms;  severe nervous symptoms of any kind,
 particularly  paralysis of  many muscles, deep coma, repeated
 spasms, eclamptic or purely tetanic spasm of the glottis,  con-
 tinuous delirium, and a maniacal  condition, complete  sleepless-
 ness,  the  greatest restlessness and excitement;  very frequent
 and  long-continued  vomiting,  with  abundant dysenteric diar-
 rhoea, especially at the outset, the latter at a later period also,
 and  then with  or  without frequent attacks  of vomiting  and
 severe colicky pains  ; purulent inflammation of the  joints with
 or without pyaemia, with a general formation of abscesses ; early
 commencement of nephritis, general dropsy with effusion  into
 the serous cavities, excessive hematuria  and albuminuria, as well
 as great diminution in the  secretion of urine, or complete  anuria
 for several days with or without the  signs of uremia, and with
 or without fever ; all the more important  complications, such as
 pleurisy and pneumonia,  oedema of the glottis, hepatitis, endo-
 pericarditis,  peritonitis,  meningitis and hydrocephalus, kerato-
 malacia, and gangrene of  the eye ; severe affections  of the  ear;
 the hemorrhagic diathesis;  a condition  of deep infection (septi-
 cemic) resembling narcotism, without local manifestations, some-
 times developing  rapidly,  especially at first, and sometimes
 slowly, and then generally at a later period.
   I find, in addition, that the following noteworthy prognostic signs  are cited, as
 being, to a certain extent, very unfavorable: Geissler, for instance, believes that a
 remarkable sprightliness and vivacity just before the attack bodes ill; Marcus thinks
 it a bad sign when there is a sharply denned redness of the face, with a chalk-white
 ring about the  mouth and a tremulousness of the lower lip ; Krauss fears  the
 result when there is a white streak traversing the dusky-red or livid  face; Reil has
 observed a chalk-white ring between the forehead and lips, while the nose appeared
 white and pointed ;  many of the older writers were  exceedingly afraid of a sudden,
 or, at least, rapid abatement of the eruption;  moreover the variableness of  an erup-
 tion, which was now pale and now florid, now more fully developed at one point
 and now at  another, was a cause for anxiety.  On  the other hand, the following
symptoms are said to be favorable: a spontaneous hemorrhage from the nose when
there are severe cerebral symptoms, excluding, of course, the hemorrhagic diathesis;
a profuse salivation; and the occurrence of sudamina, if they be not too numerous.

   Sporadic cases of scarlet fever are not always entirely benign;
many authors believe, indeed, that they should be regarded  as
more dangerous than the  epidemic forms.   At  any rate, spo-
           VOL. II.—19 
290
THOMAS.—SCARLATINA.
radic cases  are in  the minority.  The prognosis,  in  by far the
greater number of cases, is chiefly determined by the character
of the epidemic,  and this term expresses the  total result of the
action of various factors of  time and place in developing an aver-
age specimen of the disease ; the character is good or bad, accord-
ing to whether most of the epidemic cases have a  normal course
or an unfavorable or fatal one.   But few epidemics are benign in
character, and the majority of physicians  now living will sub-
scribe to  the statement of Loschner, uttered  more than thirty
years ago, when he said, "I have never seen a  benign epidemic,"
and  they will lament that the time of  Sydenham has passed
when scarlet fever  "vix nomen morbi merebatur."  The scarlet
fever of to-day owes its danger to the frequency of its anomalous
forms.  In this connection it is remarkable that the epidemics of
various places and periods are apt,  for unknown  reasons, to be
anomalous  in  single characteristics.   For  example, in one  epi-
demic severe sore throat with  inflammation of the cervical con-
nective tissue may be a  very marked characteristic, while in
another diphtheria will be very common,  and in a third there
will be rheumatic affections, as in the Rhenish provinces and in
France ; in  a fourth, again, there will be dysentery, while others
again  are extremely deadly from the frequency and severity of
the dropsy.  (In Senfft's cases 38 per cent,  of the dropsical died.)
Still, the great majority of the epidemics do not owe their danger
to a  single anomaly, but to several.  For in  almost every case
there is deep infection, severe fever, complicated  angina, severe
cerebral symptoms, and extensive dropsies ; while many persons
who have successfully defied the fever, the nervous disturbances,
and the angina and its consequences, finally die dropsical.

   Richardson observed two very benign epidemics, without deaths, on two ships of
war (comp. p. 177,) ; so, too, did Gillespie in 1852 (seventy patients); and so, accord-
ing to Graves,  whenever scarlet fever appeared in Dublin, between 1800 and 1834,
it was always mild, and on one occasion, when eighty children were taken sick in an
institution, there were no deaths. In 1834, however, there was an epidemic of extra-
ordinary virulence and extent; in this case  the character of the fever was far from
being harmless.
   Sporadic epidemics are not, however, always benign any more than are sporadic
cases, as is shown by Palmer, when he describes the epidemic of Pleidelsheim, where 
PROGNOSIS.                           291
the neighboring localities were spared.  In this instance, out of 1,500 inhabitants,
201 were attacked, and there were forty-four deaths, so that there was a mortality of
21.9 per cent.   Many patients died within the first twenty-four hours.

   Epidemics of scarlet fever where the mortality is below 10 per
cent, may be regarded  as benign epidemics, comparatively speak-
ing.

   Such have been reported, as for example by Lee, where there were 309 patients
with 13 deaths, a mortality of 4.2 per cent.; by Kostlin, of Stuttgart, in 1856, where
149 died, or 7.3 per cent.; by van Holsbeek of Brussels,  in 1856, where about 8 per
cent, died ;  by Kolb, of Amberg, in 1862-3, a mortality  of 5 per cent.; by Cremen,
where of 1,346  sick, 125 died, or 9.2 per cent.; by Gutherz, where of 76 sick, 3 died,
or 4  per cent.;  by Eulenberg, of Coblentz, in 1859, a mortality of  5 per cent.;  by
Horing, in two villages near Heilbronn, in 1856, 8 per cent, mortality.

   The majority of the epidemics described lately have  shown a
much greater mortality, and yet it must not be assumed that the
statistics which have been made known to us in most of the pub-
lications  illustrate the average  mortality of scarlet fever, for an
epidemic has often been reported because  it was remarkable for
its virulence.   The mortality very frequently reaches between 13
and 18 per cent.,  but in hot a few epidemics it is as high  as 25
per  cent., or may even reach between  30 and 40 per cent.

   Waidele found that the mortality of his patients was 12 per cent.; Kostlin, of
Stuttgart, lost  in 1853, 12.9 per cent. ; Senfft, in 1862-3, 13£ per cent.;  Reisinger
lost,  of 120, 16, or 13£ per cent.; Russegger, of Kitzbiichel, in Tyrol, in 1847-8, lost
14 per cent., so also did a physician in Remagen; Horing, in Heilbronn, Krauss,
in Walddorf (31 out of 226), and Rosch, in Schwenningen (39 out  of 261) lost  15
per cent.; Faber, of  Schorndorf, in 1825-7, lost 73 out of  460, or 15.7 per cent. ;
Bidder, in 1831, in Courland, lost  15.6  per cent.; Voit, in 1867, in Wurzburg, lost
16 per cent. ; Wunstedt, in 1864, in Copenhagen, lost 16 per cent.; Barthez, 16.6 per
cent.; Huber, in  Memmingen, in 1869, lost 17 per cent. ; Glaser, in Hamburg, lost
23 out of 118, or 19.4  per cent.;  Gauster, in  1856-7, in Stein, lost about 20  per
cent.; Feitel had a mortality of 23.3 per cent.;  Bohmen,  according to  Loschner,
lost,  in  three  settlements, 445 out  of  2,057 patients,  or  21.8 per cent.;  Stutt-
gart, in 1862, according to Kostlin, lost  23.8 per cent. ; Hof, according to Marc,
lost,  in 1842, 22+ per cent.; in 1862-3, of 450 attacked,  127  died, or 28 per cent.;
Greifswald, in 1850-1, according to C. Mosler, and in 1860, according to  Ziemssen,
lost  about 25  per cent.  The highest figures are the following:  Hambursin,  in
Namur, lost about 30 per cent.;  Arrigoni. about  40 per cent. ; Salzmann, in Ess- 
292
THOMAS.—SCARLATINA.
lingen, between  1853-7, about  36 per cent.;  at Hornbach, in the Palatinate, in
1868-9, 34 per cent. died.  Compare  in this respect especially the statistical report
of Majer.

    Comparatively  benign and malignant epidemics often alter-
nate with  one  another in the most varying manner, in one and
the same  locality, without  assignable  cause; indeed it often
appears, as if  the changing  character of  the  disease, which is
now mild  and now  severe,  did  not  only vary from epidemic to
epidemic, but with many decennia, or with periods embracing
whole lifetimes.

   The fluctuations in the severity of the epidemics do not occur at the same time
in different places.  According to Kostlin the following astonishing facts have been
observed in Stuttgart: after 1830 scarlet fever disappeared entirely, and the  first
epidemic which  at length appeared was in 1846, and there were no fatal cases.
Then in the following epidemics of 1853,1856, 1862,  and 1867-8 the  mortality in
the entire city was respectively 72, 149, 182, and 14 ; the physicians of the poor had
a mortality of 12.9 per cent., 7.3 per cent., 23.8 per cent., and 5.2 per cent., so  that
there were variations in the mortality between zero and 23.8 per cent., and besides
this there was an interval of  fifteen years in which no cases occurred.   Forster  says
that in Dresden, for the fifteen years between 1794 and 1808, and throwing the epi-
demics out of the account, one out of 29 deaths among children was from scarlet
fever, and so between 1823  and 1837 there was one in 28 ; on the other hand, in
1862, during  an  epidemic of scarlet fever, but one  died out of 36; so that a very
apparent improvement had taken place.

    It  may be very questionable whether the season of the year
has an influence on the  character of the epidemics.  Malignant
epidemics of  short  duration have  appeared at every time of  the
year,  and when such an one  has lasted for a considerable period
of time, it has generally been quite as severe in the summer as in
the fall and winter.

   According to  Ranke, the  fatal cases of  scarlet fever in Munich, from 1859 to
1868, were scattered over the different seasons of the  year in almost precisely the
same manner as  the disease itself, which shows that  the season  does not exert a
special influence over the course  of the disease.
   Tripe, reckoning from extensive material (11,566 fatal cases in  London between
1848 and 1852, with 1,575 fatal cases from dropsy) instituted an inquiry as to
whether death from dropsy was associated with certain seasons of  the year. In the
first quarter the number of such  deaths was 268 out of 2,162, or 13 per cent.; in the
second, 266 out of  a total of 2,279, or 12.3 per cent.;  in the third, 322  out of a 
PROGNOSIS.
293
 total of 2,930, or 10.9 per cent.; in the fourth, 719 out of a total of 4,195, or 17 per
 cent.  Calculating the  percentage of deaths from scarlet fever and dropsy by the
 single months, the results were, that the mortality of  the first five months, also of
 July and August, fell below the average, while in June and the last four months
 it was above it. Judging from these statistics he believes that at certain times there
 is a special activity of certain factors which augments the intensity of the poison, or
 affects the kidneys more severely,  or makes dropsy more fatal. As may readily be
 seen, the differences in the ratios are not very great.

    The question as to which show the greater mortality, the epi-
 demics of the city or those of the country, has been answered
 differently by different writers.   Richardson found it was greater
 in the cities than in the country, while Eulenberg, and especially
 Kolb, found it was decidedly less.   In  settling  this question,
 there are certainly other factors than those commonly recognized,
 such as the density  of the  population and the  availability of
 medical aid.   The latter  may be better, and accomplish better
 results in the cities than in the country, while, on the other hand,
 the country is  more exempt from  the  evils of  overcrowding.
 Meanwhile, when we  take  into consideration that some localities
 are deeply infected, while  others in the neighborhood, under the
 same conditions as regards population, remain free or suffer but
 little, the more probable view is, that the medical art will more
 than make  up for the differences mentioned, and it  is  quite
 likely that the differences that have been  observed between city
 and country are somewhat accidental, and dependent chiefly on
 the situation of the dwelling.
    The influences of poverty  and opulence  upon the  fatality of
 scarlet fever are not so cogent as  have been supposed.  Of course
 the wretched homes of the poor,  and  the  entire absence of nurs-
 ing and care, cause an increase  of danger which those in better
 circumstances are able to avoid ;  but of far more importance as a
 prognostic indication is the degree of personal predisposition to
 scarlet fever, or, in other words,  the  degree of resistance  to the
 influence of the contagion, which is  not  materially affected  by
 external circumstances. Very frequently  cases which  are  severe
at first terminate fatally, notwithstanding the best of care and
treatment.  The beneficial effects of favorable  surroundings are
seen, not so much in their therapeutic influence during the course 
294
THOMAS.—SCARLATINA.
of scarlatina, as in their prophylactic  power  to prevent  the
spread of the disease.
   As a matter of  course,  good nursing and proper medical
advice will lessen  the percentage of mortality.   It  is probable
that in many of the epidemics of earlier  times, a greater mortal-
ity was due to the erroneous therapeutical notions then in vogue
than  would have been caused  by the  average  severity of  the
cases if left to themselves.  The excellent  effect of good  nurs-
ing is most strikingly realized in the observations of Shingleton
Smith, who, while  at  the same  time attending a district and a
hospital, observed, that not  only in respect to the mortality, but
also as regards the  sequele and complications, the results were
far more unfavorable among  the cases  treated  at their homes
than  among the cases which were removed to the hospital and
received proper care and nursing.  Of  course, if a hospital is
unfavorably situated  and improperly administered, the benefi-
cial influence, which it would by proper  care and treatment cer-
tainly exert upon the cases,  will be more or less diminished.
   Sex  has no effect upon the mortality of scarlet fever.   If in
some places the mortality is greater among males, in others it is
reported as greater among females.   Striking differences of this
character are probably due  to local variations in the number of
male and female persons of the age most subject to scarlet fever.

   Richardson collected from  the decade 1838-1848, 102,382 fatal cases of scarlet
fever, of which 51,660 were males,  and  50,722 were females, a very slight differ-
ence in such a large nmnber, and  moreover, fully accounted  for  by the  surplus
of the male  population  in those districts in which the cases occurred.   Passow
observed  that of 1,579 fatal cases of scarlet fever in Berlin, in 1863 and 1867, 795
(50.35 per cent.) were males, and 784 (49.65 per cent.) females; the difference being
only 0.02 in favor of the males.

   Of all the conditions which increase the danger and mortality
of scarlet fever, age is by far the most potent.  Notwithstanding
the opinion of Faber,  that nurslings are lightly  affected by the
disease, most other authorities  consider that among  them the
severer forms of scarlet fever are more frequently met  with than
among older children.  The  smaller number of fatal cases during
infancy is solely due to the slighter predisposition of  infants, in 
PROGNOSIS.
295
consequence  of  which  they  frequently  escape  the  contagion.
The following years, up to  the fifth or sixth year, are the most
dangerous, and have a pretty equal mortality.  With the increas-
ing  years  of childhood  the prognosis  of scarlet  fever becomes
decidedly  better,  though not by any means in the same measure
as in measles.   Among the  few  adult  cases the mortality is
greatest among pregnant and puerperal women and invalids.

   Fleischmann  estimated the mortality of the first year (8 cases with  6 deaths)
at 75 per cent., of the second to the fourth  year (204 cases, 88 deaths) at 43 per
cent., of the fifth to the twelfth year (260: 51)  at 19.6 per cent.  Wasserfuhr did not
observe any decrease  of mortality from the second to  the  sixth year.  Russegger
found the mortality up to the fifth year (101 : 21)  = 20 per cent., from the fifth to
the tenth  year (126: 20) = 15 per cent., from the tenth to the fifteenth year (47 : 3)
6 per cent, over fifteen years (27 cases) no  one died.  Waidele found the highest
mortality up to the second year, and the eleventh year was very dangerous. The fol-
lowing rates of mortality were observed by Krauss in the epidemic which occurred
in 1854 in the villages of Walddorf and Oferdingen : in the first year (13 : 4) = 30
per cent., in the second to the  third year (33: 9) = 27 per cent., in the fourth to the
sixth year (80: 21) =  26 per cent, in the seventh to the ninth year (62: 7) = 11 per
cent., in the tenth to the twelfth year (44 : 3) = 7 per cent., in the thirteenth to the
twentieth year (40: 2)  = 5 per cent.   The 280 fatal cases reported by Voit are dis-
tributed thus: first year (5:1) =  20 per cent,  second to the sixth year (166: 24) =
14.4  per cent, seventh to the sixteenth year (109: 10)  = 9.1 per  cent. In the experi-
ence  of Ranke the aggregate mortality of scarlet fever was 6.8 per cent.,  while that
of children under one year of age was 10.7 per cent.  In  Zehnder's experience 66
per cent,  died in the first year, while in the following years the rate of mortality
sank rapidly to 31, 23, 12, 10 per cent., rose in the sixth year to 20  per  cent, and
in the eighth again (from 9 per cent, in the seventh year) to 17  per cent., and from
the tenth year onward, among 64  cases, only one,  a  girl  of  twelve years,  died.
According to Rosch,  out of 17 cases under one year of age,  5 died, out of 156 cases
of from two to five years of age 31 died, and of 88 cases over five years, only 3 died.
   According to Tripe, among the fatal cases of scarlet fever  those due to dropsy
are epecially frequent among children of three to five years of  age, less so among
older children, and least of all among those under one year  of age.

   The   influence  of  the  mortality   of  scarlet fever  upon  the
general mortality varies materially with the  frequency of  the
disease, and especially with  its degree of  malignancy in different
localities.

   Thus,  according to Schiefferdecker, in  Konigsberg, during years of severe epi-
demic, as 1860 and 1867, there were in 1,000 deaths 91.12 and 119.60 due to scarlet 
296
THOMAS.—SCARLATINA.
fever;  while in years that were free from epidemics, as 1858, 1866, and 1862, only
0.84, 4.76, and  6.0 were owing to that disease.  In Berlin, according to the same
authority, between 1843 and 1860, the years of severe scarlet-fever epidemics, 1852,
1854, and 1856, had in 1,000 deaths 38.44, 23.80, and 33.51 due to scarlet fever;
while years which were free from epidemics, such as  1858, 1859, and  1860, only
3.20, 1.96, and 4.31 were  due to this  disease.   In Frankfort-on-the-Main these
figures varied  during  the years 1853-1864, from 0 (1864), 0.80 (1855), 1.61 (1860)
to, on the other hand,  103.20 (1862);  in  Munich, 1862  to 1868, from  1.0 (1865) to
14.58 (1868); in Stuttgart (1853 to 1867) from 0 (1861), 0.93-2.28 (1858 to 1860)
to 100.76 (1862) and 109.27  (1856); in London (1861 to 1866) from 23.51 (1866) to
69.73 (1863).
   If the averages for the  reported years in the  different cities be compared, we
find that in 1,000 deaths in London (during six  years) scarlet fever caused 42.10;
in Konigsberg  (12 years) 31.70; in Stuttgart (15 years)  23.73;  in Frankfort (12
years) 17.29; in Berlin (18 years) 12.92;  in Munich (7 years)  6.34; in the canton of
Geneva (13 years) 4.92.
   Schiefferdecker, moreover, collected the maxima of these  individual cities  and
found  as follows: Konigsberg,  1867 (119.60 deaths from  scarlet  fever in 1,000
deaths); Stuttgart, 1856 (109.27); Frankfort, 1862 (103.20);  London, 1863 (69.73);
Berlin, 1852 (38.44) ; Munich, 1868 (14.38).   Hence we learn, provided the figures of
the years of epidemics were not at the same time materially influenced by an unusu-
ally large aggregate of  deaths from  other  diseases, that,  among the cities named,
Konigsberg, in 1867, had the severest epidemic of scarlet fever; Stuttgart and Frank-
fort were visited only rarely, but then by very malignant  epidemics, whilst London
suffered from the disease uninterruptedly, but never from  any serious epidemic.
These  facts agree with the  general law,  that large cities  suffer less from epidemic
diseases than small ones (Berlin and Munich likewise have low averages).

    The  disproportionately  large  mortality  among  children is
shown by the following statistics:

   For the above-named cities Schiefferdecker  found  that in 1,000  deaths the
proportion of persons under fifteen years of age dying of scarlatina was, in London,
80.80; in Konigsberg, 63.44;  in Frankfort, 51.37; in  Stuttgart, 46.35; in Berlin,
24.77;  while the deaths from the  same disease among persons above fifteen years
numbered, in London, only 3.67; in Konigsberg, 1.22; in Frankfort, 1.06; in
Stuttgart, 1.56;  in Berlin, 0.77.
   The following table exhibits the mortality from scarlatina per 1,000 total deaths,
and is  arranged by single years and by periods of childhood: 
TREATMENT.
297
Years.	Konigsberg.	Berlin.	London.	Frankfort
	1863-68.	1843-60.	1861-66.	1862.
0-1	5.76	2.50	10.89	3.88
1-2	50.80	16.00	58.34	(1-5)
2-3	135.20	45.78	137.41	88.81
3-4	176.00	90.33	212.31	
4-5	231.60	102.50	248.52	
0-5	45.00	15.64	64.53	33.00
5-10	223.08	120.13	256.57	216.08
10-15	155.02	40.90	109.90	118.22
15-	1.22	0.77	3.67	1.06
                        TREATMENT.

   The prophylaxis of scarlet fever can only be accomplished by
the prompt removal of the  healthy from the sick, or where this
is impossible, by the seclusion of the latter, and the destruction,
or at least complete and satisfactory disinfection, of every article
that has come in contact with them.  Hence the patient must
have a separate room, to which only his  attendants should be
admitted.  All useless articles of furniture  should be removed
from the patient's room, such as musical instruments, bookcases,
and cupboards, everything which can collect and retain dust and
dirt  (curtains,  above all  woollen ones,  carpets, etc.), and all
small articles.  Provision should be made in some way for ven-
tilation of the apartment by means of an open window, or, should
the weather not permit of this,  by one  in an adjoining room, the
door between remaining open.  The patient  should be  properly
protected from any strong draught,  which, however, need not be
particularly feared.  Further,  the patient should be kept per-
fectly clean, and every article used by him should be thoroughly
disinfected: the expectoration, urine, and excrements should be
received  in vessels containing  disinfecting  fluids (chlorinated
lime, carbolic acid), and frequently removed.   The moment the
patient's linen is  changed it should be placed in a similar fluid,
and then thoroughly washed in tubs used only for this purpose;
articles of  slight value should be burnt, for instance, the pieces
of linen  which Budd recommends in lieu  of handkerchiefs; the
sweepings of the apartment should also be destroyed by fire.  In 
298
THOMAS.—SCARLATINA.
like  manner  it is necessary to have  the" articles used by the
attendants, and especially their clothes, washed or disinfected in
the same way as those of the patient.  The best mode of disin-
fection for articles which cannot be washed is to expose them to
a high degree of heat, and then give them a thorough airing.  The
nurses should be ordered to wash their  hands frequently in some
disinfecting fluid; they  should keep their persons  thoroughly
clean, and change their clothing whenever they have to come in
contact with  a third person, and  especially when they enter the
service of another patient.  To  prevent  the dissemination of the
dusty particles of the  infecting  epidermis scales, particularly
during the  period of desquamation,  it  is of the utmost impor-
tance to  keep the whole body perfectly  clean.   Budd recom-
mends that  the  body,  including  the  head, should  be rubbed
twice daily with olive oil, especially  when bathing is impossible.
The  convalescent should not be  allowed to mingle with the
family until  desquamation has ended, and then not until his
body has been most carefully washed and clothed  in a fresh,
clean suit;  his  apartment  and  all that  has remained  in  it
during his sickness, and everything that has been used, should
be most thoroughly cleansed and disinfected.  The walls should
be repapered or  painted, and before reoccupation of the room,
the windows and doors should be allowed to remain open for a
long time.
   We have  already, when speaking of the modes in which the
contagion spreads, and  in our  observations concerning  its per-
sistency,  shown the necessity for  such rigorous measures, more
especially when diphtheria has complicated the disease.  In the
accomplishment of complete isolation of the patient  we can
expect a much better  result  than in measles,  owing to the
slight degree of  volatility possessed  by the scarlet-fever poison.
Whether the poison of scarlet fever can be propagated by means
of sewer gases, is a question not yet settled.   Druitt has urged
the  necessity of a  proper construction  of  water-closets and
sewers.   Fergus has  investigated this  point, but his results are
unsatisfactory, yet  there can be  no doubt that absolute cleanli-
ness is very desirable.
   A complete isolation of those localities and districts suffering 
                         TREATMENT.                      299

 from scarlet fever is, owing to the commercial relations  of the
 present day, impracticable, or is  only possible under the most
 favorable circumstances, as in the case  of  an island, etc.  It is
 even questionable whether the closing of houses containing cases
 of scarlet fever, as has been proposed by Reil, could be carried
 out; at any rate,  this measure is impracticable  in cities.  In
 Christiania it  has been proposed to post a  notice upon the
 infected dwelling.
   All  patients who cannot be properly treated at home should
 be removed  to hospitals set  apart for  contagious diseases, the
 scarlet-fever  patients being placed of course in separate wards,
 where suitable attention can  be secured.  In order to avoid the
 spreading  of the poison, wagons  or  stretchers devoted  exclu-
 sively to  this  purpose should be used for transporting such
 patients.   Upon the outbreak of  scarlet-fever epidemics  in the
 country, inexpensive barracks may be constructed, such as were
 used by Mosler in a typhus-fever epidemic.  Furthermore, in an
 appropriate climate camps for the sick, if favorably situated, are
 advisable.
   It is, moreover, desirable that the patients should be sepa-
 rated from each otlier, or  that at least many should not  be
 together in the same room, for experience has repeatedly  shown
 that the neglect of this precaution has  increased the severity of
 the  individual  cases.   Thorough  ventilation is consequently of
 the utmost importance.
   To prevent  the spreading of scarlet fever  by means of well
 persons, it is perfectly justifiable  to deny to the brothers and
 sisters of  the  patients entrance to nurseries, institutions, and
 schools, and this prohibition should  remain in force until the
 complete disappearance of every symptom of the affection of the
 throat and skin.  The State  should  be responsible  for the
 thorough  execution of these  all-important measures during a
 scarlet-fever epidemic.  They are of far  greater moment than in
 the case of measles, not only because scarlet fever is more dan-
gerous than  the latter, but  also  because with the increasing
years of childhood the predisposition to  scarlet fever very mate-
rially lessens, and hence it is possible that children may  entirely
escape the  disease if they be secured from exposure during early 
300
THOMAS. —SCARLATINA.
 life.  Therefore, the compulsory notification of every  case  of
 scarlet  fever is of the utmost  importance.   On account of the
 minority of those really susceptible to the disease, it is generally
 unnecessary to close the schools upon the breaking out of an
 epidemic of scarlet fever, and such a measure should be insisted
 upon in isolated communities and districts  only when  the epi-
 demic happens to be unusually extensive and malignant.
    Finally, all display should be prohibited at the  funerals of
 those who have died of scarlet fever, and even upon any other
 occasions, so long as scarlatina continues in the house, especially
 if the epidemic be of  a  severe  and  virulent type.   Children
 should  not be allowed to take part  in these funeral ceremonies,
 and the opening of the coffin in the presence of the assembled
 friends, as is customary in many places, should be strictly pro-
 hibited.
    To the isolation of the patient, when the epidemic is mild, or
 the case an idiopathic  one,  the following objections  have been
 made.  In the first place, the process is very inconvenient, and
 often fails of success if  it be incompletely carried out.  If it be
 omitted, the other  children  will quite likely take the disease in
 the same mild form, and thus be protected against a later attack,
 which might be of a malignant character. Again, it is urged that
 it is better to have  scarlatina in early childhood, rather than in
 later years when  the patient may at great loss be suddenly and
 for a long time taken  from his business, and when the danger
 from the disease is fully as great.  Finally, even  the most rigid
 isolation and most careful disinfection will not prevent the reten-
 tion of  the poison  in the house ; the  other  children who have
 been  isolated for perhaps weeks may contract the disease upon
 the renewal of the exposure, and the quiet of  the  household
 has again to be disturbed;  while if  isolation were not adopted
 all the children liable to contract the disease would go through
their  illness at about the same time,  and the care of them would
 therefore be less onerous.  Notwithstanding these objections, no
 physician should advise or approve of  the sick remaining among
the healthy.  Even during an epidemic of a mild type, or when
one or more members  of a  family have a mild form of scarlet
fever, a well child may take the disease in its malignant form 
                          TREATMENT.                       3Q|

 and die, or may survive with some  irremediable sequel, such as
 deafness.  At  any rate, should the first case prove of'a malig-
 nant type, isolation should certainly be enforced, and all delicate
 children should be removed from the influence of  the  poison of
 scarlet fever.
    There are no other prophylactic measures except  isolation
 and the disinfection of everything contaminated  by the conta-
 gion. The good result of any kind of inoculation is exceedingly
 doubtful,  and still less worthy of recommendation  is that old,
 much-vaunted  pseudo-prophylactic, belladonna,  or any  other
 similar  narcotic, while the internal administration  of carbolic
 acid, lately recommended  (Gfiersing) is as  yet untried.  Mouth
 washes and gargles are likewise of very dubious efficacy ; such,
 for instance, as  very strong dilutions of muriatic acid, which
 Godelle proposed as a means of destroying the poison of scarlet
 fever at the point where it is supposed to enter the  body.
    A common  mode of  treating scarlatina is  by the  internal
 administration  of substances which are supposed to destroy the
 poison as  soon as it has manifested itself in the system, such
 as acids,  organic (acetic)  and  mineral (muriatic, sulphuric),
 chlorine, and especially the carbonate of  ammonia,  combined
 with the external use of the same means (vinegar and chlorine
 lotions).   While very valuable and reliable antimiasmatic pro-
 perties have been ascribed to these measures by individuals, the
 experience of many physicians, in large numbers  of cases, has
 not been  able  to  confirm  them.   Perhaps the warm praises
 bestowed upon them may be explained by their  having been
 used only during mild epidemics, when nearly all  the cases get
 well of themselves.
    The efficacy  of  the non-specific methods  of treatment,  so
 highly advocated by many,  is entitled  to no greater confidence.
 They have  perhaps in one way or another  proved beneficial in
 individual cases  or epidemics, but no one of them has succeeded
 in obtaining general approval.
   The following are those most worthy of mention:
   Bloodletting, general  as well as local,  and  carried out with more or less
energy, has been looked upon by many physicians as the most certain means for
reducing the mortality to a minimum. Extensive experience, however, has shown it 
302                   THOMAS.—SCARLATINA.

to be a dangerous remedy, only to be resorted to under certain circumstances for the
removal of individual casual complications.  In malignant  cases, more or less ener-
getic bleeding has not only not produced any decided beneficial result, but has has-
tened the threatening collapse.  The mild cases of the disease will recover without,
and even  in spite of, blood-letting.
   The indiscriminate  administration in large quantities of  laxatives  and emetics,
in accordance with a theoretically conceived method, is highly objectionable.   It is
impossible for  one to  know beforehand whether the  case may not present such
marked intestinal symptoms that the use of powerful remedies of this character
would prove very detrimental.  Furthermore, as many a patient has died notwith-
standing  powerful purging,  whether spontaneous or the result of remedies,  this
method of treatment seems entirely worthless.
   Anointing the body  with lard  was first  recommended by Dahne, and later by
Schneemann.  The latter, in cases of scarlet fever, has the whole body except the
face anointed twice a day for three weeks, and once a day during the fourth week.
Besides this, he orders  the sick-room to be kept at a low temperature (61 ° Fahr. at
the  most), free  ventilation, no medicines; the patient to avoid going to bed and to
move about as much as possible, and after the tenth day to go out of doors regard-
less  of the weather.  He declares that with the practice of  his method  no regular
desquamation occurs, but merely the ordinary natural shedding of  the epidermis.
Hence, when the redness of the skin has disappeared the disease is supposed to have
run  its course, notwithstanding the fact that the period of desquamation is the most
dangerous not only on account of the contagiousness of the disease but also by reason
of the complications and sequelae.  This method of treatment has never been strictly
followed out to any extent, although some of its individual features have been
adopted  more  or less  completely by many physicians;  but  in  malignant  cases
experience has proved that the treatment by the anointment  method is as ineffectual
as any other.
   The old-fashioned  general treatment for all the exanthematous diseases, which
sought by any means to produce  diaphoresis, is simply preposterous, and although
regarded  as detrimental by physicians, and therefore entirely abandoned by them,
has  unfortunately remained in such general use among  the  people that it is not
unfrequently a great obstacle to the proper practice of the  more rational therapeu-
tics of the present time.

    The symptomatic is  the only  rational  and   advisable treat-
ment for  scarlet  fever.   In its application  it must constantly be
borne  in mind that the disease, which cannot be  cut  short or
interrupted  in its  natural  course, always tends to recovery, pro-
vided  the  fever  and  local   symptoms  remain  within  certain
bounds.  Hence  every feature of  the disease  should  be  most
carefully  watched,  in order that with the  appearance of  any
anomaly  the necessary interference may be resorted to. 
TREATMENT.
303
   During the normal and uncomplicated course of  scarlet fever
the following plan of  treatment is to be followed.   The patient
should remain in bed from the beginning of the disease until the
completion of  desquamation.  The bed coverings should not be
oppressively heavy nor of too great warmth.  The  situation of
the bed should be such that, without compromising the thorough
and constant  ventilation of  the  room, the patient will  not be
exposed to any strong draught, which might possibly be injuri-
ous  to him.  The  temperature of the room should be a low one
—59° Fahr. is  amply sufficient; a higher one  is only necessary
when the over-sensitive patient really complains of feeling chilly,
which is only likely to be the case when, with the decrease of the
fever, a cooler  temperature is no longer needed  to counterbalance
the effects of an  excessive production of heat.
   In scarlet fever it is particularly necessary to pay some atten-
tion to the skin ; for instance, baths should be used in the man-
ner described farther on, or, if they are impracticable under the
circumstances, other hydrotherapeutic measures may be resorted
to.   At all events the  body should be sponged  two or three times
daily with cold or tepid water, which at the same  time will be
found very effective in soothing or  removing the annoying itch-
ing and burning of the congested  skin.  The linen of the patient
should  be  frequently changed.   During the angina it  is suffi-
cient for the patient to use a slightly astringent gargle, and to
rinse his mouth with  some cleansing fluid.  Let him have fresh
water or lemonade to drink.  During the height of the disease
the diet should be restricted, without excluding, however,  such
light alimentary articles as milk and thin soups, especially in the
case of young  children, who perhaps have some desire for food ;
during the decline of  the disease  good nourishing food may be
allowed, although  overloading of  the stomach  is of  course to be
avoided.  During  the whole affection  care should  be taken to
keep the bowels regular, either by the judicious administration
of fresh or stewed fruit, or possibly by the use of a mild aperient,
calomel excepted.  The physician should  not  allow the patient
to leave his bed until  the process of desquamation  is complete,
or at any rate  not  before the end  of the third week,  lest by per-
mitting him to get up too soon  he incur the blame of  having 
304
THOMAS.—SCARLATINA.
caused the nephritis which may come on later.   He should also
examine the urine daily, both microscopically and chemically, in
order to recognize the kidney affection early, and so to obviate,
as far as possible, its dangers.
   A very  serious  question nowadays in  the treatment  of
scarlet fever is, whether or not under all circumstances a hydro-
therapeutic course shall  be pursued.   A very  high degree of
fever, occurring in the course of an otherwise perfectly normal
case, of  course necessitates the use of cold water as much as do
the high fevers of  other diseases (measles for instance, page 120,
et seq.), partly to afford the patient personal relief, and partly to
ward off those real  dangers which  an excess of fever entails.
Yet in cases which  run a mild course,  with only  a moderate
amount of fever, the antifebrile hydrotherapeutic measures may
seem unnecessary.  But it has been stated that the cold-water
treatment, if begun early in the disease, and continued regardless
of the intensity of the fever, is able not only to entirely cure the
disease, but also to protect against the localization of the scarlet-
fever poison in the kidneys.  If  these facts were  true, they
would certainly show a most brilliant and important therapeuti-
cal result; but unfortunately the assertion in  question seems to
have  no trustworthy foundation.   The  various complications
and anomalies in the course of scarlet fever can by no means be
prevented by hydrotherapeutics, for cases have  been reported
in which, notwithstanding a perfectly appropriate  water-treat-
ment during  the febrile  exanthematous  stage, an extensive
dropsy set in, and finally carried  off the patient.  The results
also of my own experience—chiefly, it is true, in private practice,
in which the thorough execution of the  cold-water treatment is
unfortunately not so practicable as in a well-equipped hospital—
do not corroborate the truth of the above-mentioned statement.
It seems therefore advisable, at least for  the present, to practice
hydrotherapy energetically only  in the severe  cases; in  the
meanwhile trustworthy statistics should be collected from vari-
ous epidemics and districts (for the frequency of nephritis varies
in the most extraordinary manner),  upon which a definite  judg-
ment may be based concerning the treatment of the lighter forms
of the disease. 
TREATMENT.
305
   In any case it is judicious to bathe scarlet-fever patients ; the
old prejudice, so prevalent against baths, and based upon the
fear lest the  patient may thereby take  cold, must be laid aside.
I feel convinced that the nephritis has been less frequent, and of
a decidedly lighter character, since I have ordered a daily bath,
than before I was in the habit of prescribing it.   This would lead
to the conclusion, that if early in the  disease  the  skin  receives
proper care the congestion of the kidneys, which is of such fre-
quent occurrence,  may perhaps be prevented altogether, or cer-
tainly lessened, and  thereby dangerous  consequences avoided.
At all events, the  temperature of the baths should be graduated
according to the intensity of the fever.  During the period  of
high fever, in the beginning of scarlet  fever, Ziemssen's baths,
in which the water is gradually cooled down, should be used ;
and in  the following days, as the fever sinks,  the temperature
of the  baths should gradually  be increased ;  during convales-
cence the baths  should be warm.   In cases of mild scarlet fever,
when the  children are  especially  sensitive to cold, and the
parents very apprehensive, it is best to use only the warm baths,
bearing in mind, however, that such  considerations should have
no influence in  preventing the canying out of the appropriate
and correctly administered cold-water treatment, which alone is
suitable in serious cases with an intense degree  of fever.  Bagin-
sky advises that after the tepid bath  the cases with very high
fever should be quickly and thoroughly dried, and then anointed
with lard and allowed to lie down with  only a light covering ; he
further recommends  that during the period of defervescence a
slight diaphoresis be  kept up for about two hours, between the
warm bath and  the anointing with lard, during which interval,
of  course,  the patient must be guarded against taking cold
through any unnecessary exposure.
   Although  in simple  and therefore  typical cases of  scarlet
fever the above-described dietetic and  expectant mode of treat-
ment is sufficient for the abatement of present  and the prophy-
laxis  of further disturbances, yet there are anomalous and com-
plicated cases which require not only a  strict carrying out of the
above-mentioned measures, but also the employment of further
means.
          VOL. II.—20 
306
THOMAS.—SCARLATINA.
   An intense degree of fever is generally  the  most frequent
indication for some energetic interference, and is most appropri-
ately met by the  combination of active  hydrotherapeutic meas-
ures, with antifebrile medicaments, and in individual cases these
may be supplemented by anointing the body with lard  or with
carbolic acid salve (Betz), a plan which is of special benefit when
the skin is very dry and hard.   Literature is rich in the  records
of cases of scarlet fever with a high degree of fever, accompanied
by serious disturbances of the nervous system,  which have been
successfully treated by means  of pretty  cool baths,  properly
administered packs, the cold douche, or the more or less  general
use of cold dressings; in like cases, therefore,  no rational phy-
sician  should  hesitate  to  employ hydrotherapeutic measures.
Among the medicaments quinine is of special value, in doses of
eight grains (in adults as high as fifteen grains), which  may be
given,  except in  the case of  very young children, two or three
times daily, during one or two days ; these large doses, however,
must not be given for several  days in succession, on account of
the toxic  effects of the drug.  Digitalis, in doses of from seven
to thirty grains daily, according to age,  is of service in reducing
an extreme frequency of the pulse.
   Energetic measures for  a reduction  of temperature  are not
only necessary when the fever is for a longer or shorter period of
an  intense nature, but  they should also be employed in those
cases in which the fever, whether of a high or low degree, is con-
tinuous and disproportionately prolonged, without the  existence
of any local trouble which might explain  its persistence.   The
appropriate treatment  in  these cases  should be that above
described, although the doses should be smaller and the hydro-
therapeutic measures less frequently repeated.
   Whenever  a  highly febrile  condition assumes a constant
character, there should be no hesitation  in anticipating a  state of
extreme  exhaustion, which may set in  suddenly, by the timely
and frequent  administration of  nutriment, although  an utter
lack of appetite  and great embarrassment in  swallowing may
render the accomplishment of this very difficult.   For  this pur-
pose Hare recommends frozen beef-tea, in order at the same time
to fulfil an indication for the pharyngitis. 
TREATMENT.
307
   An endeavor should be made to meet those symptoms due to
the toxic effects of the scarlet-fever poison by the administration
of antiparasitic and antizymotic remedies, while symptoms of
collapse may be met by powerful stimulants.  Among the former
I will mention quinine, in medium and large doses, the internal
and subcutaneous use of carbolic acid, the sulphocarbolate of
soda (in daily doses of from fifteen grains to a drachm, according
to the age, as recommended by Sansom), the hyposulphites, and
the inhalation of ozone (Francis); to the latter belong especially
camphor, benzoin, musk, and the carbonate of ammonia,  as also
rum, Cognac, and the stronger wines ;  and finally, cold affusion
in the empty tub  or while in the bath.   In desperate cases, more-
over,  it may be worth  while  to practise  transfusion of blood.
Bennett reports that by the administration of fresh yeast, from
one to two tablespoonfuls, repeated several times during the day,
according to the age of the patient and the  malignancy of  the
disease, he has never lost a case of malignant scarlet fever.
   The  symptoms appertaining to the  skin, as a rule, no longer
require such active treatment as in former times, when the great-
est importance was attached  to the eruption.  It will, for  the
most part, suffice to fulfil the general indications, should the erup-
tion show any irregularities ; it has, moreover, been proved that
by the application of the  hydrotherapeutic measures the fluxion
to the skin  is in no way interfered with, but frequently rather
favored.   Thus  the eruption has frequently  been  observed to
come out, or to increase, when, on account of a high degree of
fever, the patient has taken a tepid bath with cold affusions, or
has been in a pack.  When the eruption is slow in developing, it
may frequently be hastened by the use of mustard poultices, and
by anointing the skin with lard ; and if the fever be moderate,
diaphoretics  may also be tried.  The same means are frequently
of use in prolonging for  a time an eruption  which has a ten-
dency to fade too soon ;  and such a measure should certainly be
attempted if dangerous  symptoms appear imminent.   If the lat-
ter really come on, and these  simple means do not  suffice, there
should be no hesitation  in employing more powerful ones.  For
this purpose may be employed,  externally, the warm bath as
recommended by Wunderlich, warm and hot douches, simple hot 
308
THOMAS.—SCARLATINA.
 poultices containing some mustard, the cold pack, and cold affu-
 sions, followed by the use of warm wrappings; and internally, the
 diaphoretic infusions, ammonia and musk.   Max Langenbeck
 speaks in the highest terms of the use of the hot flat-iron, com-
 bined with a mustard bath, followed by a sweat brought  about
 by warm wrappings.
    Severe brain symptoms are generally only due  to the fever
 caused by the specific  poisoning, and will yield to active anti-
 febrile treatment in proportion as the latter is able to control the
 fever.   Congestion of the brain, incipient meningitis,  etc., when
 diagnosticated,  demand energetic antiphlogistic measures; the
 whole  head to be covered with a bag of ice, the application of
 cold dressings, leeches to the forehead  and behind the ears, and
 possibly venesection.  Unfortunately brain trouble cannot always
 be recognized with a sufficient degree of certainty to render advis-
 able a more energetic blood-letting, which might prove beneficial.
 Narcotics, in doses  suitable to the age,  are appropriate  in cases
 of simple brain excitement where there is no suspicion of hyper-
 emia, and where no improvement  has followed the use of cold
 derivatives, etc. ; and they are of great value in nervous delirium,
 during and after the period  of defervescence.
   As long as the angina remains at all  moderate, and gives rise
 to no dangerous symptoms, it is sufficient to do nothing special
 beyond the frequent application to the neck of cold dressings, or
 those recommended by Priessnitz, the taking  of pieces of ice into
 the mouth, and the use of detergent  mouth washes and gargles ;
 for very often, in the case of young scarlet-fever patients, any
 further local treatment is impossible, or at least throws them into
 the greatest excitement.  The application of leeches to the neck,
 or cauterization of the tonsils with nitrate  of  silver, in strong
 solution  (thirty grains to the  ounce), or in  substance,  is only
 necessary when, in  the cases  of children, these glands  rapidly
 enlarge and threaten suffocation ;  while in older patients pretty
free scarification of the tonsils may also be practised.  Ganore-
 nous affections of the throat are to be treated with  disinfecting
and deodorizing gargles (permanganate of potash, fifteen grains
to the  ounce  of water;  chlorate of  potash, chlorine water, car-
bolic acid, one part to two hundred  of water), and with  cauteri- 
                         TREATMENT.                      309

 zation of the ulcerated surfaces.  Complicating diphtheria should
 be treated like simple diphtheria, either  in a simple manner or
 with weak or  concentrated  disinfectants, etc. (compare p. 128).
 If the diphtheria extend into the larynx, tracheotomy can afford
 but little hope, for I have never seen the operation succeed dur-
 ing scarlet fever.   In diphtheria  of  the nasal fosse, an effort
 should be made to remove the membrane mechanically, or by
 means of solvent and  softening agents (lime-water), as well as
 astringent and cleansing injections, especially if there are  any
 ulcerations.
    A similar plan of  treatment should be pursued in the case
 of  simple coryza or purulent ulcerative coryza.  In young chil-
 dren the nares should always be oiled or greased.
    Any kind of stomatitis demands, besides  thorough cleansing
 of the oral cavity and timely cauterization of  the ulcerations, an
 absolute disuse of any form of mercury, on account of the danger
 of causing noma.
    The treatment of disease of the ear should never be postponed
 until convalescence has set in.  Wendt advises that  from  the
 beginning the  secretion should be very carefully removed from
 the nose, throat, and the lower portion of the Eustachian tube by
 means  of douches and gargles, and from the external auditory
 canal (after spontaneous or artificial  opening of the membrana
 tympani) by means of injections.   The forcing of  air into  the
 middle ear is a measure of very great importance (of course,  not
 by means of the catheter).  The frequent repetition of these pro-
 cedures will, when the swelling  has nearly, if not quite, obliter-
 ated the canal,  guard against the formation of adhesions between
 the two mucous surfaces.  At first, for the pain, leeches should
 be applied, while later, poulticing  is  more  effective  (Wendt).
 Disease of the ear does not  contraindicate cold baths, but dur-
 ing their  use  the auditory  canal  should be closed with oiled
 cotton.
   For  severe  conjunctivitis, the assiduous application of cold-
 water dressings is  necessary.  In severe cases of  keratitis  the
 spontaneous rupture of the cornea may frequently be prevented
by the local application of intense  cold,  the use of  atropine, or
finally by puncture of the cornea.   In  such cases it is proper to 
310
THOMAS.—SCARLATINA.
keep the eye closed ; some endeavor should be made to remove
the secretion,  but with  struggling children no force should be
used, lest the dreaded  perforation be thereby produced.  As a
result of purulent  keratitis the extirpation of the globe of the
eye may finally become necessary (Senfft).
   Intense inflammation of the cervical cellular tissue, with or
without  severe lymphadenitis, demands the application of ice or
cold-water dressings, while leeches should only be used in case
of necessity.  As soon  as the formation of pus and fluctuation
are demonstrable, the cold-water dressings, as far as the general
condition will allow it, should be changed for warm ones, and
the abscess speedily opened, in order to guard against dangerous
burrowing, erosion  of large vessels with fatal hemorrhages, or
the destruction of  important  nerves.  During  the  treatment of
the abscess, as well  as during its evacuation, disinfectants should
be made  use of.   Glands that  are the seat of  chronic infiltration
require the external use of absorbents, iodine, etc., as in the case
of simple glandular affections.  The moment disease of the cel-
lular tissue shows signs  of becoming gangrenous, some powerful
caustic should be  made use of (Hebra  recommends  caustic
potassa or a  concentrated acid or the nitrate of silver) and the
wound assiduously dressed with preparations of carbolic  acid.
The  secretions from such wounds  and all gangrenous shreds or
sloughs should be  frequently removed.  The internal adminis-
tration of quinine and  acids,  as well as stimulants and strong
nourishment, with wine, is most urgently indicated.
   Every case developing  diphtheria  or  gangrene  should  be
separated at once  from the other scarlet-fever patients.  For that
very  rare occurrence, hematoma  of the neck, the indications
are, according to  Huber, the application of ice and  ligation of
the carotid.
   The presence  of  bronchial and pulmonary complications ren-
ders a pure and  constantly renewed  air of the utmost import-
ance. Aside  from  its other advantages,   such an atmosphere
strengthens the respiratory act, and thereby the expectoration of
the secretion  is very materially facilitated  and the dyspnoea
relieved.   Otherwise, with the  avoidance as far as possible of the
abstraction of blood in any form, the treatment is the usual one ; 
TREATMENT.
311
stimulation of the heart's action, maintenance of the strength,
antifebrile measures, and the judicious use of expectorants.  In
cases of oedema glottidis or stoppage of the air-passages from
other causes,  diphtheria  excepted, tracheotomy is,  not unfre-
quently, perfectly successful.  Warm baths, and if necessary the
application of hydrotherapeutic  measures (compare p. 124), are
often of material aid in determining a favorable issue to the lung
affection.
   Intestinal disturbances, generally  diarrhoea, do  not as a rule
require any internal remedies.  They should be treated, especially
when the fever is high, with frequently changed ice-water dress-
ings or with an ice bladder over the abdomen, and the cold packs,
described on page 125, are likewise of great benefit.   A careful
diet is of special importance, as in the intestinal affection of ty-
phoid fever.   If there is constipation, enemata should be given,
and if necessary any mild purgative, excepting calomel, or in fact
any of  the mercurials.   A moderate diarrhoea  coexistent with
dropsy is rather to be desired, and requires no active treatment.
   Rheumatism of the joints is generally of a mild character and
of short duration, and  may require,  besides an anesthetic lini-
ment and rest, some form of support like a snug bandage, but, as
a rule, no further treatment.  If it should result in a synovitis,
as now and then  occurs, with or without the formation of pus,
the case  should be treated in the ordinary way, beginning with
the application of dry cold and the  abstraction of blood, as in
all severe joint inflammations.
   Upon  the first symptoms  of inflammation of either of  the
serous membranes the thorough application of cold should be
tried,  to prevent an excessive  exudation; the abstraction of
blood is only allowable when the patient is robust—a condition
rarely met  with—and when  the diagnosis is  without doubt,
which is  not  always the case in meningitis. Pleuritis with an
excessive  or purulent exudation should be  relieved by paracen-
tesis, performed by puncture or incision, under the same indica-
tions which authorize the operation in primary or non-infectious
pleuritis ; and this procedure, whichever way performed, has not
unfrequently  been followed  by excellent results  (Trousseau,
Albu, Brotherston, Muhsam). 
312
THOMAS.—SCARLATINA.
   The treatment of endocarditis in scarlet-fever patients is the
ordinary one; the continuous application of cold to the  pre-
cordial region, absolute rest, and digitalis for great frequency of
the pulse.
   Hemorrhagic scarlet fever requires  the early employment of
antifebrile and antimiasmatic means and methods ; an abundant
supply of fresh air  and the administration of appropriate medi-
cines, especially quinine; the hyposulphites, carbolic acid, and
salicylic acid (five or ten  grains  to the ounce) are highly recom-
mended.  For the  severe hemorrhages cold  should be applied
locally.  Besides the internal remedies just mentioned, ergot,
the sesquichloride of iron, and preparations of tannin have  often
been used with advantage.  Compare,  moreover, what has been
already said concerning hemorrhages during measles (page 126).
Wine, stimulants, and nourishment are all-important, and should
always be comprised in the treatment.
   After nephritis  has  set  in, an aggravation of its  intensity
and the consequences may frequently be prevented by the con-
tinuance of the warm baths recommended for the period of def-
ervescence, and by favoring a condition of diaphoresis ;  hemor-
rhages from the kidneys also will generally yield to these sim-
ple measures,  so that there may be no necessity for resorting
to any special  remedy (hypodermic injections of ergot).   Other
far more active measures must, however, be promptly—for any
delay would be dangerous—employed whenever a rapid decrease
occurs in  the  amount of  urine  excreted (the latter containing
an  increased volume of  albumen and blood), and dropsy has
set in and is rapidly extending.   In  this case the results of
experience indicate,  as the  most appropriate, an antiphlogistic
treatment of the fundamental inflammatory affection of the kid-
neys.  Hence, when dropsy sets in and rapidly increases, with
a renewal of the fever, or an increase of that already present,
accompanied by a full, slow pulse, and especially by pain in the
region of the kidneys, with considerable hematuria  (hydrops
calidus), the treatment should be, for robust patients, one gene-
ral bleeding (Romberg even bleeds in a child two years old ; but
copious bleeding may prove fatal!);  for such as are less strong,
a judicious local (in young children about three leeches,  while 
TREATMENT.
313
adults had better be cupped) abstraction of blood in the  region
of the kidneys.  If diarrhoea is not present, purgatives are indi-
cated, in order, by their action upon the bowels, to relieve the
kidneys ;  while diuretics, which increase the hyperemia of these
organs, and warm baths, which, if the fever is high,  would
increase it, should be avoided.  If some improvement in the
symptoms is not  soon  manifest, the abstraction  of  blood, but
only locally, should be repeated ;  but in weak and anemic chil-
dren, derivatives in the region of the kidneys  should be substi-
tuted  (frequently repeated dry cups, and, less worthy of note,
those agents which excite local inflammatory action, as blisters,
and the like);  the mild antifebrile and cooling  hydrotherapeutic
measures  are also  of service  (cold  packs, or moderately cool
baths).
    In many cases the abstraction of  blood causes immediate and
permanent relief ; the fever and the pain in the region  of the
kidneys cease,  the secretion of urine becomes augmented, the
albuminuria lessens from day to day, and the moderate  degree
of dropsy that  has been  developed disappears.  Now the warm
baths  should be renewed and a slight diaphoresis promoted, and
a gradual but  steady recovery will take place.  In  other cases,
however, while the fever lessens or entirely ceases, the suppres-
sion of urine continues, the dropsy increases, and many  other
disturbances set in.  In  a similar manner dropsy of an extraor-
dinary degree  may finally develop in those cases which, during
the beginning of the kidney affection,  were attended with less
fever  and  other alarming symptoms, but  in which a high degree
of  albuminuria,  and an abundant shedding  of cylinder casts,
with or without some hematuria, were present (hydrops frigidus).
Here the thorough trial of warm, and in complete  torpidity with
excessive  dropsy, even hot (that is, heated by the addition of
water  of 95° to 108° or  109° Fahr.) baths (Liebermeister, Ziems-
sen, Steffen), followed by about  two hours of diaphoresis, will
not unfrequently  succeed in materially reducing  the weight of
the body.   Like measures are indicated in anasarca, and when
the peritoneal  sac, the pleural cavities, or the pericardium are
the seat of excessive exudations; and they are contraindicated in
cases  of  capillary bronchitis and incipient oedema of the lungs, 
314
THOMAS. —SCARLATINA.
and  also when eclamptic symptoms  threaten and intercurrent
attacks of fever occur,  as  under  such circumstances  sudden
paralysis  of  the heart  or  dangerous  convulsions  may cause
death.  When  the  patient is very weak the water bath  may be
replaced by vapor baths  in  bed, or by  hot-air baths as recom-
mended by Bashan.   Diaphoresis  may be considerably aided
by mild diuretics (juniper, ononis, acetate,  tartrate or citrate of
potash, lemon-juice, iodide of potassium,  etc.),  and  alkaline
salts, since, by  their use, combined with the liberal  administra-
tion  of water, the secretion of urine is  promoted, and the absorp-
tion  of the effusions hastened.  Whenever, notwithstanding an
inconsiderable  albuminuria, and  a pretty  copious secretion of
urine,  these measures are inappropriate or unsuccessful, either
in very young children or in cases in which  insufficient food  and
great  poverty  have brought  about  a condition of  extreme
anemia, or where there is a profuse or long-continued intestinal
catarrh,  etc.,   a disappearance  of  the dropsy is  frequently
brought about by large doses of some good preparation of iron,
which is also, for other reasons, indicated during convalescence.
   Any excessive accumulation of fluid in either  of the serous
cavities may require  the operation of  puncture; this  is con-
sidered by many (for instance Oppolzer, in  case of ascites) to be
accompanied by some danger, since  during scarlatinous nephritis
an inflammatory condition of the wound is  more likely to occur.
In a  high degree of anasarca, scarifications  should be practised,
and the wounds covered by dressings  soaked in solutions of  car-
bolic acid.
   Eclamptic or uremic symptoms  are  among the other possi-
bilities which may obtain during dropsy, and should be  borne in
mind.   Uremic attacks,  with severe  convulsions,  should be
treated, in strong patients, by  venesection  or by the  energetic
local abstraction of  blood upon the forehead, whenever  the pro-
dromal symptoms (headache, vomiting,  mild delirium, or slight
coma) have been  treated in  vain, by  means of baths with some
rubefacient  addition  (for  instance,  caustic potash as recom-
mended by Geissler), the promotion of  diuresis, powerful dras-
tics,  cold affusion, cold to the  head and precordial region ; in
mild uremic conditions,  with or without incipient convulsions, 
TREATMENT.
315
these latter means will  generally  suffice.  Whenever  the  con-
vulsions continue, in spite of free abstraction of blood, resort
should be had to the inhalation of chloroform, the subcutaneous
injection of morphine (especially in adults, and  in  any case in
doses proportionate to the age), and to compression of  the caro-
tids. 
 
          SMALL-POX.

(VARIOLA, VARIOLOID AND OTHER MODIFICATIONS,
    BLATTERN, PETITE VEROLE, DIE POCKEN.)
CURSCHMANN. 
 
SMALLPOX.
An exhaustive statement of the vast literature of Small-pox would  far exceed the
    design and limits of this work.   We will content ourselves with an enumera-
    tion of that which  is most important, and  even  for this a considerable space
    will be required.—Rhazes, de variolis  et  morbillis, arab. et latin.   London,
    1766.—Th. Sydenham,  Op. Sect. III. edit.  Batav.  1700.  Epistol. de observ.
    nuper. circa curat, variol. conn. 1682.—Huxham, Op. T. II. and III.—van Swieten
    (Comment, zu Boerhave) edit. Batav.  1772.—Fr. Hoffmann, Op. Sect. I. Cap.
    7.—Mead, De  variol. et morbill.   London,  1747.—Storch, Abhandlung  v.  d.
    Blatternkrankheit.   Eisenach, 1753.—C. L. Hoffmann, Abhandl. v. d. Pocken.
    Miinster u. Hamm, 1770.—Cotugno, De sedib. variol.  syntagma 1771.—Borsieri,
    Instit. med. pract.—de Haen, Abhandl.  v. d.  sicherst. Heil. der naturl. Pocken.
    Wien, 1775.  (Well known as an obstinate opponent of the prophylactic inocu-
    lation of variola.)—Peter Frank, De  curand. homin. morb.  Deutsch v. Sobern-
    heim.  § 327 ff.—Hufeland, Bern, iiber die naturl. und geimpft. Blattern.  Ber-
    lin, 1798.—Moore, Histor. of the Small-pox.   London, 1815.—Monro, Observ. on
    the Differ. Kinds of Small-pox.  Edin., 1818—J. Thomson, An Account of the
    Varioloid Epid., etc. 1820.—Stieglitz, Horns Arch. Xl.—Miihry, Hufel. Journ.
    XXVIII. u. XXX.-—Heim, Horns Arch. X. u. XIII. — Albers, Ueber das  Wesen
    der Blattern etc.  Berl.,  1831.—Naumann, Handb.  Bd.  IH.  Abth. L—Eich-
    horn, Die contagios. fleberh. Exanth.  Berl, 1831.—Bayer, Trait, des mal. de la
    peau 1835.— Petzhold, Die Pockenkrankh. mit bes. Riicksicht auf  pathol. Anat.
    Leipzig,  1836.—Gregory, Vorles. iiber  die Ausschlagfieber, deutsch v. Helfft.
    Leipz., 1845.—Williams, Elements of Med.  I. 1846.—Simon, Hautkrankh.   2.
    Aufl.  1851.—Chr. H. Eimer, Die Blatternkrankh. in pathol. und sanitatspoliz.
    Beziehung etc.  Leipzig, 1853.—#.  B.  Leo, Bericht uber  das  Auftreten  der
    Pocken etc.  Arch, der  Heilk.  V. Jahrg.  S. 481.—Th. Simon, Das Prodro-
    malexanthem  der Pocken, Arch, fur Dermat.  u.  Syph.   II. Jahrg.  S. 347 ff.
    Derselbe iiber denselben Gegenstand, Arch, fiir Derm.  u.  Syph. HI.  Jahrg.
    S.  242 ff. u. S. 309 ff. u. IV. Jahrg. S. 541.—Knecht, Ueber Variola.   Arch,  fur
    Derm. u. Syph.  IV. Jahrg.  S.   159 ff.  u.  S. 372 fi.—Scheby-Buch, Bericht
    iiber  das Material des Hamburger Pockenhauses u. s.  w. ibid. V. Jahrg.—
    Wagner,  Die epithelialen Blutungen.   Arch, der Heilk.   Bd.  LX.  (hamorrh.
    Pocke).—Derselbe,  die   Todesfalle in  der  letzt.  Pockenepid.  von Leipzig.
    Arch, der Heilk.  Bd. XHI.—Obermeier, Beitr. zur Kenntniss der Pocken, Virch. 
320
CURSCHMANN.—SMALL-POX.
    Arch.  Bd. 55 S. 545.—Ponfik, Ueber die anatom. Verand. der innern Org. bei
    hamorrh. u. pust. Variol.  Berl. kl. Wochenschr. 1872.  Nr. 42.—Zulzer, Beitr.
    zur Pathol, u. Therap. der Variola.  Berl. kl. Wochenschr. 1872.  Nr. 51.—
    Westphal, Ueber Nervenaffect. nach Pocken.  Ibid. Nr.  1.—Derselbe, Ueber
    eine  Riickenmarkserkr. bei Paraplegie nach Pocken. Ibid. Nr. 47.— Wendt,
    Ueber das Verhalten des Gehororg. u. Nasenrachenraums bei Variol.  Arch.
    der Heilk.  Bd.  13 S. 118 ff. u. 414 ft.—Bierwirth, Ueber Febr. variolos. sine
    variolis, ibid. S. 226.—
E. Jenner, An Inquiry into the Causes and Effects of the Variolae Vaccinae, known
    by the name of the Cow-pox.   London, 1798.—Idem, A Continuation of Facts
    and Observations of the Variolae Vaccinae.  London, 1800.—Sommering und
 >.   Lehr, Priifung  der Schutzblattern durch Einimpfung  mit d. Kinderblattern
 »  Frankf.  a. M.  1801.—Osiander,  Ausfiirhl.  Abhandl.  iiber die Kuhpocken.
    Gottingen, 1801.—Hessert und Pilger, Arch. f. Kuh- oder Schutzpockenimpfung.
    Giessen, 1801.—A complete statement of the older literature is given by Canstatt,
    Med. Klin.  See also the works of Fuchs,  Hebra (Hautkrankh. Virch. Pathol.),
    Wunderlich, Lebert, Barthez et Rilliet, Trousseau, Rayer,  Willan, Bateman, etc.


                               HISTORY.

    The question  as to the antiquity, spread,  and  origin of small-
pox,1 by  far the most important of exanthematous  fevers,  has
been for a long time the object  of  most zealous  inquiry, with-
out, however, eliciting an answer that can be designated as very
definite.
    It appears certain  that small-pox is not indigenous in Europe.
It reached us at rather a relatively late period from other lands,
no one of which, however, can with  certainty be alleged to have
been its cradle.
    The attempts which,  with great pretensions to learning, have
been made to show that Hippocrates, Celsus, and others were
acquainted with this  disease may be considered as unsuccessful,
and even the  assumption appears untenable that Europe har-
bored the evil guest at the time of Galen.

   1 The word "pock " has properly the meaning of " bag" or " sack," and therefore
served originally to characterize  the most prominent symptom of the disease, viz., the
eruption.  The word "variola" arose in a similar manner, being the diminutive of
"varus," a pimple.  It  occurs in manuscripts  of  the ninth century, and originally
included other skin affections accompanied by the formation of papules and pustules.
Later the  expression came to be applied to small-pox alone. The first physician who
used it in this limited sense appears to have been Constantinus Africanus. 
HISTORY.
321
   From remote antiquity, on  the other hand, tolerably unam-
biguous accounts of small-pox have proceeded from China and
Hindoostan; and indeed, according to Moore, its outbreak  in
these countries can  be authenticated  as  far  back as  the  year
1120.'   Although,  as Gregory,  Friend, and Mead have shown,
Moore's dates  cannot  be maintained with such precision,  still,
on the  whole,  we must share his opinion as  to the great  anti-
quity of the disease in  those countries.
   Many writers, Gregory for example, are inclined to regard  as
the first historically authenticated account of small-pox the  cele-
brated  description of  Procopius  (de bello Persico, lib. II. cap.
22) of a scourge which broke out at Pelusium about  the  year
f)44,  and thence  spread over Egypt, Syria, and the rest of  Asia
Minor.   They  base their  opinion  upon certain symptoms2 men-
tioned by that author which are undoubtedly very well referable
to variola.   Others have considered the epidemic of Procopius as
a mixed or transition  form of the bubo-plague and small-pox ;
and  believed themselves able to discover in its history grounds
for this Darwinian representation.  Both  views are now entirely
abandoned, and  the  epidemic  is universally regarded  as having
been the true bubo-plague.
   Not long after,  however, in  the year 581, we have an account,
by Gregory of Tours, of an epidemic which, from the description
of the  chronicler,  we  must  certainly  recognize as  variola.  It
raged in almost the whole of southern Europe, and was spoken
of as "Lues cum vesicis,  Pustula, Pustulse, or Morb. dysenteri-
cus cum pustulis" ;3  and Gregory distinctly separates it from the
Morb.  inguinarius,  the real bubo-plague, which  broke out  at
Narbonne  in  the year 582.  It may appear strange that none of
the physicians of that  time even mention this  no doubt long and
destructive plague.  But when it is considered how deeply the
  1 The statement is founded upon a work written in China at that time, " Treatise
on Small-pox " (Teontahinfa), which contains a collection of the oldest medical knowl-
edge of the Chinese concerning this disease.  It is  also reported from India that long
before the birth of Christ a particular goddess had been worshipped as protectress
against the disease, and also, that from a remote period her  priests had practised the
inoculation of  small-pox for  protection against the disease.
  2 Compare  Gregory, 1. c. page 34.
  ;! Compare  Hecker. Volkskrankheiten des Mittelalters.
           VOL. II.—21 
322
CURSCHMANN.—SMALL-POX.
medicine of  that period was sunk in superstition and mystery,
and how entirely wanting was the  desire  for objective investi-
gation, we shall wonder far less thereat, and shall prefer the sim-
ple record  of the chronicler  to any medical descriptions of that
period.
   To the Arabians, and among them to Rhazes, we are indebted
for the first useful scientific accounts of variola.
   Rhazes (900), who by the way ascribes to Galen a knowledge
of small-pox, hands down to us, in addition,  fragments of the
pandects of  Ahron  (about the  sixth century),  in which this
writer makes undoubted mention of the disease.
   The  descriptions of  Rhazes  are  comparatively clear and per-
spicuous, and many of his therapeutic suggestions are highly
judicious.1   His theory of  the disease, according to which small-
pox is the expression of a ferment essential to all men, a boiling
up of  fluids impregnated with the small-pox virus from embryo-
nic life, appears to us to-day paradoxical in its details.3  The
fermentation theory in  general, however,  has  recurred from the
Arabians, in  the history of variola at all times, even the most
recent (Liebig), merely modified in accordance with  the medi-
cal views of the period.
   Among  Latin writers the already-mentioned Salernian, Con-
stantinus Africanus, appears  to have been  the first to  have
given  a scientific description  of  small-pox—in  closest resem-
blance,  it is  true,   to  the descriptions of the Arabian physi-
cians.    Before Constantine little is  known to us concerning the
appearance of variola  in  Europe,   except the aforementioned
   1B.e ordered his patients, e.g., to drink cold water, combated the abuse of purga-
tives, and, as a rule, treated light cases expectantly by suitable diet. He prescribed,
too, steam-baths at the outset, and later, the inunction of oil and salt.
   2 The theory, moreover, is not peculiar to Rhazes, but is given, in its  principles, by
Ahron and Messue.  Even during the epidemic described by Gregory of Tours similar
views prevailed among the people, whence the terra " corales," then in use for the
dreaded plague, which is said to be derived from the old German "koren " " koren"
or  "kuren," i.e., "to choose," " to separate," " to purify ;" therefore indicating a
sort of process of bodily purification from certain (corrupt) fluids.  Bishop Felix of
Nantes, as the writer relates, was a victim of this theory, inasmuch as, being attacked
by  the fever, he applied a cantharidal poultice to his thigh in order  to hasten this
excretion, and died of gangrene in consequence. 
HISTORY.
323
records of Gregory.   That  the  disease occurred is beyond a
doubt; but  the limited means of communication at that time
evidently prevented  extensive spreading.  At the time of the
crusades we  first see the scourge again assume terrible dimen-
sions ; just as epidemics in general cling to the heels of wars and
great popular tumults.  At the time of the crusades too, proba-
bly, small-pox houses were first generally erected in Europe.
    The disease effected an entrance into  Germany towards the
end of the fifteenth  century ;* while  in England it had already
been introduced in 1241-42.  Sweden was visited by the scourge
at  a comparatively late date in the fifteenth century.   Small-
pox was  conveyed from  Europe to  the American  continent,
where it does not  appear  to be indigenous, soon after  the dis-
covery of  America.  It  first  raged  in Mexico, in the year 1527,
and to a fearful extent,  sacrificing its victims in millions  ; thence
it gradually  overran  the whole of America.   Later epidemics
appear to have been repeatedly  occasioned by the importation of
negroes from Africa, the colored races in general being decidedly
more liable to this disease than the white.
    In  the  preceding  remarks we  have presented a few of the
most reliable data in the defective history of  small-pox, to the
incompleteness  of  which  numerous  circumstances contribute.
Not the least important of these is the fact that for a long time
we did not know how to distinguish variola from other diseases.
It  was principally confounded with the  plague, with other
papulous  and pustular  cutaneous eruptions, and  until a  com-
paratively recent date it was invariably classed with measles.3
Syphilis,  also,  to which the  name  '' large-pox''  had been as-
signed, was confounded with variola with special frequence ;  so
that in England and  France the latter was at an early date dis-
tinguished from the former  as  "small-pox"  and   "petite-
verole."
   In Europe, as in other countries, small-pox long constituted
one  of the greatest scourges of mankind.  Not a decade passed
in which the disease  did not decimate the  inhabitants in one
country or another, or over great  tracts of country;  so that it
1 Most probably imported from the Netherlands in 1493.
5 Sydenliam first definitely drew a sharp Line between the two affections. 
324
CURSCIIMANN.—SMALL-POX.
came to be more dreaded than the plague.'   No matter how assi-
duously physicians  labored to discover a method of treatment,
none of them  accomplished a result worthy  of mention.   The
Arabian theories of the disease, requiring  sweating and other
remedies designed to "drive out the poison," were the order of
the  day till the first half  of  the  seventeenth century.  These
notions, which still  linger  in the  minds of the laity,  however,
were first overthrown by the talented Sydenham,  who replaced
them by the cooling, antiphlogistic method of treatment which
we  still consider rational in its fundamental principles.   Yet, as
may be imagined, even this treatment  was but a feeble weapon
against the  terrible  enemy.  With the introduction of the inocu-
lation of variola the great change first began in the history of
small-pox.  This was completed at a later date by Jenner's dis-
covery of vaccination, and to-day the occurrence, intensity,  and
spread of  the disease in different countries depend greatly upon
the manner in which this  eminently protective remedy  is  em-
ployed.
   Starting from the knowledge that small-pox usually occurs
but  once  in the same individual,  the attempt had early been
made, now and then, in Europe, to bring children intentionally
into the vicinity of  small-pox patients, in order that they might
be protected for the remainder of their lives by means of a pos-
sibly milder form of the disease acquired in  this manner.  Actual
inoculation of small-pox poison, however, was first practised in
China and  India, and  even at a very remote period.  It thence
gradually  extended through western  Asia to Constantinople,
where Lady Wortley Montagu learned the process, and promptly
subjected her  son  to it  (1717) with  a  satisfactory  result.   She
carried the method to England,  where  she had her daughter
  1 In England, in the seventeenth and eighteenth centuries, seven to nine per cent, of
all deaths were attributable to small-pox.  In Berlin, from 1783 to 1797, one-twelfth of
the total mortality, according to Casper, was due to the same.  In the fourth number
of the "Archivs der Aerzte und Seelsorger wider die Pockennoth," of the year 1798 von
Junker computes the deaths occurring from small-pox in the year 1796 among the 7 000 -
000 inhabitants of Prussia at  26,646 {KussmauVs letters).  In the eighteenth century
30,000 died annually of small-pox in France.  Of the resignation to the disease exhibited
in the middle ages, a proverb of that time gives the best proof, " From small-pox and
love but few remain free." 
                            ETIOLOGY.                       325

 (1721) likewise inoculated; and she was  soon enabled to bring
 the new  process  into  widespread  esteem, despite the  violent
 opposition of physicians at the outset, and the silliest objections
 of the clergy.  From England inoculation travelled  rapidly to
 Germany, France, and other European countries ; and  the expec-
 tations to which it gave rise were actually realized in  so far that
 the inoculated small-pox ran a decidedly milder course than the
 natural disease, and also afforded the same protection as the
 latter against  new infection.   The  unfortunate feature of the
 method,  and that which eventually  condemned it,  was,  that
 individuals  inoculated with small-pox were as likely to infect
 others as if  they  had contracted the disease naturally, so  that
 provision was thus again made for the maintenance and spread
 of the variola contagion.
    The  introduction  of vaccination  put an  end  of  course  to
 inoculation ; the merits of which it possessed in a high degree,
 without partaking of its  disadvantages.  A few words on the his-
 tory of vaccination we reserve  incidentally for a more thorough
 consideration of the subject.


                           ETIOLOGY.

    Since  the time of  its first recognition variola  has  sooner or
 later found its way to  nearly all the countries  of the globe.
 Differing from most other  epidemic diseases, small-pox exhibits
 a  comparatively slight dependence upon conditions  of soil or
 climate.    It  breaks out where predisposed individuals  are ex-
 posed,  under especially favorable circumstances,  to  the influ-
 ence of its contagion.   Certain geographical peculiarities of the
 disease have become greatly obscured since the general introduc-
 tion of vaccination.
    The disposition to small-pox is of very general prevalence.
 Individuals  who can  boast of  an absolute immunity  from the
 disease are quite exceptional.1   In our day,  when  vaccination
and revaccination afford such  powerful protection against the
   1 Morgagni, Boerhave, and Diemerbroek, it is said, could claim this peculiarity, and
the latter was evidently led from this circumstance to the opinion, which he upheld,
that small-pox was contagious only in a very limited degree. 
326
CURSCHMANN.—SMALL-POX.
disease, we have fortunately but limited means of observing the
conditions of which the records of former centuries present to us
such horrible pictures.
   No  period of life is wholly excluded from the susceptibility
to variola.  In this respect small-pox shows itself far more inde-
pendent than the majority of acute infectious  diseases, although
a  fully similar  relation to all periods  of life  is in nowise to be
asserted.  In  the earlier  months of life the disposition appears
to be  less than  after  the first year.   From that time until the
age  of  forty years it is most strongly  manifested, and tolerably
equally throughout that period.  Even from this age until sixty
small-pox is frequently observed, and in the latest period of life
its appearance is by no means a rarity.

   The statement  that children in the first months of life are less susceptible to the
influence of small-pox poison than older children and adults, is found in the works
of all the older authors.  Even inoculation in these cases is said to be less effectual
{Moore).  Since vaccination has reduced the number of cases occurring in childhood
to a  minimum, we  lack to-day the most important grounds for judging of  this
statement, viz.,  the opportunity for comparison.
   Of the children who were born in the small-pox department, I did  not see one
that  remained  free  from the disease, although a few, to be sure, exhibited but a
strikingly slight development of the eruption.  The following group of 632 cases
will illustrate the susceptibility of the various ages (with the exception of children
from 1 to 12 years),  not one of whom, in Mayence, did I see taken sick after well-
performed vaccination:
12-	-14 .	1
15-	-16	18
16-	-20	138
20-	-25 .	179
25-	-30	110
30-	-35	55
35-	-40	49
40-	-45	27
45-	-50	23
50-	-55	14
55-	-60	11
60-	-70	7
   We see in this table the great  participation even at a late period of life.  The
numbers between 50 and  60, and  especially between  60  and 70, though  small in
themselves, express an enormous  ratio when it is considered how relatively small
a proportion of the population is composed of individuals of this age.

   Even  uterine life  does not  exclude  the danger of small-pox
infection, although the  predisposition  of the  foetus is  far less
than that of the  child during the first few months  after birth,
and it may be  included among  rare occurrences for a child to 
ETIOLOGY.
327
come into the world already ill with small-pox, or with traces of
having  gone  through  the disease.   Under what  conditions an
infection of  the embryo takes place is wholly unknown.   A
priori,  one would imagine that in consequence of  the close rela-
tionship of its blood to that of  the mother,  the foetus would pass
through all  the phases of  the  disease  coincidently with her.
Strange to say,  however, this appears to have been observed  but
seldom.  In the majority of  reported cases the infection of  the
embryo appears rather to have taken place at  a later period than
that of  the mother (pustular or desiccative stage), which would
indicate infection by  simple contact rather than  by the blood.
This  is  quite in accord with  the assertion of  older authors, that
infection takes  place most readily when the liquor amnii is pres-
ent in least amount.  Were the blood of the mother the principal
infecting agent, the disease in the foetus would be of decidedly
more frequent,   if not  of constant, occurrence ;  for at no other
time of  life do such absolutely favorable conditions exist.

   The following case will serve as an exemplification of the preceding argument:
   M. G., a female  servant, aged  22 years, in the fifth month of her first preg-
nancy, was sick in hospital with varioloid from November 28th to December 12th,
1870.  The disease ran its course without complication.  Foetal movements during
the disease were,  just as usual,  tolerably strong.  On December 24th she was again
admitted with acute gastric  catarrh.   On the 25th and the following days foetal
movements were at times very strong, and on the 28th they suddenly ceased.  On the
31st, birth of a five to six months' child, evidently dead for several days (doubtless
since the  28th), which presented a well-formed small-pox  eruption in the stage  of
suppuration, covering the whole body; least marked on the face, and most abun-
dant on back and buttocks.   As far as this case goes, the period  of infection of the
foetus  does not coincide with the beginning, but with the  latest  period of the dis-
ease in the mother.  The mother had fully recovered on the 10th of December,
and could not have  been the source of infection later.  On the 28th, eighteen  days
afterwards, whin the foetal movements had finally ceased, the death of the foetus
doubtless  occurred.   If we  accept for the foetus the same duration of separate
stages as is common  to children under one year of age,1 the appearances were  such
as to place the time of  death in this case somewhere between the sixth and eighth
   1 It is  scarcely possible to state exactly the duration and course of  the separate
stages  in  the  foetus.  That the eruption is developed rather more rapidly than more
slowly, and its stages completed, might be inferred from the circumstance that the
foetus is immersed, as it were,  in a permanent warm bath, and in a condition very
favorable to inflammation and suppuration. 
328
CURSCHMANN. —SMALL-POX.
day of the disease ; and hence we must accept an incubatory period of at least ten
to fourteen days, and the latest period of the disease of the mother as that of
infection.

    Small-pox has been  observed as early as the  fourth month
of  embryonic life.   I can vouch for its appearance at the fifth
month  of gestation from  my  own  observation.   Individual in-
stances are cited in medical literature of perfectly healthy mothers
(not attacked by small-pox during pregnancy) who have given
birth to  children affected with  variola.   It has  usually  been
concluded that the embryo has been directly affected through
exposure of  the  mother,  who at  the time was not personally
susceptible to the contagion.   The  possibility of such an occur-
rence is not  to be excluded.  Some of these infrequent cases,
however,  might be explained upon the hypothesis that the mother
suffered from  "variola sine  exanthemate,"  and  thus infected
the child.  Such a connection would be the  more readily over-
looked, because the foetus, as in the above case, does not suffer
simultaneously with the mother, and the mild and rapidly pro-
gressing  disease  in  the mother might be  mistaken, or  long
forgotten before the birth of a child covered with  the  character-
istic eruption.  I am myself able to relate a case in point:

   During a severe epidemic of small-pox, a midwife, aged 40, in the eighth month
of pregnancy, fell sick with rigors, followed by violent fever, headache, pain in the
back, etc.,—apparently the initial stage of small-pox.  On the  fourth day, how-
ever, she was free from fever, and, in spite of the most careful examination, exhib-
ited no trace of the expected eruption.  Ten days after the commencement of the
disease, feeling at this time perfectly well, she gave birth to a child covered with a
small-pox eruption, evidently just appearing,  which developed still further, and in
three days terminated in death during the stage of suppuration.

    Sex, upon the whole, causes no difference in the  susceptibility
to the disease.  Under similar conditions, men and women are
liable to variola in  the same degree.  In women, of course,  two
physiological conditions, pregnancy and childbirth, occasion a
certain  predisposition to  the disease,  and also  to its greater
malignancy.   This  predisposition  is  counterbalanced in  men,
however,  because their duties and employments  far  more fre-
quently expose them to the danger of infection. 
                           ETIOLOGY.                       329

    In regard to certain peculiarities of the several races of man-
 kind, the dark-colored—and among these the negroes—appear to
 be decidedly  more predisposed to,  and on the average suffer
 more violently from, small-pox, than the white races ; even under
 exactly the same conditions.   Not  only in their  own country,
 but in foreign lands also, the blacks retain this peculiar sensi-
 tiveness to small-pox contagion.
    The assertion is often read and heard that existing diseases
 lessen the disposition to small-pox ; a proposition which is quite
 untenable in such generalization.  The great majority of chronic
 diseases appear to exercise little or  no influence upon the  sus-
 ceptibility  to  variola.  We see patients, with heart, lung, and
 abdominal  affections,  attacked during  an  epidemic, as well  as
 healthy persons, with only the fatal difference that  they are more
 likely to fall victims to  the scourge.  In like manner lunatics,
 and patients with chronic cutaneous affections, are apparently no
 less seldom infected.   Whether or  not  more exact statistical
 investigations  would show any one affection, or group of affec-
 tions, to be exceptional in  this respect, we leave undecided.   It
 would be an interesting  problem at any rate to sift a good deal
 of material in this direction.
    With acute affections,  especially with  the acute infectious
 diseases, it appears to  be otherwise  than with chronic diseases.
 As regards the acute exanthemata, especially scarlet fever  and
 measles, their  concurrence with  small-pox was formerly  much
 more frequently believed to exist than was really the case, inas-
 much as the so-called  prodromal eruptions, which will later be
 fully described, led not  infrequently to an erroneous  belief in
 such  combinations.   Indeed,  even at a very recent date  many
authors' have not avoided this error.   It would be going too far
to consider all record* >d  cases of the simultaneous existence of
small-pox and  some other acute exanthem as such interchanges.
At  present we may  consider  as proven  the possibility of  the
simultaneous affection of an individual with small-pox and with
  'Compare, e.g., the  case of Robinson (Dub. Journ. of Med. Sci., May, 1872, p.
365,  ff.), where hemorrhagic variola with a prodromal eruption simulating measles is
described as a combination of measles with hemorrhagic small-pox 
330
C U RSCHM ANN. —SMALL-POX.
measles or  scarlet-fever,' but we must regard the occurrence as
rare, and  in nowise  consider the diagnosis easy.   Especially
should no one  be  misled {e.g., by the lectures  of  Barthez  and
Rilliet) into the belief that the character of the eruption is in this
regard the most reliable basis of judgment.   On the other hand,
far  greater weight is to be placed  upon  other  circumstances,
especially the aetiology, the curves of temperature, etc.
    A  coincidence  of  variola  and  typhoid  fever was  not estab-
lished beyond  a doubt until a most recent date.  But the possi-
bility of this occurrence, especially since the publication of the
decisive case of Th. Simon,2 is not to  be denied.
    Apart from  these rare occurrences it can be asserted with cer-
tainty,  that for an  individual suffering from  scarlet fever,
measles, or typhoid fever,  there  is,  during the entire duration
of the affection,  a very slight liability to an attack  of variola
only.   There is a certain exceptional proportion in this relation.

   In the hospital  at Mayence, where the small-pox building stands very near the
other wards, I had the opportunity of observing with unfortunate frequency the
relation of patients  otherwise affected, particularly those attacked by typhoid fever,
to the small-pox contagion.  Typhoid-fever cases are hardly ever wanting  in the
hospital at any period of the year;  yet during  the entire duration of  the small-pox
epidemic, almost two years, I saw no case in which infection had taken place during
the course of the typhoid processes. I saw, however, unfortunately, a considerable
number of typhoid convalescents attacked.  Reckoning back  in these cases from the
beginning of the first stage of variola, the longest  possible accepted period of incu-
bation, the date of infection always occurred at the time of complete convalescence,
i.e., at a period when the body temperatures had permanently returned to the nor-
mal degree.  Among six infected typhoid convalescents, of whose cases I have spe-
cial notes, the  primary stage began in two cases  on the nineteenth, in two on the
seventeenth, and in two others respectively on the  sixteenth and fourteenth day
after the last  febrile temperature (referable to the typhoid fever).  Hence, even in
   1 Compare Rbrber, Petersb. Zeitschr. XII., Steiner, Jahrb. fiir Kinderheilk. Bd. I. 4
(Morbill. -Variola),  Fleischmann, Zeitschr.  fiir Dermatol, u. Syph.  IV.  Jahrg. ditto
Jahrb. fiir Kinderheilk.  Bd. IV. 2 (Scarlat. -Variola).
   2 Berl. klin. Wochenschr.. No. 11, 1872.  The case was observed during the simul-
taneous existence of an epidemic of typhoid fever and small-pox.  S. appends a note
of remarkable value, considering the great reliability of this author, that in many cases
of typhoid fever a more marked development of the roseola  became noticeable at that
time (under the influence of small-pox). 
                             ETIOLOGY.                        331
 the last case, supposing a period of incubation of at least fourteen days, the date of
 infection would fall upon the first day free from fever.
   The cases appear to me to be especially instructive, in so far that—as could not
 be otherwise in an overcrowded hospital during a violent epidemic—external oppor-
 tunity for infection being present as much during the typhoid fever as after it, the
 opportunity was afforded of seeing the same  individuals exposed to tolerably simi-
 lar contagious influences in the typhoid and in the relatively normal condition.

    The assertion of many authors, that influenza  (Rosenstein),
 malaria, and  whooping-cough  lessen  the possibility of infection
 with small-pox, I will not pass over in  silence, although recent
 literary data or personal observations in the matter are not at my
 command.
    As we have just seen, in regard to  certain diseases, so also
 observations relative to the infection of healthy persons may be
 cited, which can scarcely be otherwise explained than upon the
 assumption of  a  temporary  failure, or at least an occasional
 diminution of the susceptibility to  small-pox contagion.   It is
 not infrequently noticed that in healthy persons, exposed in tol-
 erably equal degree during long continuance of the prevalence of
 the contagion,  when finally attacked, the period during which
 infection could have taken place is longer than the longest pos-
 sible normal duration of the stage of incubation.  Such observa-
 tions are made with more  precision  in unvaccinated individuals,
 since in the case of those attacked after vaccination  or revaccina-
 tion  the objection (though perhaps rather far-fetched) may  be
 raised that we do not know but that the person was still under
 the  protecting  influence of the vaccine  up to  the  very day of
 infection.

   The history of small-pox inoculation presents us with data concerning the tem-
 porary insusceptibility to contagion, which have almost  the convincing jjower of
 experiment.  We learn  that this  operation (performed with the same lymph and
 under similar circumstances) by no means produced the desired result in all cases.
 Gregory (1. c, p. 19) states that Woodville reckoned the proportion of temporarily
 non-susceptible children to be 1: 60, and of adults 1 : 20.

   In the case  of most persons the  disposition to small-pox,
 after one attack, disappears for the remainder of life, or at least
for a long time.  We have as  yet  scarcely an  idea of the rela- 
332
CURSCHMANN.—SMALL-POX.
tions of this strange manifestation, since we still lack, as we shall
see,  an accurate  knowledge of the nature of  the small-pox con-
tagion, which is  the  conditio sine qua non  of its explanation.
When, twenty-five years ago, the resplendent light of the newly
arisen organic chemistry threatened to obscure all other  scientific
methods of research, it was hoped  that by its aid the  problem
would  be solved ; but we  will  not  reproduce here  those long-
abandoned misconceptions.   Exceptional cases have  occurred
where individuals  have been attacked with  small-pox for the
second time,  and  even since  the introduction of  vaccination.
Indeed, persons have been reported so unfortunate as to contract
the disease more  than twice, even five and six times.

   The lapse of time between such recurrences is reported as differing widely;
ofttimes  as extremely short.   An intermission of a few months constitutes the ex-
treme of brevity, while more frequently there is an  interval of from two to three
years.
   Extreme caution is requisite in accepting such " secondary or recurring " small-
pox, and all acounts of this kind are not to be taken for granted.  It is seldom that
the same physician has himself observed  both or all attacks, which would be  the
surest protection against error. To rely upon the statement of patients who may
characterize all imaginable skin eruptions  as small-pox, is entirely out of the ques-
tion.  Had not the individual credulity of observers come into play there could not
exist, even taking  into account the intensity and character of the  epidemics, such
entirely irreconcilable numerical  statements concerning the relative occurrence of
secondary small-pox.    These statements vary between  1: 250  (Eichhorn) and
1:10,000 (Condamine).

   It is said that in general  a violent  attack  of  small-pox is a
better protection against future attacks than a mild one ; and for
extreme cases this statement is perhaps true.   But that even the
slightest infection in this respect works favorably, was proven by
small-pox inoculation, the mother  progenitor  of the beneficent
vaccination.  It  has been  repeatedly asserted  that when small-
pox attacks  a person for  the second time, it generally runs a
milder  course.1  Yet  exceptions to  this  rule occur, as is illus-
trated by the  well-known case  of Louis XV. of France, who,
   1 Hebra, on the contrary, holds that the prognosis in the case of those attacked the
second time is especially unfavorable. 
ETIOLOGY.
333
after having variola  in  his fourteenth year, died of the  same
disease in his sixty-fourth.
   It is asserted on the part of many (Gregory) that certain con-
ditions—puberty, inflammatory diseases, changes of climate, etc.
—favor the reawakening of the predisposition.
   Of the  earliest origin and mode of extension  of small-pox
the most varying opinions have prevailed since the disease first
became  known,  in accordance  with  the varying theories  as
to its nature.  The most manifold general  causes—certain con-
ditions of the earth or of the  air, changes of temperature,  mois-
ture, etc.,  were formerly held responsible;  and the  possibility
of a miasmatic origin of the disease  was never for  a moment
doubted.  Boerhave first overthrew these ideas, and established
the theory of the exclusive spread of variola by contagion, which
to-day we  regard as firmly grounded and may formulate as fol-
lows :
   Small-pox spreads at the present time exclusively by means
of a specific virus, which is begotten in the body of a small-pox
patient,  and conveyed directly or indirectly to a predisposed,
individual, thus causing the outbreak of variola again in the
latter.  Though here and there one still reads  or  hears that at
least mild "incomplete" forms  may  arise without  contagion,
no reliable proofs therefor can be adduced.  These  statements
are based  upon the very frequent failure to trace directly the
source of contagion ; a difficulty resulting from  certain peculiar-
ities to which reference will subsequently be made.
   Of the  nature of  the  small-pox contagion there  is,  so far,
nothing  definite known.  On  the other hand, tolerably accurate
knowledge is possessed of some of its peculiarities.   These we
will   pass  in review,  and ascertain to what  extent, from its
effects, conclusions may be drawn as to the agent.
   The contagion reproduced by an affected organism takes effect
first  of  all upon  the patient himself.  It is  principally the
small-pox  pustules which  contain this, as is  clearly proven by
small-pox inoculation.  This teaches us further  that the  virus is
most active at the time when  the previously clear serum of the
pustules begins  to become turbid.   That inoculations  succeed in
the later stages also, is sufficiently well known.  Even the small- 
334
CURSCHMANN.—SMALL-POX.
pox crusts possess the power of infection in so high degree that
they were even used for inoculation.'
   Whether the secretions of patients (when small-pox pus or
crusts are  not  accidentally  mixed  with them) are infectious
when inoculated upon other  individuals is doubtful; according
to the direct experiments of the older authors perhaps the ques-
tion is even to  be answered in the negative.   Such experiments
have been made with urine, saliva, expectoration, and even with
fa3ces.
   In like manner blood inoculated from man to man is said to
be altogether ineffective.   I consider this as at least doubtful.
Direct inoculatory experiments  upon men, upon  which  earlier
observers relied, are regarded as absolutely criminal in the pres-
ent day, since inoculation has been supplanted by vaccination ;
and therefore, unless proved  by accident, we cannot expect any
solution  of this problem.  Certain experiments upon  animals,
therefore, appear the more significant in reference to this  ques-
tion.  Osiander was able to inoculate healthy sheep successfully
with the  blood  of other  sheep affected with  small-pox.   Still
more important is the  experiment of Ziilzer,  who inoculated a
monkey with small-pox with the blood of a variolous patient.
   The contagion not only adheres to the patient  himself, but
is also present in his immediate vicinity, in  the  '''■perspira-
tion'''' impregnated with transportable gaseous particles.  It
appears  to  be  "secreted" by all  emunctory surfaces of  the
body, among which the skin  naturally plays a prominent part.
Whether  the frequently  noticeable peculiar (specific?) odor of
the patient  is closely related  to the  contagion, as was formerly
believed, is  quite undecided.   In general it can be said  that the
contagion  loses efficacy  with  increasing  distance  from  the
patient.   Predisposed persons are the more readily infected the
longer they remain in  the vicinity  of patients, the smaller the
apartment,  and the greater the number (and severity) of the
cases occupying it.  In  large spacious apartments, with few
  1 The crusts were formerly used in China in the most singular manner, inoculation
being practised by placing them in the nose.  Even in more recent times, powdered
small-pox crusts were recommended, e.g. by Gatti, as convenient inoculatory material. 
ETIOLOGY.
335
patients or but one, the danger  is slighter;  and  it is still more
decreased in the open air.
    It is difficult to determine with accuracy the stage in which
patients are most likely to spread infection (by diffusing the poi-
son through the neighboring atmosphere); the earliest period of
suppuration is usually so considered.  Many ascribe an especial
danger to the stage of desiccation ; but on insufficient grounds,
however.  When there has been frequent communication with
patients,  the  time of infection cannot be accurately determined,
principally on account of the variable duration of the incubatory
stage.
    In the initial stage,  moreover, at a time when as yet no trace
of  small-pox  eruption  exists,  infection  may take place; and
infection is also possible during the period of incubation, which
is generally free from every symptom of the disease.
    The frequent cases in  which patients are  unable to indicate
the source of infection, not having come in  contact with any
small-pox patient,  are in  part to be referred to infection during
the initial stage.

   The possibility of transferring the disease from an individual during the period
of incubation is exemplified in an interesting case reported by Schaper (Deutsche
Militairarztl. Zeitschr., 1872, p. 53): In the Charite Hospital of  Berlin, small pieces
of skin were taken for transplantation upon other individuals  from the amputated
arm of a person who, before and at the time of the amputation, did not manifest the
slightest  symptom of general disease.  Several hours after the amputation the
patient was attacked with violent  fever, followed two days later by an eruption of
small-pox.  One  of the individuals upon whom the transplanted skin had been
placed was attacked by variola on the sixth day after the operation; the three
others remained exempt.

    Besides  the atmosphere about the patient, the contagion  is
imparted to certain objects which have been used by him or been
in  his neighborhood; and it clings to them  also for a  varia-
ble  length  of time after they have  been removed from his per-
sonal  influence.  Foremost in this respect may be mentioned
clothing and bedding; and especially  all things which have a'
rough,  woolly surface.  According  to  general belief, the poison
adheres much less,  or not at  all, to smooth  objects, especially 
336               CURSCHMANN.—SMALL-POX.

glass,  metal,  etc.  (dried  small-pox  secretion,  of  course, being
excepted).
   The personal effects of a patient are not alone able to convey
infection, but healthy persons  also,  under some circumstances,
carry the poison in their clothes ; so that caution in this respect
is especially necessary on the part of physicians, nurses, etc.
   Small-pox virus impregnating gaseous media,  and excluded
from the air, is possessed  of  very great permanence.   Where
this exclusion has been as complete  as possible, the duration of
contagiousness of  the virus has been estimated at many months,
and even years, without, however, adducing exact evidence for
the extremest statements.
   Exposed  to the  atmospheric air the contagion is  readily
destroyed ; most probably by being  more and more  diluted in
the air until it becomes inefficacious and finally disappears.
   High temperatures, vapors  of chlorine, iodine,  bromine, and
sulphur,  and alcohol,  act  deleteriously upon the contagion,
though only  after very intense and long-continued  influence.
   Infection  may  undoubtedly take place through the  medium
of the bodies  of patients  dead of small-pox.   Whether a repro-
duction  of the contagion may  follow in them, is  hardly to  be
determined in our ignorance of its  nature.  It is more proba-
ble that it is the  same  thing  with  cadavers as with other life
less  objects, the virus generated during life simply adhering to
them.
   Concerning the mode  in which the contagion adherent to
transportable gaseous particles enters the body in case of in-
fection, we still lack accurate knowledge.   According to a gen-
eral and quite probable view, the poison is principally absorbed,
in breathing,  by the  mucous membrane of the respiratory tract.
That this may happen in the  upper portion of this  tract—the
nasal mucous membrane—is evident from the ancient method of
inoculation by the introduction of the crust into the nose. We
may look upon the exceedingly fine  particles detached from the
skin of the patient, and from the pustules and crusts, and which
are suspended in great numbers in  the air surrounding  small-
pox patients, as the carriers  of  the "inspired"  contagion.
   It does not follow, however,  that  this  particular  mode is 
ETIOLOGY.
337
 the only one in which the respiratory mucous membrane absorbs
 the contagion.   It may not even be the most important.
   The possibility of the absorption of the virus by the mucous membrane of the
 alimentary canal, especially  by the stomach, is positively asserted by the older
 writers.  Indeed, it was regarded as quite an ordinary means of infection.  Camper
 assures us  that he observed the outbreak of severe variola in a patient who had
 swallowed some small-pox pus ; and it is said that it was formerly the general cus-
 tom  in Bengal to inoculate variola by the deglutition of small-pox crusts (Eimer).
 Very recently, Ziilzer met with a negative result  in the case of  a monkey who was
 made to swallow the crusts.  The question is not yet to be considered as definitively
 settled.

    It is highly probable that the contagion never enters the sys-
 tem through  the  external  unbroken skin.   Both at  an  early
 date, and more recently, experiments  have been  made to deter-
 mine  this  point, and wherever a success  has been noted, it has
 almost always appeared that the virus had been rubbed into the
 skin with force, and  for a length of  time.   It is probable, there-
 fore, that the skin  became superficially wounded in  the opera-
 tion. 1
    We  have  thus far seen,  that,  concerning the majority of
 questions relating to the origin and  spread of small-pox, only
 so much as is general  is known with certainty.   Mystery and
 doubt prevail wherever we investigate more  closely.  The  prin-
 cipal reason of this lies in our ignorance of the primal causes
 of the entire  process, and especially of the nature of the conta-
 gion.  Positive views and  ideas concerning  these questions are
 to be found indeed from the  earliest accounts of variola; but
 these  have undergone  constant change,  chiefly  in accordance
 with the changes of pathological ideas.

   The  Arabians believed, and Rhazes expressed the decided opinion, that the
 small pox process was derived from the fermentation and  effervescence of a certain
 material present in the blood  of every person from the embryonic period.  Syden-
 ham and von Diemerbrock likewise held the  opinion, that in the period of incuba-
 tion,  a kind of fermentation  took place in the  blood, the product of which was

   1 In India, where small-pox inoculation has been practised by the Brahmins from a
very remote period, this  result  was  accomplished, as we are told,  in the very manner
indicated,—by the application of cotton saturated in small-pox pus upon a  portion of
the forearm previously made sore by rubbing.
           VOL. II.—22 
338
CURSCHMANN.—SMALL-POX.
manifested in the outbreak  of small-pox.  This  theory of fermentation held its
ground from that time until the first half of the present century.  It gained fresh
support again with the development of organic chemistry under Liebig, who merely
specialized the old views and revived them in accordance with the ideas of modern
chemistry.
   Within the last decade  these  theories  have gradually been
losing ground.   Following in the progress of the  times, views
as to the parasitic nature  of  the  contagion  have taken their
place;J and these are  now advocated with the same  confidence
with which the supporters of the chemical theory formerly stood
up for their opinions.   An opportunity will be  offered in the
anatomical part of this article for a full consideration of  these
questions.  We will simply remark here, that we are still  very
far removed from their solution, and prefer to advise an especial
skepticism in this matter,  without maintaining  an attitude of
positive opposition.   Even  the most practical observers are in
danger of  being borne along  the  rapidly swelling  current of
modern parasitic research, which,  without  doubt, conceals some
golden grain.
   In concluding  our  setiological  observations, let us say a few
words concerning the general conditions favorable to  the spread
of the disease.
   Small-pox  is  seen  in all possible  grades  of intensity and
extent, from sporadic, domestic endemics, or small epidemics, to
the fatal ravaging scourge which overruns entire countries, and is
not  checked until it has  attacked  nearly all who are  predis-
posed.   In the larger cities  of Europe small-pox is  seldom at
any  time  entirely extinguished.    Isolated  cases  are  almost
constantly observed there, like a lingering, slumbering fire that
bursts forth in mighty flames  from time to  time, under a  com-
bination of favorable circumstances.  As in frequency, so also in
intensity,  small-pox exhibits the greatest variation in  individual
endemics  and  epidemics.   That  its danger  has diminished a
   1 Nil novi sub sole applies  also to  this theory, although apparently so modern.  As
early as the seventeenth century some (Chr.  lange, BoreUi) believed  that they had
seen worms in the small-pox pustules. In the present century, Henle in particular has
advocated with great energy the parasitic nature of certain diseases, including small-
pox, in opposition to the chemists.  Gluge, also, as early as 1838, described small shin-
ing bodies, often united in small chains, as integral elements of small-pox lymph. 
ETIOLOGY.
339
great deal, on the whole, since the introduction of vaccination,
is beyond the slightest doubt.  Nevertheless  we pass through
epidemics in Europe (as  for  instance  that  of 1870-71)  which
carry off  from eighteen to twenty-five per cent,, and even more,
of all attacked.
   The  attempt was formerly made to prove that small-pox epi-
demics  return with mathematical accuracy at certain intervals.1
The  truth at the base of this exaggeration is the simple observa-
tion  that,  from an early date up to the present time, fluctuations
have occurred in the recurrence of the disease,  so that periods of
rest  have alternated, with some uniformity, with years of intense
prevalence.   Although we  are not  yet perfectly  clear in our
ideas respecting this sort of periodicity, still certain facts may
be advanced which influence it at  the present  time.  We know
that one attack of small-pox protects a person for life, or at least
for a long time ; and that the  inoculation of  cow-pox exerts the
same effect also,  although it is of shorter duration.  In a popu-
lation, then, where as many individuals as possible  are subjected
to these favorable influences—and in vaccination we have a  sure
means for its agreeable accomplishment—the chances of the dis-
ease taking a firm hold and spreading become extremely slight.
But  when this immunity has lasted a  certain time, and the inocu-
lation of  cow-pox  has therefore  been  insufficiently carried on,
then, of course, the  susceptibility of those previously protected
becomes gradually re-established. To this  number still others
are gradually added, who have  neither passed through the dis-
ease nor  been vaccinated.  In  this manner the fruitful soil is
again provided upon which the contagion  only needs to work to
give  speedy rise to a scourge of mighty dimensions.  If such an
epidemic is finally extinguished, all the predisposed  among the
community have usually been attacked,  and  thereby become
exempted again for a  long  time.  Moreover, the second impor-
tant  factor, vaccination, is  more carefully performed under the
fresh influence of fright which attends the return of small-pox;
and  this likewise protects for a long time  afterwards.  Hence a
long time must elapse before available material has again been
collected for the disease.
     1 A recurrence of the disease every twelve or fifteen years has been stated. 
340
CURSCHMANN.—SMALL-POX.
                         PATHOLOGY.

   A few preliminary words only are  necessary concerning the
limitation and  division of the subject.  Complete accord pre-
vails, at the present time, in reference to the relation  of variola
vera to varioloid.  No one any longer considers varioloid as an
independent  disease,   as was  formerly zealously maintained.
Every one knows that we see nothing further in this affection
than  one of the many forms in  which small-pox  is manifested
according to circumstances.  All  the  remaining "forms"  of
variola, which we shall study more closely as we proceed, are to
be regarded in the same light.
   Concerning  the  relation  of  varicella to variola,  no perfect
unity of opinion has yet been reached.   While  Hebra' s view of
the close connection of both processes was  universally respected
until a short time since, and has its supporters even at the pre-
sent day, authoritative  voices are  again  raised in favor of  their
separation.  In this manual, firm  ground  is taken for the view
that varicella is not a simple modification of variola,  but a dis-
ease sui generis.  The section relating to the disease in question
is written by the most prominent champion of this view ; and we
will content ourselves here  with simply referring to his argu-
ments.

           Symptoms and  Course of the  Disease.

   Stage of Incubation.—From the moment of  reception of the
variola contagion until  the consequent outbreak of the disease,
a certain time always elapses during which the individuals, as a
rule, present no abnormal symptoms, subjective or objective ; or
merely  make some vague, insignificant  complaint. This period
we term the stage of incubation.  Concerning its duration in
small-pox we  are  better informed than in other acute exan-
themata, for the reason,  perhaps, that  it exhibits greater regu-
larity in this respect.
   In the cases where  I have been able to fix the duration exactly,
I found it, in  accordance with  the majority  of authors,  to be 
SYMPTOMS.
341
most frequently from ten to  thirteen days, less frequently four-
teen days or eight to ten days ; and in one case only five days.
   After inoculation of variola,  forty-eight hours elapse before
the commencement of the resulting phenomena.
   A frequent opportunity is  by no  means presented to determine accurately the
period of incubation.  (I was able to do  so but ten times in 1,034 cases.)  Those
cases only are available in this connection in which the individual is known to
have been exposed to the contagious influence but once, and for a short time.  Where
exposure has taken place repeatedly, or for a  long time, correct data for the com-
putation are evidently lacking. I would not care to rely, without further examina-
tion, even upon observations which satisfy this requirement,  provided they were
made during a great  epidemic;  since,  in addition  to  the single  authenticated
exposure, the individuals may, unknowingly,  have been repeatedly exposed to con-
tagious influences  (through healthy persons, articles belonging to patients, patients
in the primary stage, etc.).   Perhaps many of the cases of unusual length or brevity
of this stage, sometimes occupying several weeks, or, just the reverse, a few hours
only, may be explained by-such oversight.

   We do not know whether the manner of infection or certain
peculiarities of  predisposition play  a  part  in the  duration  of
incubation.   We must  not omit to  mention that Ziilzer found
the stage of incubation in hemorrhagic variola to be considerably
shorter (six to eight days in nine  cases) than in pustular variola.;
   Whatever  may take place in the body  during  this  period,
when the infected person ordinarily presents nothing  abnormal,
is yet unknown  to us.   The contagion,  of  course,  does  not
slumber;  certain processes  go  on,  rather,  in  the meanwhile,
which do not  yet give  rise to distinct  symptoms.   In this very
connection, however, it is interesting to  note that in rare cases
certain vague  symptoms of disease, such as languor, pain in the
head  and back, or slight gastric disturbances are observed, even
during the period of incubation.1  Sometimes, indeed, apharyn-
   1 With almost  all of my own patients, from whom a regular history could be
obtained, I have sought on theoretical grounds  for some symptoms during the stage of
incubation; but out of 1,000 cases, in eleven only (about one per cent.) could I authen-
ticate  such symptoms  with certainty.  Scheby-Buch saw the  stage of incubation
accompanied by symptoms in about four per cent, of all his cases.  I am inclined to
regard this large proportion as a peculiarity of the Hamburg epidemic, and believe that
my own figures come nearer the rule.  Buch  was unable to discover any prognostic
indication in the appearance of such symptoms, an observation which I can substan-
tiate as far as my own few cases go. 
342
CURSCHMANN. —SMALL-POX.
 geal catarrh,  with redness and swelling of the uvula  and  tonsils,
 has been noticed in the last days of this stage (Obermeier).
    Initial Stage.—Only in the most infrequent, and  then mostly
 in very  mild  cases, does the  characteristic exanthem  make its
 appearance immediately  upon the  termination  of the period of
 incubation.   As a rule, the outbreak of the eruption is  preceded
 by a more or less considerable space of time, usually associated
 with fever and disturbance of  the general system, which we will
 designate as  the initial  staged   The transition of the stage of
 incubation  into  this  new phase of  the  disease is a  gradual one
 only in the minority  of cases ; and then most frequently in those
 in which the stage of incubation was not free from symptoms of
 disease.   Almost constantly the  beginning of  the initial stage
 can be fixed with a certain accuracy.  Its duration, the termina-
 tion of which is well  marked in the outbreak of  the eruption, is
 tolerably constant.   As a rule, it lasts three days ; although two
 to four days are likewise not unusual.  A still shorter or longer
 duration is far more  rare, and probably  indicative of varioloid ;
 which, in respect to  the  extent and nature  of  its initial stage,
 exhibits  far greater variations  than true variola.

   In forty-two per cent, of all cases in which I could limit the initial  stage accu-
 rately, it amounted to three days; this being, in variola vera, almost a rule.   A
 shorter duration  of this stage was  decidedly more frequent than a longer one;  a
 duration of from one to two and a half days being  found  in thirty-eight per cent.,
 and one of four days or more in only ten per cent, of the cases examined  in refer-
 ence to this inquiry.  Sydenham at times saw the initial stage lengthened  to six or
 seven days ; and de Haen indeed speaks of f ourteen days.  That the initial stage is
 usually lengthened in Febr. variol. sine exanth., and in purpura variolosa, we shall
 have occasion to mention hereafter.
   As for the influence of age upon the  duration of the initial stage, it appears to be

   1 Although no admirer of new nomenclatures, I have,  nevertheless, in  accord with
 Canstatt and Obermeier, thought  it best in this article to drop the expression " Pro-
dromal stage," heretofore in use, which involves false ideas, and to take the liberty to
replace  it by the simple and less pretentious term of  " Initial stage."  The old incor-
rect designation took its rise, as is well known, from  the fact that the imposing erup-
tion was instinctively conceived to be the essence of the disease, and not simply one of
its most important localizations.  As  is  generally known,  it  may be entirely wanting
 {Febr.  variol.  sin.  exanth.), and  it is indeed absent in purpura variolosa, the most
 dangerous form of the disease. 
SYMPTOMS.
343
somewhat shorter in children than in adults.  Barthez and Rilliet found two days
to be the most frequent duration.  In old age, again, the course of this stage is
retarded, just as in certain chronic diseases.

   To draw from the duration of the initial stage precise conclu-
sions respecting the intensity of the subsequent stage, and of the
course of the disease in general, I hold to be unjustifiable in spite
of contrary assertions made here  and there, chiefly upon the
authority of Trousseau.   The passage in  question in Trousseau
reads :' " The longer  the manifestation of variola upon the skin
is delayed, the more harmless will be the affection ; but inversely,
likewise, the more rapidly the eruption is developed, the more
dangerous will be the  disease."   In  what manner  we are to
explain the  origin of this  view, whether, as would  seem most
likely, through the changeable  peculiarities in the character of
the several epidemics, we leave undecided.
  • We notice a far greater variation in regard to the intensity
of the initial stage than in its  duration.  We find this  stage
manifested in  all possible grades and  under  the most varying
forms, from slight and  often wholly  overlooked disturbances
up to the severest picture of the disease, attended with extremely
violent fever.   Isolated cases of death have been recorded in
almost all extensive epidemics,  fatal before a trace of  eruption
had appeared.
   How these differences are occasioned  is not yet  accurately
known ; but individual  peculiarities appear to play no inconsid-
erable role.  It can in nowise  be maintained as a general rule
that the intensity of the initial stage bears a ratio proportional
to the severity of the entire morbid process.   The most violent
symptoms, especially  in sensitive individuals—women and chil-
dren—are not infrequently seen  to eventuate  in a quite  harmless
varioloid.  With a mild onset of the initial stage it may be more
justly predicted that  severe variola will not follow, or only as a
rare exception.
   The usual symptom which distinctly marks the beginning of
the  initial stage is a  violent rigor, or, as  I have observed more
frequently, several chills, usually of slight intensity, repeated at

        1 Med. Klin.  II. Aufl.  German by Culmann, Vol. L, p. 5 and 6. 
344
CURSCHMANN--SMALL-POX.
fixed intervals.  Fever is thus ushered in, usually lasting until
the eruption appears, and in isolated cases of  varying inten-
sity ; but sometimes so severe that in conjunction with the other
symptoms a picture  of  disease is presented severer and more
serious than almost any other to be witnessed in acute affections.
   The  temperature  of the body often  rises  on the first day
to 103°  or 104°  Fahr.,  and  subsequently with comparatively
slight morning remissions, and much more rarely discontinuous,
rises considerable higher, so that on the evening of the second or
third day it frequently rises to 105° or 105i° Fahr., and in some
cases, not the most infrequent, even above 107°  Fahr.*
   The pulse, usually full and tense in the  previously  healthy
individual, generally corresponds in frequency with the tempera-
ture of the body,  so that the curves  of  both  run  approxima-
tively parallel.  Even in full-grown, powerful  men, it is seldom
under 100 ; usually it is from 108 to 120 ;  in women frequently
130 to 140 ; and in children as rapid as 160.   In very rare, and
principally severe cases,  I found  the pulse soft and sensibly
dicrotic,  resembling the condition so frequent in typhoid fever.
   The frequency of respiration is almost always considerably
increased.  The respirations are short and labored; and many
patients  actually complain of dyspnoea;  although  the most
careful  examination  reveals  no  essential  change in the respi-
ratory or circulatory apparatus.   I must  say,  that to my mind
the repression of the respiration  stamps the picture of  a severe
initial stage as somewhat characteristic,  and  it gives  me  the
impression  that its frequency often reaches a  somewhat higher
degree than in other febrile  systemic affections with a similar
temperature of the blood.  Perhaps this  is explicable upon the
ground that in few febrile conditions does  the  temperature of
the blood rise so quickly from a normal  to the  highest  degree,
and that just in this rapid manner of ascent  there is an addi-
tional essential element,  namely, the irritation of the febrile heat
upon the respiratory  centres.

   1 These figures, like nearly all the observations of temperature in this treatise, are
those obtained in the axilla. Sphygmographic observation, which I frequently made,
as might be expected, furnishes nothing characteristic,  but rather the same curves as
are produced in analogous acute general febrile disease. 
                           SYMPTOMS.                      345

    The patients are languid and weak in proportion to the grade
 of  fever, and even the most powerful individuals are hardly able
 to stand out of bed.  While, for example, typhoid-fever patients
 among the lower classes, with temperatures already quite marked,
 are able not infrequently to make their way to hospital on foot,
 patients in a severe initial stage of small-pox stagger as if  drunk,
 and are scarcely able  to  take a few  steps  without support.
 When observed  out of  bed the face often  appears  sunken and
 pale, the features expressionless, the extremities cold, the arterial
 vessels contracted, and the pulse small and extremely frequent;
 so  that many patients, when seen soon after in  bed with a red
 turgescent countenance,  are hardly to be recognized.
    In the majority of such cases the skin feels hot and dry, or is
 covered with a moderate perspiration.  Profuse perspiration con-
 tinuing through  the  following  stage, as generally witnessed by
 Trousseau in the epidemics which  he observed, and which he
 was inclined to regard as a favorable critical event, occur much
 more rarely.1   According to many authors,  and particularly the
 older ones, it  is asserted that this  perspiration  already possesses
 a specific odor ; a fact, if so, of which I have not as yet been able
 to convince myself, in spite of tolerably delicate olfactories.
   Most patients complain of severe thirst.  The lips and tongue
 appear much parched.   The tongue is  usually  covered  with  a
 thick, whitish-yellow coat, and an insufferable fcetor oris is some-
 times already noticeable.
   The appetite is almost always entirely in abeyance.  At the
 same time nausea, gagging, and  actual vomiting are frequent
 as distressing symptoms.   While in most cases vomiting is pres-
 ent only at the beginning  of the initial stage, it continues, in
 others, with great obstinacy through its entire duration,  and is
 often bilious.   In cases where hemorrhagic forms  are  subse-
 quently developed, vomiting and gagging are frequently as obsti-
 nate as in toxic gastritis, or even in obstruction  of the bowels.   I
recollect one  case of rapidly fatal hemorrhagic  variola,  which
was sent to the hospital in the  initial stage with the apparent
  1 In the Hamburg epidemic of 1871, also, this profuse sweating was not so frequently
observed.  Compare Knecht, loc. cit., p. 167. 
346
CURSCHMANN.—SMALL-POX.
diagnosis of intussusception.  In addition to the vomiting, com-
plaint is often made of violent pain  and dull pressure  in the
epigastrium,  and these symptoms appear to be especially con-
stant in hemorrhagic variola.
   Most patients suffer from const ij) at ion, which often continues
during the entire course of the disease, and requires therapeutic
interference.   Diarrhoea without other apparent causes is rare in
adults, though somewhat more frequent in children.
   Headache is among the most constant symptoms, and scarcely
ever  entirely  absent.   It appears,  as a rule, shortly after the
chill, or simultaneously with it; or it may precede  this a few
hours, associated with pain in the back, languor, etc.  It either
continues unchanged during the whole  initial stage, or, as is
more common, gradually subsides as the eruption approaches.
Meanwhile the headache is unusually severe,  often  to such a
degree that even powerful  men, usually of great endurance, are
forced to make  loud  outcries.  Its usual location is the entire
head, and when a particular limited spot is designated, it is usu-
ally referred to the forehead.  Patients describe this pain in the
most  varying manner; as if a  rope  tightly  encircled the head,
or as severe lancinating, throbbing pain,  increasing with every
pulsation.  The face  is usually red and  bloated, the forehead
hot, and the carotids in violent pulsation.
   Towards evening, especially on the second or third day, it is
not rare to hear patients talk incoherently now and then; and
many even fall  into violent delirium, which cannot  always be
considered as alcoholic, although that form may certainly be
included among the  most  frequent occurrences.   Nearly  all
patients suffer from sleeplessness and great disquiet.
   Coma I have seen but once in the adult (in a case terminating
fatally in  the initial  stage), but often in  children.  Convulsive
symptoms are sometimes associated with it, sudden starting-up,
grinding of the teeth, and even complete "epileptiform" parox-
ysms (Sydenham,  Peter Frank, Trousseau,  et  at.).   Sydenham
found this  to occur more frequently than before the outbreak of
other acute exanthemata ; and the observation  appeared to him
of diagnostic value.
   Many patients complain of vertigo; and in sensitive individu- 
SYMPTOMS.
347
als  syncope often occurs  upon  attempts at rising.  Even col-
lapse is now and then observed, and is generally of evil augury.
Pain in the back is a no less striking symptom than headache,
and generally seems to be especially characteristic of the primary
stage of small-pox.  It is by no means as constant as the gastric
symptoms and the headache.  I have observed it in rather more
than half my cases, and in one-third it was so severe that the
patients voluntarily complained of it.  It appears  as though the
pain in the back were found more frequently in variola vera than
where varioloid is subsequently developed.   It is  most constant
and violent in those cases which become hemorrhagic.
   Like the headache, this symptom usually appears just at the
commencement of the initial stage, sometimes a few hours before
the chill, and continues until the outbreak of the eruption.  The
seat of pain is usually in the lumbar region, extending down to
the sacrum, and at  times confined to this region, while it is less
frequently complained of higher up towards the dorsal vertebrse.
Stiffness and contraction of the muscles of  the neck, on the con-
trary,  occurs somewhat more frequently.   When pain  in the
back is present, it constitutes one of the principal troubles of
the patient.  When accompanied, moreover, with drawing, tear-
ing pains in the extremities, as is very often the case, it may be
erroneously attributed to  acute articular rheumatism, especially
in sporadic cases, or the first cases of an epidemic. In pregnant
women the  pain  in the back may be mistaken for labor-pains,
and in those not pregnant  it is often simply  regarded as the
precursor of the speedy appearance of the menses.
   Bronchitis occurs  among  the less'constant symptoms, and is
far more frequent in the stage of efflorescence.  In  patients previ-
ously suffering from pectoral affections there is usually  an exa-
cerbation of their  symptoms, cough and dyspnoea ordinarily
undergoing increase, and pleuritic pains being increased or
appearing anew.
   No important anomalies  affect the heart, if this organ has
been previously unaffected.   In the case of sensitive females and
topers palpitation may occur now and then, although  without
perceptible material occasion for it.
   Not infrequently anginose symptoms occur towards  the end 
348
CURSCHMANN.—SMALL-POX.
of the initial stage.  Swelling and diffuse redness of the tonsils
and soft palate are usually apparent at that time, and, much less
frequently, discrete red spots are already apparent upon these
parts.   Most frequently the  throat  affections occur in cases in
which definitely grouped pustular eruptions are established, later,
upon the mucous membrane of the mouth and pharynx.  Coryza
sometimes appears in connection with the anginose  symptoms,
and with this epistaxis, photophobia, and lachrymation may also
be  associated.  In other  infrequent cases the affection  of  the
mucous  membrane extends  down into  the larynx,  so that  the
various degrees of hoarseness are produced.
   I have directed my attention to the condition of the spleen
in a  large number  of patients in  the  initial  stage (and also
during  the  subsequent course  of  the disease)  without, how-
ever, having arrived at any definite  results.   So  far, I only feel
safe in  saying that I have never been able to detect an enlarge-
ment of the organ in the initial stage of varioloid ; while this has
frequently occurred to me, and often in a marked degree, in true
variola.   In  other cases of  variola vera,  however,  the splenic
tumor in the initial stage1 has been wanting.  I have not suc-
ceeded in establishing any law in  reference  to its  presence or
absence.  The condition of the organ in severe grades of the dis-
ease, however, appears to me to be well deserving of  study; and
more extended observations  on  the  occurrence, beginning, and
duration  of  the  splenic  enlargement  during future epidemics
would prove, perhaps,  a task well worth undertaking.
   When certain  authors speak of an enlargement of the liver as
belonging to the  initial stage, it is, perhaps, theoretically de-
duced from certain post-mortem appearances, to be subsequently,
described.  Here  and  there,  indeed, I  have found  the  hepatic
region somewhat more abnormally sensitive on  pressure, but
never distinctly enlarged as a result of the acute process.
   In the initial  stage the examination of the urine does not
yield anything characteristic.  The urine is usually tolerably
concentrated, according to the degree  of fever;  and the quan-
tity passed in the  twenty-four hours is diminished.  The chlorides
are usually considerably diminished, sometimes to a minimum;
and the other solid constituents are quantitatively proportional 
SYMPTOMS.
349
to each other,  and to the degree  of  concentration.   In severe
cases more or less albumen is frequently to be detected in the
urine, sometimes more than is usually found in similar grades of
fever from otlier causes.   Grounds explanatory of the last symp-
toms are to be found in  the anatomical  portion of this article.
Abundance of albumen is an unfavorable prognostic  symptom.
In cases which  terminated in hemorrhagic small-pox I found
albumen tolerably constantly and early.  Women  not  infre-
quently complain of strangury,  but I do not recollect this to
have been the case with men.
   Special attention has recently been very properly directed to
the condition of menstruation in the initial stage (Quincke, Leo,
Knecht, Scheby-Buch, Obermeier, et al.1).  At the beginning of
small-pox, and especially in  the  initial stage, the menses set in
with striking frequency, whether before their time  or  at the
regular period.   We  cannot help referring  to  the premature
appearance of the menses, a not  infrequent event in other infec-
tious diseases, also to a direct action of the variola process upon
the genital functions, the mechanism of which action is unknown.
Moreover, the  punctual appearance  of the menses is so often
observed in connection with the initial stage (before the beginning
of the eruption), that it  is difficult to regard  this as something
purely accidental.  Obermeier found himself inclined to suggest
this  interpretation : that the period of menstruation was able to
modify the duration of incubation, to cut it short during its later
days, or to  lengthen it,  and thus to exert a decided influence
upon the commencement of the initial stage.
   It is  but recently that attention has been paid  to certain
changes of very great interest and practical importance, which
the skin sometimes undergoes during the initial stage.  They are
the so-called initial (prodromal) rashes.  These have  indeed
been observed before, and some mention of them  is to be found
in medical literature.  But they have  been, in  part, errone-
ously described as independent  forms of eruption,  occurring
simultaneously with that of  small-pox, and in part have  been
   1  Quincke, Annalen der Charite, 1855, Heft I.  Leo, 1. c, page 491.  Knecht, 1. c,
p. 219 and 220.  Scheby-Buch, 1. c, p. 509 and 510.  Obermeier, 1. o, p. 31. 
350
CURSCHMANN.— SMALL-POX.
casually mentioned as insignificant curiosities.   That records of
these exanthems are wanting in the descriptions of the best of
the older authors,  may be  most readily explained by the  cir-
cumstance  that  they occur with very  dissimilar frequency in
different epidemics.   Thus, in 1870-71, there was abundant
opportunity for their  observation almost everywhere;  while in
most other epidemics during  the  present century they have
appeared with comparative rarity.1   From an anatomical stand-
point these exanthems may be divided into two forms : erythem-
atous and hemorrhagic.  The first are either diffuse, and cover
more or less extensive parts, rarely the whole body (" scarlatini-
form  exanthem"), or they are macular or  "measly."   The
hemorrhagic exanthems are composed of extremely, small punc-
tate, often  pinhead-sized, hemorrhages in the epidermis, which
are more or less dense, and at times so crowded together that the
impression of a diffuse redness is produced.  In a large number
of cases the two forms are  combined as petechise upon an ery-
thematous base.   Frequently petechial-erythematous and purely
erythematous  exanthemata  are found at the  same time upon
the various parts of the body of the same individual.
   As a favorite seat of the petechial eruptions we may mention
the lower abdominal region, together with the genitals and inner
surfaces of the thighs.  When the patient lies with his legs in
contact, the exanthem presents the form  of a triangle, the apex
of which is towards the mons pubis, while its base crosses  the
abdomen  transversely in the  neighborhood of the umbilicus
(crural triangle of Simon).   Very often the eruption also extends
along  the lateral  surfaces of the trunk  up to the axillae,  and
from this point it frequently invades the axillary folds,  the  con-
tiguous portions of the  arm, and the pectoralis major  muscle.
In the latter case Simon speaks of a "brachial triangle."
   The erythematous eruptions, both  of macular and  diffuse
form, do not evince such marked preference for particular parts.
They sometimes spread over the greater part of the body.  When
more localized, it is usually upon the extensor surfaces of  the
   1 Beyond a doubt, the greatest credit for investigation of the initial exanthemata
belongs  to Th. Simon, whose articles on the subject,  cited in our introduction, we
especially recommend for closer study. 
SYMPTOMS.
351
extremities,  especially at the joints, and  (according  to  Simon)
with especial preference in the form of a streak starting from the
ankle, and covering the skin over the extensor hallicis  longus
muscle.  In women I have very often seen  a macular initial ery-
thema around the nipples, even in those cases in which no exan-
them was discoverable upon the remainder of the body.
   The time of the appearance of  these  interesting  eruptions,
which imprint something extremely characteristic upon the often
indistinct form of the initial stage, is tolerably variable.  In gen-
eral, however, the second day may be designated as  that upon
which they most frequently make  their appearance.   A later
or earlier advent, however,  is not infrequently observed ; and,
indeed, in certain cases they have been seen to appear as the first
morbid symptom,  before  the initial  chill, at which  time they
were, of course,  of especial diagnostic importance.
   The duration of the initial eruptions is also extremely varia-
ble.   The  erythematous do not last as long as the  petechial,
usually twelve to twenty-four hours; though cases where they
have lasted several  days are not as exceptional.
   For a  long time after the petechial1 exanthemata have dis-
appeared, and often during the entire  duration of  the disease,
their marks remain in the form of very small brownish or bluish-
green spots.  We will  return, later,  to the opinion adopted by
Trousseau and Hebra,  that  these parts remain exempt from the
actual small-pox eruption.
   The frequency of the initial exanthemata is exceedingly vari-
able.  While they appear almost everywhere in certain epidemics,
as, for instance, in that of 1870-71,  they are rare in  other epi-
demics.  In this way only is it to be explained that the keenest
of early observers make no  mention of them.  Were  they more
constant, their diagnostic, and perhaps likewise their prognostic
value would  be  very much increased.  These two points, which
  1 I intentionally use the term "petechial," as applied to these exanthemata, and
endeavor to avoid the expression "hemorrhagic," because the latter might readily
create the impression of a certain malignity of this eruption, which belongs to it only in
a limited measure, and not at all in the sense in which it applies to actual hemorrhagic
Bmall-pox. 
 352               CURSCHMANN.—SMALL-POX.

 in any case are not to be undervalued, will be referred to again
 at the appropriate place.
    The group of symptoms thus far described, as well as the
 special symptoms of the initial stage, may be greatly modified in
 certain cases.   Many of the symptoms described may be entirely
 absent,  while  others may  appear with special severity.  The
 intensity  of the  fever may exhibit  the greatest variation, from
 the slightest grade up  to a severity such  as is attained in few
 diseases.   The initial stage is thus presented under the  most
 varying phases.  We will  here  recall to mind the  fact, that
 neither in the intensity nor in the  mode of appearance of the
 initial symptoms can any indications be found  capable of sepa-
 rating variola from varioloid; and  that  the  severity  of the
 symptoms never  justifies the  certain expectation of variola and
 the exclusion of varioloid.
    The initial stage not only presents itself under the  most vari-
 able guise, but it is apt to terminate in a variable manner.  Even
 the mode  of transition into the eruptive stage is tolerably vari-
 able,  as we shall  see, according to individual idiosyncrasies, and
 especially to  the intensity of the  case.   It does not  always
 progress  to the  characteristic eruption,  but the  disease may
 terminate with the initial stage, even before distinct efflorescence
 becomes apparent.   And herein the  two extremes of small-pox
 meet: the Febr. variolosa sine exanthemate, the most benignant
 form, and the so-called purpura variolosa, the most  malignant
 form, leading to certain death.
     The older authors, especially Sydenham,1 as well as de Haen,
 Peter Frank,  et al.,  describe  the Febr. variolosa sine exanthe-
 mate, and at the present time also cases  are encountered  in
 every epidemic which admit of no  other designation.  The symp-
r toms are  altogether those of the initial stage.   An introductory
 chill, single  or repeated,  is  succeeded by  a  fever of variable
 intensity, often quite severe,  with prostration, pain in the head
 and back, gastric symptoms,  and sometimes anginose difficulty.
 Then, after three to four, rarely  six days' duration of the dis-
 ease,  instead of the expected small-pox eruption, recovery takes
1 Sydenham called this form '' Febris variolosa." 
                           SYMPTOMS.                       353

 place, with rapid decrease of temperature.  Sometimes one or
 the other form of the initial exanthemata appears, of which the
 petechial eruption in  the crural triangle is of especial diagnostic
 value.   If such characteristic changes in the skin are not mani-
 fest, the diagnosis of  variola sine exanthemate, in  an isolated
 case, is  doubtful; and it is  often better,  when  no weighty cir-
 cumstantial evidence is present,  to leave it entirely in suspense.1
 To deny the existence of  this  form,  however, as some do, is
 certainly going too far; and is only  reconcilable with the art-
 less view that the cutaneous affection  substantially represents
 the small-pox process.
    The  purpura variolosa  represents  the worst course which
 small-pox can take in the initial stage.  It leads steadily and
 rapidly  towards death.  Under this title we  understand those
 cases in which the process designated " hemorrhagic diathesis,"
 the nature of which is yet unknown, and which, as we shall see,
 may also appear during  the exanthematic  stage, imprints its
 frightful stamp upon  the disease, even in its initial  stage,  or at
 the end  of it, before even the first rudiment of a  small-pox  pus-
 tule can be  detected.   If this view is firmly held, that purpura
 variolosa is  the initial stage of variola that has  become hemor-
 rhagic, the manifold objections disappear which have been made
 concerning  its relation to  other hemorrhagic and  non-hemor-
 rhagic forms of the small-pox process.  It disposes particularly
 of the doubt, recently revived, whether this form should not be
 withdrawn from the chain of  small-pox processes and assigned
 to a separate position, inasmuch as the anatomical  conditions,
 especially of the internal organs, indicate results different from
 those observed in the remaining forms.   The anatomical varia-
 tions present are explained most readily upon the ground  that
 the hemorrhagic diathesis causes death in another stage, in which
 a different condition of the organs occurs.  The uninterrupted
 transition of purpura  variolosa  into the hemorrhagic pustular
 forms is exhibited in those cases  in which, in addition  to the  pur-
 pura, there are a few actual (hemorrhagic) papules or pustules.
  1 We will here recall the  oft-mentioned though rare cases of Febr. variol. sine
exanth. in pregnancy, where  at times the  birth of a child  covered with variola has
revealed the nature of the previously doubtful maternal disease. Comp. page 9.
          VOL. II.—23 
354
CURSCHMANN.—SMALL-POX.
   Young  and robust persons are attacked with  striking fre-
quency ; a circumstance for which we are unable to offer a plau-
sible  explanation.  The best observers are in accord as to the
fact, and my own experience leads me to agree with them.  I
have also seen many invalids and debilitated persons fall victims
to this terrible  form of the disease;  and drunkards, pregnant
women, or lying-in women succumb most  readily among those
previously healthy.  The initial  stage in these cases usually
begins in the ordinary manner with rigor, headache, very intense
pain in the back, and great prostration.  Very soon (even in
from eighteen to thirty-six hours) a diffuse  scarlatiniform, rarely
macular, redness invades the trunk and extremities, but leaving
the face almost always exempt.  This redness disappears upon
pressure with the finger, and is scarcely  distinguishable from
an ordinary initial  exanthem, and is sometimes suspicious only
by  its  peculiar  intensity.  In  this  erythema,  petechise  and
larger  cutaneous hemorrhages rapidly appear, and vary in size
up to  that of  a silver half-dollar.    They  are  usually  small
and discrete upon  the extremities, and confluent  on the breast
and abdomen in large irregular  figures.  The  face is rendered
red and puffy, the conjunctivae bloodshot, and large black rings
are formed around the eyes, through hemorrhage into the cellu-
lar tissue of the lids and their contiguous parts.   The counte-
nance thus presents a truly frightful appearance, and the patient
is often wholly unrecognizable.   The tongue is usually thick,
with a whitish-yellow coat, and  looks  almost as it might do if
it  had been boiled.  Diphtheritic processes take place in the
pharynx, and a horrible fcetor oris increases the  loathsomeness
of the  entire symptoms.  There is almost always severe pain in
the precordial region, frequent nausea and vomiting of bilious
and often bloody matters, thin bloody stools,  and turbid and
often offensive urine.  With this there usually is a troublesome
cough, with serous and likewise  bloody sputa ; and in women,
particularly when, as is common, menstruation, abortion,  or
lying-in coincides, a violent metrorrhagia continuing until death.
A  suspicious quantity of albumen is almost always present in
the urine before the occurrence of hematuria.
   The temperature in purpuric  cases does not usually attain 
SYMPTOMS.
355
any considerable elevation.   In nearly all cases observed by my-
self I found it but seldom more than 40° C.—104° Fahr.—and that
usually just before death.  Towards the end, the body,  parti-
cularly the trunk, has a blackish or leaden-gray hue.  The intel-
ligence is  unimpaired  during the whole course, usually until
very shortly before dissolution. Only a few patients are fortunate
enough to fall speedily into delirium or coma.  Ziilzer has fre-
quently observed  partial or general hyperesthesia or anesthesia
of the skin,  and  even  paralysis,  especially of  the extremities.
The  course  of  the entire  process is  extremely rapid.   Some
patients die within three days after the beginning of the symp-
toms,  and some even earlier.  According to my observations it
is exceptional for them to survive  the sixth  day.
   Except in the cases described, where the small-pox process is
cut short in one way or  another  during the initial  period, the
patient, after the  expiration of this stage,  enters that in  which
the characteristic small-pox   eruption  appears and develops.
More in the interest  of superficial description than  in  accord-
ance with nature, this period has been again subdivided into two,
gradually merging into one another ;  that of the development of
the  eruption, stadium  eruptionis, and that of  its  blossoming
and maturity, stadhtm foritionis (s. maturationis, s. suppura-
tionis); then follows  (in cases not previously fatal), the stage of
retrogression, the drying of the eruption, and the final fall  of the
scabs, stad. exsiccationis  et decrustationis.  As in the initial
stage, the disease exhibits the greatest variations in  this period
also, in regard to the  manner and  intensity  of its manifestation,
dependent principally upon the grade of the cutaneous affection.
   We shall see  our way most clearly in the multiplicity of these
forms if we first describe the morbid appearances of true variola
as a prototype, and then diverge to the severer forms  on the one
hand, and the varioloid group on the other.

              Regular Course of Variola vera.

   Stadium eruptionis.—-With a  certain regularity,  lacking in
varioloid,  the beginning of the small-pox eruption upon the skin
ensues during, or shortly after, the third febrile exacerbation of 
356
CURSCHMANN. —SMALL-POX.
the initial stage.  The eruption almost always appears first upon
the face and the hairy scalp.  In the latter location, as a matter
of course, it is seen only when the hair is thin.  It appears in the
form of slightly elevated macule, pale red at the outset, more or
less thickly studded, and varying from a millet seed to a pin-head
in size.  The forehead,  eyes, ale of the nose, and upper lip are
usually covered first.  The eruption increases, with  a  sensation
of slight burning and itching, without, however, becoming con-
fluent, even in the severest cases.  At  the commencement, when
the patients are cold or the facial capillaries are contracted from
other causes, the traces  of  the eruption may be temporarily dif-
ficult or impossible of detection ; but it again appears distinct as
soon as the patients become warm.
    Somewhat more tardily, usually a few hours  later,  small red
points appear upon the body and  extremities; not  all at once,
in the majority of  cases, but in such succession  that the back,
breast, and arms  exhibit  the  efflorescence at first, the body
next, and the legs and feet last. The eruption is almost always
less dense upon the trunk than on the face,  and remains so.  The
breaking  out of the eruption in other parts of the  body at the
same time as upon the face, or sooner, is very rare in true variola,
though more frequent in varioloid.  A minute study of the red
points teaches us that they have a certain preference for locating
themselves around the hair follicles and the orifices of the sebace-
ous glands, and often, also, those of the sudoriparous glands; a
circumstance which is  of  importance  for the explanation of a
manifestation to be subsequently described.
    The definite number of efflorescences is usually reached  in
from one  to two days, new points,  meanwhile, making  their
appearance in the spaces between the  older ones.  Occasionally,
however  (and  here again  more frequently in varioloid), fresh
points appear  still later, also  between those further developed.
In their normal course these points pass through certain changes,
until they eventuate in  the complete formation of the pock.   On
the second day of  the  eruption, the fifth of the disease,' these
   1 For the sake of computation we must fix the duration of the initial stage at three
days, which indeed for variola vera is very near the rule. Of course the periods assigned
as the duration of the phases of development of the eruption are likewise not infallible,
but only of average value. 
SYMPTOMS.                      357
spots have become more darkly reddened, enlarged in diameter,
and elevated into distinct papules.   On the sixth day of the dis-
ease (third of the eruption), having meanwhile become more coni-
cal, they present at their apex a vesicle filled with a clear opaline
fluid.  This vesicle enlarges until the seventh or eighth day, when
it is usually  the size of a pea, and nearly hemispherical in form.
As they continue to enlarge, a central depression is found in a
greater or less number of these vesicles.   This is  the so-called
umbilicus, at the bottom of which the opening of a hair follicle
or sweat gland is frequently observed.  This circumstance, as will
be shown in the anatomical division of our subject, is closely con-
nected with the origin of the umbilicus, concerning the nature of
which so much  has been  said.   A large  number of distinctly
depressed vesicles, which have neither a central opening  nor a
hair,  proves, however,  that this is  not a  conditio  sine qua non
for the production of the umbilicus.
   If the vesicle be punctured at a circumscribed point, a small
yellowish drop of lymph  escapes through the opening, by  no
means its entire  contents.  This observation leads to the conclu-
sion that the interior is not uninterrupted, and  that  the fluid is
not entirely  free.  In  fact, anatomical examination,  as will  be
more fully discussed hereafter, reveals a sort of cellular construc-
tion of the vesicle, of course genetically and morphologically, in
a sense somewhat different from that understood by the older
authors who  occupied themselves a good deal with this point.
   Stage of suppuration.—About the ninth day of the disease
the contents of the pustules, which have gradually been growing
turbid from  admixture of pus corpuscles, become  completely
purulent.  The  disease  then enters the  stage  of  suppuration.
Upon complete maturation of the pustule the red edge of its base
becomes considerably broader and darker (halo of the pustule).
The skin in the immediate vicinity undergoes considerable tume-
faction  at  the same time,  and this swelling becomes confluent
where the pustules are  thickly set, greatly increasing  the dimen-
sions  of  the  affected parts.  The head, in particular, attains a
frightful thickness in this manner; the face swells to a shapeless
mass, and the patient becomes absolutely unrecognizable.  Those
portions of the skin of the face where the connective tissue is lax 
358
CURSCHMANN. —SMALL-POX.
as the eyelids and the lips, become very oedematous, even under
the influence of few pustules.   The scalp, according as it hap-
pens to be the seat of pustules, often undergoes a great amount
of swelling, which is so  painful that simply lying upon the occi-
put becomes unendurable, even in the case of patients but little
sensitive.
   We have already mentioned that the eruption is apt to appear
on the trunk and extremities somewhat later than on the face.
In like manner the pustules on  these parts pass through the
metamorphoses described, from one to several days later; but
without any further essential difference.  Consequently suppura-
tion may  be complete  on the  head  while vesiculation is just
commencing in the efflorescence  on the  legs.   Even  when the
eruption on the trunk is perfectly discrete, that on the hands is
frequently very dense.  This occasions, especially upon the fin-
gers, where the eruption readily becomes confluent, extremely
violent pains, in comparison with which all the other grievances
often disappear.   Next to a greater nerve supply, this very pecu-
liar susceptibility is due to the fact that in the skin of the fingers
very contracted sacks are tightly fastened around thin cylinders
of bone, which must be subjected to great tension  by the slight-
est tumefaction, inasmuch as yielding  is impossible.
   When we  recall the suffering  occasioned by a single paro-
nychia, we may estimate the torture of a small-pox patient, who
really has a paronychia on each finger.  The feet, and especially
the toes, are in conditions quite similar  to those of the hands,
except that they are less thickly covered with pustules.  The
character of the  efflorescence differs  somewhat on  the callous
portion  of  the fingers  and toes,  inasmuch  as  the unyielding
nature of the  horny epidermis admits of  but  little or no projec-
tion.  The eruption is therefore usually presented in the  form
of simple, or very slightly elevated, macule.
   Of the different regions of the trunk  the hypogastrium, and
especially the crural triangle previously mentioned, are often but
sparsely covered or quite free from the eruption, even when it  is
very abundant elsewhere.  Many (Hebra,  Trousseau) are inclined
to bring this into a causal connection  with the initial exanthem,
the favorite seat of which is just this locality.  But cases may be 
SYMPTOMS.
359
seen in  every epidemic in which no initial eruption has existed,
and yet the  locality in question  has  remained  comparatively
exempt  from pustules,  so  that it may with  justice be asked:
Have we here really to do  with cause and effect, or do not both
phenomena exist  independently of  one another;  so that the
region in question (from  causes as yet  unknown) is  firstly com-
paratively  protected against the pustules, and  secondly, presents
a favorable soil for the initial eruptions ?   Frequently as the cir-
cumscribed exemption of  the hypogastric region  impresses us,
when other parts are covered with an abundant eruption, it is not
rare, also,  to see this region thickly covered with pustules (even
after a preceding initial eruption).
    Portions of  skin,  upon which mechanical or  chemical irri-
tation has acted, either before infection or during the stage  of
incubation, are usually affected in a very characteristic manner.
Even when the eruption is extremely scanty upon the  remainder
of  the body,  the pustules here are usually very abundant, and
frequently even confluent.

   This behavior of the exanthem comes most frequently under observation where,
shortly before, irritating inunctions or pencillings with iodine have been made, sina-
pisms or drawing plasters applied, or contusions or superficial erosions have taken
place.  A case especially striking in this regard presented itself to me in a man who
had been seriously infested with body-lice before his infection.  He came in with a
varioloid of moderate severity, and exhibited numerous scratches extending over the
whole body, studded with pustules, crowded thickly one upon another like pearls
on a string, and partly confluent.   Many of those  streaks were three to four inches
in length, and, at a distance,  gave  the patient the  appearance of having been
tattooed.
   It would seem easy upon these interesting facts to construct  theoretical conclu-
sions respecting the causes of the density and distribution of the variola eruption in
ordinary cases, but we do not get beyond the preliminary speculations.   Further
observations,  however, and especially experimental research, may  prove of great
value in this inquiry, and perhaps clear up the principal points.   I will not omit to
mention that, according to my experience, the conditions  of the skin in question
give occasion to this peculiarity of the localization of the pocks only when existing
before infection or in the stage of incubation.  On the contrary, when I produced such
conditions of the skin experimentally, in the initial stage (by sinapisms, painting
with iodine, etc.), the eruption was never thicker here than on other localities.

    Almost simultaneously with the appearance of variola upon 
360
CURSCHMANN. —SMALL-POX.
the external integument, small-pox eruption occurs upon  the
mucous membranes in  general, wherever they clothe the  ori-
fices of the various canals of the body.  This eruption is scarcely
ever wanting  on the mucous membrane  of the mouth, phar-
ynx, and contiguous regions.   As the intensity and extent of
the eruption is generally very variable in different cases, so  the
different portions of the mucous membrane are apt to be covered
in variable degrees.   Sometimes  it is the inner surface of  the
cheeks and lips which is  principally affected;  sometimes, and
this is more frequent, the soft palate and tonsils, as well as  the
remaining pharyngeal structures, are severely attacked by  the
eruption ;  and this condition is often followed by secondary
phlegmonous inflammation, with the formation  of abscesses in
the tonsils and arches of the palate.   Thence the eruption  not
infrequently extends farther upon the mucous membrane of  the
pharynx, the  larynx, and trachea (decreasing in density as it
extends in depth).  Hoarseness is then associated with the dys-
phagia, and sometimes even complete aphonia.  Deep ulcers  are
formed  not infrequently in the laryngeal mucous  membrane,
and even perichondritis, with secondary necrosis of the cartilage,
and sometimes acute oedema of the glottis; from the mucous
membrane  of  the trachea the process sometimes extends into
the large bronchi.  The tongue, which alwaj^s appears  heavily
coated, is, in some cases, more or less thickly studded with pus-
tules.  Often, too, it is so strikingly free from them  that, in its
normal size and smoothness, it  contrasts characteristically with
the greatly swollen mucous membrane of the rest of  the mouth.
Cases, fortunately rare,  occur, in which the  parenchyma of  the
tongue  becomes  secondarily phlegmonous,   and the organ is
enormously enlarged, so that often it can no longer  be retained
wholly within  the mouth (Glossitis  variolosa).   The  older
authors, under the influence of ideas based upon the humoral  pa-
thology, busied themselves a great  deal with the salivation  not
infrequently existing in cases affecting the  mucous membrane
of the mouth, and which may be so copious that the secretion
runs continuously from the mouth.   We now either recognize
its origin in parotitis, or regard it simply as a reflex symptom
induced by the inflammatory irritation of the mucous membrane 
SYMPTOMS.
361
 of  the mouth.   From the  pharynx,  the  small-pox process
 usually extends into the nasal cavities,  so that these  passages,
 swollen and filled with scabs, sometimes  become obstructed, and
 breathing may be seriously impeded, especially if the tonsils and
 larynx participate.  The  eruption  has often  been observed to
 extend posteriorly as far  as the orifice of the Eustachian tubes
 (Wendt).   The eruption occurs less frequently upon the mucous
 membrane of the vulva, vagina, and lower portion of the rectum;
 and then it  is later in appearance and comparatively sparse.
 Annoyances  of  these parts, therefore, are  often first instituted
 at the very time when those  of  the mouth  are already on the
 decline.  The urethra is almost always  exempt from  pustules.
 At most they are quite isolated, and close to the meatus.
   The pocks on the mucous membranes are somewhat different
 from those on the skin, as  can be  most readily observed  in the
 mouth and pharynx.  They appear first as whitish or pearl-gray
 elevations upon a  reddened  base ; when  present in considerable
 numbers  the mucous membrane is usually diffusely swollen.
 The efflorescences  do not develop to  such  large and  complete
 vesicles as those on the skin; but, under  the influence of the
 warm and likewise macerating fluids  of the mouth, they very
 soon lose the epithelium at  their  apices,  thus undergoing  slight
 losses  of  substance.  When the pocks are confluent these abra-
 sions usually unite into  larger irregular  excoriations.   As a
 matter of course, the pain, at first only moderate, is considerably
 augmented by these ulcerations.
   We will now glance at the changes in the general condition
 of the patient during the development  and progress of the  exan-
 them.
   With reference, in the first place,  to the febrHe symptoms,
 we  have already mentioned that  the first signs of the  eruption
 usually appear upon the skin, at  the height of  the  third febrile
 exacerbation.   In  mild forms  of  the process  the  temperature
 falls rapidly, and  often declines to  the normal degree at once,
 or falls still lower.  In variola vera it often remains for twelve
 to eighteen  hours, according  to  the intensity of the case,  at
about  the  highest degree reached,  or rises at evening even a
tenth higher.   Then the temperature  undergoes a similar but 
362
CURSCHMANN.—SMALL-POX.
much slighter and more gradual decrease, during which transi-
tion the normal temperature is reached ; not altogether in severe
cases, but quite so in rather mild ones.  The descent of the tem-
perature occurs either in a remittent type, often with consider-
able evening exacerbations (in somewhat milder cases), contin-
uously, the evening temperature being but  slightly higher than
that of the  morning, and  sometimes the  same, or even less.1
The pulse, in uncomplicated cases, corresponds, as in  most of
the stages of the disease, with the temperature, varying between
90 and 112 to 120 beats in the minute.
   The remaining  troubles  of the  patient usually become con-
siderably lessened when the eruption commences.   There may be
almost absolute comfort, the remission usually bearing  a  direct
proportion to the remission of the fever.   The pain in the back,
the vomiting, and the  tormenting  headache moderate or cease
entirely; the delirium abates, and a salutary rest, or even sleep,
ensues.  Such absolute comfort as  is experienced at this time in
varioloid occurs very rarely in variola vera.
   As soon as the contents of the pustules begin to be purulent,
the febrile condition, which had been greatly lessened during the
eruption, again augments in a notable manner (Febr. secundaria
s.  suppurativa).   Sometimes this  suppurative fever  (most fre-
quently in the case of very sensitive persons, women and chil-
dren) is ushered in by a chill, or by repeated chills, and con-
tinues from  three to six, or even  eight days, according to the
severity of the case.   When moderate, the temperature at even-
ing rises to about 39-39.5° C. [= 102-103° F.], and (in the absence
of complications) seldom rises above 40° C. [= 104° F.], and then
only in the severest critical cases.
   The form of the curve in this stage is very different from that
in the initial fever.   It has .chiefly the remittent type,  and daily
variations of nearly 2° F.  are not rare.   The pulse  fluctuates
between 100 and 120 beats in the minute.  The course and height
of the suppurative  fever are,  in uncomplicated cases, directly
dependent upon the cutaneous affection, its intensity also being
greater the  severer the dermatitis.  With  the suppuration the
   1 In severe cases the temperature during its descent does not fall below 100° F. in
the morning, nor below 102° F. in the evening. 
SYMPTOMS.
363
other sufferings of the patient,  who rejoiced too soon in the
eruptive stage, again  undergo a marked  increase.  With con-
siderable augmentation of the pain, and an increasing sensation
of heat, great disquietude and  absolute  sleeplessness usually
again occur.  The headache returns, and the disturbances of the
sensorium, especially delirium, form a complication as fatal as it
is frequent.
   This mental disturbance often attains such decided severity
that it sometimes becomes dangerous both for the patient" and
those in his vicinity, and the most careful watching is impera-
tively requisite, and even  the  use of  the strait-jacket where
attendants are  deficient.  The delirium  is partly occasioned by
the intensity of the fever, but is partly, also, as it seems to me,
dependent on hyperemia of the brain, associated with  the often
colossal tumefaction of the skin of the head and face.  Alcohol,
too, often plays an  important role in the causation of delirium ;
and unmistakable delirium  tremens is well known to belong to
the most frequent complications of variola.  The delirium some-
times continues day and night, and when the patients are con-
scious in the daytime, sufferings of the most varied kind, burning
pains in the face and  in the hands and feet,  affections of the
mucous membrane,  etc., keep them in continuous disquietude
and excitement.
   About the eleventh  or twelfth day—sometimes later,  seldom
earlier—the drying of the pustules—stadium exsiccationis—
begins, and with it  an alleviation of the numerous severe local
and general symptoms.   The desiccation naturally commences
in those parts in which the eruption first  appeared, and there-
fore usually on the face.   Even before  the eleventh day,  and
sometimes as early as the eighth or ninth day,  an exudation of a
viscous fluid occurs upon the surface  of the  pustules;  at first
yellowish and honey-like, and forming, upon further desiccation,
a firm, somewhat rough coating.   The remainder of the contents
of the pustules now dry speedily also, and then small brownish
scabs  are formed,  at first rather  firmly adherent to the  surface.
With the continued desiccation  of  the pustules,  the redness,
I know of a case where such a patient, in his febrile fury, stabbed himself. 
364
CURSCHMANN. —SMALL-POX.
swelling, and tenderness of the skin lessen, the eyes again open,
the nasal passages become patulous, and the countenance resumes
its proper appearance.
   On the trunk and extremities, where desiccation begins some-
what later,  the pustules become  ruptured  in many localities,
their purulent  contents, soaking into the bed and body linen,
undergo decomposition upon the skin  and in the clothing,  and
thus a highly offensive odor becomes disseminated.  Many pus-
tules dry into brown scabs without rupturing.  These are  usually
those  small ones  which are  observed upon certain parts of the
body, e.g., the  extremities,  or in certain cases over almost  the
whole body. On the palms  of  the  hands and soles of  the feet
the drying usually commences earlier than on the remaining por-
tions of the extremities, although the scabs adhere longer.  This
circumstance, as well as their peculiar, flat,  lenticular form,  is
dependent  upon the greater thickness of the epidermis, which is
here  quite horny in the laboring classes.  Just as we  saw the
efflorescence, in the  suppurative stage, according  to the compact-
ness of the epidermis, form only  flat prominences, or none at all,
so, after drying, the scab, which retains the flat lenticular  form  of
the pustule, remains  for  a  long time  encapsuled  between  two
thick layers of epidermis, and is often artificially extracted by
the intolerant patient from beneath the horny layer.
   An often irresistible itching takes the place of the pain at the
period of  desiccation, so that many patients can only with diffi-
culty refrain from scratching.  The general belief, that scratching
renders the resulting scabs less sightly,  is unfounded, except for
such lesions as may possibly be directly due to the scratching.
After the  complete formation of the scabs, at a  time varying  in
accordance with individual conditions of the skin,  and the grade
of the disease, they fall off gradually, and likewise with variable
rapidity.
   After the fall of  the scabs, pigmented and often slightly ele-
vated macula, almost always remain, which  sometimes  become
pale and sometimes extremely hyperemic, under the influence of
changing temperatures.   The whole body of the patient  appears
spotted, and this, unfortunately, is  particularly marked in the
face,  so that the individuals often present  a  truly frightful 
SYMPTOMS.
365
appearance, and are  hardly in a condition to appear in public.
According as the  pocks (as will be more minutely discussed in
the anatomical division) have been limited in their  seat to the
epidermis, or,  as in severe forms, have involved and destroyed
the papillary portion, these macule, after the pigmentation  has
subsided,  may disappear without  any traces whatever, or else
depressed radiated scars remain, which  in time become whiter
than the surrounding skin.   On narrow folds of skin, especially
on the nostrils, and on the nose in general, this loss of substance
takes place in a particularly unsightly manner ; so that the bor-
ders of the ale of the nostrils  often appear  indented,  and  the
ridge of the nose and  its tip appear split and torn.
   As already remarked, a considerable improvement  takes place
in the general condition of the patient with the commencement of
decrustation;  and this continues, in normal cases, until recovery
is complete.  The fever in particular undergoes a decrease more
rapidly or gradually according to the grade of the dermatitis ; so
that the patient is completely free from fever in a short  time.  It
must be asserted here, in opposition to the views of many, that a
subsequent rise of temperature is not occasioned by  the normal
course of  desiccation.  Where this  does occur, and  it  is no rarity
in severe  cases,  it is referable to complications,  especially to
erysipelas, phlegmonous processes, and  more or less  extensive
furunculosis ;  while internal affections are rare at this period.
   When the  patients  are not affected in  this  manner  they
become quiet,  sleep well, have a strong desire for food,  and only
suffer slightly from the constipation which has existed through-
out  the  entire disease.  With  the fall of the scabs, often  also
somewhat later, many patients  lose their hair, especially if the
eruption has been abundant upon the scalp.   The prospect of its
return is favorable where the pocks have  not been  very deep;
while, of  course, this is not the case if the process has involved
and destroyed the hair follicles to any great extent. With many
persons it is only necessary to grasp the hair, and barely pull it,
in order to remove a handful  of loosened locks.  Loss of the
nails is much  more  rare, though more frequent in the  confluent
form about to be described.
   After  regular uncomplicated variola  vera, with a  moderate 
366
CURSCHMANN. —SMALL-POX.
course, five or six weeks usually elapse before convalescence is
complete, while severe cases often last much longer.
   We have now presented variola  vera in the first place as a
prototype, solely, as was remarked, for the  sake of superficial
description.  The remaining forms of the small-pox process may
present certain complications, according to the general condition
of the patient, and especially the intensity of the skin affection.
These variations from the course described may present the most
extreme limits from the severest and absolutely fatal forms  to
the very lightest cases of varioloid, in which but a few small pus-
tules reveal the fact that we are dealing  with a sick patient.
None of these forms are sharply defined amidst the great group
of variolous affections ;  but there  is rather a gradual transi-
tion from one into the other, so  that general  outlines are to be
associated with the most customary designations rather than
sharply circumscribed features.   According  to the individual
tendency of different  authors, more or less  numerous special
forms  are  described in medical literature, and designated with
special names, in part arbitrarily based upon subordinate pecu-
liarities.  We  are neither able nor  desirous  of considering all
these,  and will call attention  at once  to a particularly severe
form of small-pox, the so-called

                      Variola confluens.

   Even the initial stage in this variety runs an unusually severe
course; at all events,  mild symptoms  at this time  justify the
exclusion of confluent small-pox  with tolerable certainty.  The
initial fever is unusually violent, and the eruption in many cases
develops far more rapidly than  in ordinary  cases;  frequently
twelve, or even eighteen hours  earlier.  The spread of the erup-
tion  over the whole body is usually completed more quickly too
than in the other forms, and  often does not  require more than
thirty-six hours.  Indeed cases are not infrequent in which the
eruption is completed almost simultaneously on the face and on
the other portions of the body.  The spots are particularly nume-
rous on the face and hands, and the macule  are in  such close
juxtaposition  on the head, even on the first day of the eruption, 
                          SYMPTOMS.                      357

 that they appear almost confluent.  On the second day the skin
 is already pretty uniformly swollen, and intensely reddened, and
 so thickly studded with large flat papules, that they rapidly coa-
 lesce in large tracts, though individually smaller than those of
 discrete variola.  In the ordinary progress of things suppuration
 speedily follows, and flattened,  irregularly outlined, confluent,
 yellowish-colored prominences are seen upon a darkly reddened
 and diffusely swollen skin.  With the progress of their develop-
 ment these patches run together over still  larger surfaces, the
 remaining  septa  disappear, and  the epidermis is elevated  in the
 form of large flat bulle filled with sero-purulent fluid.  In  this
 manner the entire skin of the face may be converted into a bulla,
 and the patient appears as absolutely unrecognizable as though
 concealed by a mask.1  While  in severe cases  the  pocks may
 completely  coalesce on the face and hands, on other parts  of the
 body they  almost always remain discrete, even though closely
 crowded together, and at all  events never become  confluent
 except  over limited surfaces.
   The   mucous  membranes  in  this form  are  almost always
 attacked with  extreme severity, so that the condition of  the
 patient, which  was in other respects deplorable, becomes thereby
 aggravated  to an unbearable  degree ; indeed, in some cases,  this
 complication is  the  immediate  cause of  a fatal termination.
 Upon the mucous  membrane of  the mouth and throat the erup-
 tion is usually  confluent, and even diphtheritic. Affections some-
 times ensue which may spread over the soft  palate,  the tonsils,
 the posterior wall  of the pharynx,  and  thence into the  nasal
 cavities.  The  above-mentioned glossitis variolosa, if  it occur at
 all, is most apt to  make its appearance in confluent small-pox.
 The  larynx is  attacked with marked severity in almost  every
 case, the affection often eventuating in the formation of submu-
 cous abscesses, necrosis of the  cartilages, and acute oedema of
 the glottis.  While in the other forms of variola the conjunctiva
 either remains  entirely free from the exanthem, or is affected in
 but a moderate degree, in this  variety it is beset with points
 of efflorescence in great numbers,  which unfortunately  some-
   1 The comparison is frequently made—and it certainly is true of a few cases—that
the face looks as if it were covered with a parchment mask, or sprinkled with sand. 
368
CURSCHMANN. —SMALL-POX.
times lead to purulent forms of keratitis with perforation.  The
affection in the buccal cavity is often accompanied by inflamma-
tion of  the  parotid glands,  probably depending upon an exten-
sion of  the inflammatory  process along Steno's duct.  A very
annoying  symptom  also  is a  severe salivation,  which  is fre-(
quently aggravated on account of the violent pharyngitis which
renders  deglutition almost impossible.
   The  gravity of the derangement of the general condition
corresponds to the severity of the local manifestations.  Promi-
nent among the symptoms of  the general derangement is fever,
which is here characterized by great severity.  The temperature,
which, as we have seen, attains an  extraordinary height (106°-
110° F.) in the initial  stage, falls very slowly after  the appear-
ance of  the  eruption, and only very  slightly.   It remains until
suppuration at 103°-104° F., and then again rises even higher than
before.  Violent delirium is of very common  occurrence in con-
fluent small-pox, and not infrequently coma takes place.   Fur-
thermore,  a vast number  of complications are  peculiar to this
variety of the disease :  inflammations of the serous membranes—
especially pleurisy and pericarditis—pneumonia, both croupous
and lobular, the latter ensuing upon the violent and obstinate
bronchitis which but few patients who suffer from  variola con-
fluens escape.  Many persons are tormented by violent, uncon-
trollable vomiting and retching, and in some epidemics, accord-
ing to older authors,  especially obstinate diarrhoeas are observed,
which, beginning in  the initial stage, last throughout the entire
disease.   In the  majority of confluent  cases a  considerable
degree of  albuminuria is  present, which is fully accounted for
by the changes which take place in the renal parenchyma, and
which will be described under the division of pathological anat-
omy.
   The  integument often  presents,  besides  the variolous erup-
tion, certain other severe affections, the most prominent of which
are multiple abscesses, extensive phlegmon and erysipelas, and
even gangrene in those places where the confluence is most pro-
nounced.  •
   The  mortality in confluent variola is  of course  enormous.
The patient may succumb  at  any stage  of the disease.  Fre- 
SYMPTOMS.
369
quently they pass  through the entire torment and suffering pre-
ceding the period  of desiccation, and  finally  die in  this stage
from exhaustion or from the complications.  More rarely death
is preceded by marked symptoms of pyemia, which occur now
and then during every extensive epidemic.  In still other cases
deaths take  place at an earlier period in the  course of the
disease, sometimes even in the  stage of  eruption, following ady-
namic symptoms  with  an extremely  high  temperature (107°-
109° F.).  The older  pathologists regarded the latter as a special
form, under  the name  of  "variola typhosa seu adynamica."
It is  hardly possible to conjecture under just what  circum-
stances small-pox  assumes a typhoid character.   This condition
may,  however, ensue in the discrete form of the disease also.
   If confluent small-pox terminates in recovery, the convales-
cence takes place very slowly, and is usually  interrupted by
various sequele, among which the above-mentioned  cutaneous
complications (particularly furunculosis) play an important part.
   In the stage of  desiccation  large coherent scabs are formed in
the confluent patches, which for a long  time remain firmly adher-
ent to the skin, while beneath them suppuration of  the papil-
lary layer, which is  always markedly implicated, generally con-
tinues for some time.  After the scabs  have  fallen off, deep
losses of  substance  are left behind in the cutis, giving rise  to
extremely  ugly scars which,  in  the face especially,  often pro-
duce  permanent and very unsightly disfigurements.   Permanent
alopecia is also a not infrequent sequel of confluent small-pox.

              Variola Hemorrhagica  Pustulosa.

   We have already seen that, in consequence  of hemorrhagic
diathesis,   the small-pox process may  prove fatal  even in the
initial stage.   But aside from  this form, which is known as pur-
pura  variolosa,  hemorrhagic symptoms may  also occur  at
almost any time in the stage of efflorescence, and in order to
distinguish this group of symptoms  from purpura variolosa
the term variola hemorrhagica pustulosa may be emploj^ed.  It
will be at once seen that this nomenclature is rather for the sake
of convenience than  designed to express any essential difference
          VOL. H.—24 
370
CURSCHMANN. —SMALL-POX.
between the two  affections.  The cases observed  in  every epi-
demic where  extensive hemorrhages of  the skin and internal
organs  occur, in  connection  with a few sanguinolent abortive
pustules, form a connecting link between the two forms.
   The  characteristic hemorrhages into the pustules in the hem-
orrhagic form of variola take place under various circumstances.
It occasionally happens  that the papules  become hemorrhagic
immediately after they are formed, or even at the moment that
they are developed ; in other  cases the papules first become vesi-
cles, and the  change then  occurs in the contents  of the  latter,
and in  still other cases the hemorrhage first takes place in the
pustules, after the}^ have  attained nearly their ultimate form
and  size.  Again,  a  great  diversity is  manifested in  that the
eruption sometimes becomes  hemorrhagic over the entire body,
with  petechie and ecchymoses appearing between the spots  of
efflorescence, or the larger  portion only of  the  eruption may be
so affected, or the half only, or even but a small portion of it.
The interesting modification where extensive hemorrhages occur
in the skin during the initial stage, and the patient lives long
enough  for simple (non-sanguinolent) pustules to develop be-
tween the hemorrhagic spots (Reder, Hebra's Handbuch), I am
unable to vouch for from personal observation, nor, as it appears
to me, can the majority of recent observers.
   The  most  frequent  of all these forms is that  in which the
pocks become hemorrhagic after  they have attained about the
size of  a lentil.  In  these  and in the rest of  the hemorrhagic
cases, the hemorrhage does not occur all at once, but by degrees.
I have  almost invariably noticed that the  hemorrhages  begin
upon  the  lower extremities,  and on this  account I  deem  it
advisable,  whenever  there  is  apprehension  of this unfortunate
event, by all means to examine this region very  carefully.1
  1  In this connection I would suggest the following caution : Cases occur, especially
in delirious patients, who leave their beds and run about, where pustules of the lower
extremities become filled with blood  in a purely mechanical manner (as happens in
ulcers of the leg under similar circumstances). That this occurrence is no dangerous
symptom, is proven by the normal course of the disease subsequently.
  I remember distinctly the case of a waitress, twenty-one years old, who entered the
hospital in the suppurative stage of a very moderate attack of discrete variola, which 
SYMPTOMS.
371
    In connection with the  hemorrhagic eruption  livid spots of
 variable extent appear upon those mucous membranes which are
 exposed to the atmosphere, as well as upon the external integ-
 ument.  The mouth and throat, with the parts adjacent, are prin-
 cipally affected.   Very often diphtlieritic affections,  especially
 of  the pharynx,  velum palati,  and tonsils, are present, which
 infect the neighborhood of  the patient with an extremely offen-
 sive odor.  Moreover, in many cases there is a peculiar spongi-
 ness  of the gums, which  are  of  a dirty hue and  readily bleed,
 closely resembling what we see  in scurvy.  Next in frequency
 come  the  hemorrhages  from the nose, lungs, rectum,  kidneys,
 and uterus, already described  in  connection with purpura vario-
 losa.   In females  metrorrhagia  is  commonly present, being
 consecutive  either to  childbirth, abortion, or  menstruation.
 Scarcely less frequent are hematuria, conjunctival hemorrhage,
 and bloody stools, while bloody expectoration and hematemesis
 are  somewhat  more  rare.   Sometimes but a single one of these
 symptoms occurs,  and as  regards their intensity and persistency
 cases differ in a very great degree.
    The general  condition is often considerably disturbed  from
 the very beginning. But neither from the character nor intensity
 of the symptoms is it possible to predict with any certainty the
 subsequent development  of the  hemorrhagic form.    The  con-
 stancy and unusual intensity  of  the pains in the  back appear,
 however,  to be somewhat characteristic, as has been mentioned
 in connection with purpura.  When a post-mortem examination
 reveals extensive hemorrhage in the renal pelves and in the renal
 and retroperitoneal tissues, it is very natural to  refer these pains
 to the h}^peremia of these parts which has obviously existed.
 Frequently the initial stage is marked  by an exceedingly violent
 fever, while in  the eruptive period, and, in fact, during the entire
 subsequent course, the  temperature remains comparatively low.
 Cases are seen, especially in aged persons, or those debilitated

 was running a perfectly normal course, on whose feet and legs, up as far as the thighs,
 nearly all the pocks appeared to be filled with blood. Under the influence of a slight
 delirium potatorum, and being poorly attended, she had been rambling about, out of
 bed, as we were informed, almost the whole of the day and  previous  night.  The
accompanying card of admission exhibited the ominous diagnosis, " variola nigra." 
372
CURSCHMANN.—SMALL-POX.
from other causes, in which the bodily temperature during the
entire course scarcely runs above 102° F., or even fails to reach
that.  When the fever is very intense at the beginning, it often
remains of a high grade until death occurs.  The curve of tem-
perature in variola hemorrhagica bears scarcely any resemblance
to the typical  curve  of the  common  variola vera.  The pulse
very early exhibits a considerable frequency, which is in contrast
with the relatively low temperature of the body.   Where exten-
sive hemorrhages have taken place from  internal organs,  and
continue until death, we often observe a rapid fall of the tem-
perature (to 81° F., or even less) just before the fatal termination,
while, at the same time, the frequency of the pulse is increased
to 140-160.
   The course pursued by the hemorrhagic small-pox is  usually
more  protracted  than  that of  purpura variolosa, but almost
always quite as fatal.   The cases which terminate in  recovery
are extremely rare, and where one does occur, only a few pus-
tules, or at least not all, become hemorrhagic, and these usually
at a relatively late period.   The absence or  slight  degree  of
hemorrhage in the internal organs may also be a  favorable sign.
Should  a  patient have the rare fortune to survive, the convales-
cence is very slow, and for a long time  accompanied with
evidences  of extreme inanition.
   The special etiology of this form of variola hemorrhagica is
quite as obscure  as that of purpura variolosa.   Somewhat  in
contrast with the latter, the pustular form occurs more frequently
in older persons,  usually in those over  forty  years of  age.
Weak, sickly persons and convalescents,  as well as pregnant
women and those in  childbed,  appear also to  be particularly
predisposed to this form.

                         Varioloid.

   From the severe forms of small-pox which we have thus far
considered, let us now turn to the varying phases of its mild
course,  which  are  included under  the  name  of  Varioloid.
(Variola modificata seu mitigata).  The opinion that varioloid
is a special disease, differing in its nature from variola vera, has 
SYMPTOMS.
373
long since been  given up.   It  is  generally  conceded at the
present time that varioloid  is nothing more  than a form of
small-pox with a milder  course  and a  shorter duration, and
this view being accepted it is readily seen that between varioloid
and variola vera no absolute line of distinction can be drawn.
During every  epidemic of any  considerable  extent a  number
of cases are found which show a transition from one to the other
form,  and which,  even when we  have followed  their entire
course, leave us in doubt as  to whether we shall call them cases
of "variola" or "varioloid.1'  The quantity  or quality of the
eruption is as far from  being a good criterion in determining the
nature of the affection as the  presence or absence of the suppura-
tive fever, which some  consider as decisive in this respect.  The
latter does not even depend entirely upon  the intensity of the
disease, but  upon personal peculiarities, and particularly upon
the sensibility of the person attacked.   As  regards the peculiar
conditions under which varioloid occurs, it is  important in the
first place to  observe that many  persons are  only attacked by
this form, on account of a naturally slight susceptibility to the
small-pox contagion.   We find,  accordingly,  frequent mention
made  of  cases in  which  the disease runs  an extremely  mild
course.  A circumstance which has a still greater  influence upon
the occurrence of  varioloid  lies  in the fact of  the individual
having had a previous  attack of variola, or in recent times this
influence  is generally due to vaccination.   One attack of true
variola, or likewise of vaccinia, protects most persons completely
from  the  action of  the small-pox poison for  a  certain though
variable  length of time, but  the longer the period that  has
elapsed since the termination of  the protective process,  the less
will the influence  of the latter  be.  Thus individuals, whose
immunity from the disease has in this way become impaired, are
capable of withstanding the contagion of small-pox to only  a
limited extent, and consequently undergo a modified form of
the disease, namely, varioloid.  At the present time vaccination
exceeds by far all other agencies in  the production of varioloid,
and under  its in'licence this form has become very much more
frequent than informer times.
   A prominent characteristic of varioloid is, that it exhibits 
374
CURSCHMANN. —SMALL-POX.
far greater variations and " irregularities" than variola vera,
in  respect to the duration and course of its stages and  the
character of its symptoms.  This is manifest even in the initial
stage.  The widespread opinion that  this is always milder than
the initial stage of the variola vera, when asserted in this positive
way,  is decidedly incorrect.  To be sure, in very many cases it
is mild, and at times almost devoid  of symptoms; but, on the
other hand, the most violent initial symptoms, with intense fever
and marked disturbance of the general condition, are  observed
by no means infrequently in quite insignificant cases of vario-
loid.   The length of the initial stage appears often to be less
than  in variola vera, lasting sometimes only two  days, or even
but one.  But  more frequently a decidedly protracted duration
is observed, and in  this respect a certain lack of uniformity is
evinced, in contrast with variola vera, in which this  stage, as we
have  already seen, lasts three days with scarcely an exception.
When the initial fever is  present,  the curve of temperature
undergoes a sudden and very rapid descent either just at  the
outbreak of, or  more frequently after, the appearance of  the
eruption.  Thus by the end  of the first, or at the commencement
of the second day, the bodily temperature has reached the nor-
mal degree, or  even  gone below it.  From this time the tempera-
ture usually remains normal, and only occasionally at the com-
mencement of suppuration it again undergoes a slight elevation,
which,  however,  seldom  lasts  more  than  twenty-four hours.
This elevation  of temperature is not  so much the result of the
intensity of the disease  as  it is due  to individual irritability,
especially in the case of women  and children, and other deli-
cate persons.   During the  period of  desiccation I have never
observed febrile excitement unless complications were present.
   The initial  exanthemata which were mentioned above have
been designated by many of the older authors (Trousseau) as a
group of symptoms belonging  to varioloid; but  so general an
assertion is incorrect. It comes nearer the truth if we except the
petechial eruptions,  whose favorite seat, as already mentioned,
is in Scarpa's triangle.  As regards the non-hemorrhagic, purely
erythematous eruptions, both macular and  diffuse, it may be
stated  that they precede varioloid almost exclusively.   I do not 
SYMPTOMS.
375
remember of having observed, out of a large number of cases, a
single one  where severe variola  vera developed  after a well-
marked simple initial erythema.  It appears to me, in fact, that,
as a rule, the development of the pocks is less, the more extensive
the initial eruption  is.  Viewed in this light the purely erythe-
matous initial exanthemata prove to be of decided prognostic
value.  Where they are well developed we may predict, in spite
of the severe disturbance of the general system, that with great
probability the form  of  the disease will  be  mild, while, after
well-marked petechial exanthemata,  variola  vera will nearly
always ensue, and not infrequently the confluent variety.
   The true varioloid eruption presents  a comparatively great
diversity with  regard to  its mode of  beginning, form,  arrange-
ment, and distribution. In contrast with variola vera, which is so
regular in this respect, the eruption does not always begin in the
face,  but often upon the trunk,  or simultaneously on various
parts of the body.  The length of  time from the beginning to the
completion of the eruption  is also very variable.  Sometimes all
the pocks  appear simultaneously, or in such rapid succession
that their definitive number is reached far earlier than in variola
vera.   At  other times late consecutive crops appear, so that,
together with  far-advanced pustules, we  may have  incipient
spots,  papules,  and vesicles, and  occasionally on a surface of
small extent all the various stages of development of the  erup-
tion may be seen side by side.  Moreover, the form and degree of
perfection which the pocks finally attain often differ upon  the
same individual.
   The structure of the varioloid pustules does not vary essen-
tially from that of  the  other forms.  Frequently the pocks
develop quite as perfectly as those of variola vera, even to  the
implication of the papillary layer,  together with the formation,
ultimately,  of  distinct and deep  scars, so  that then  the only
marked point of difference between them  and the pustules of
variola vera lies in their smaller number.  But more commonly
the eruption either does  not pass through all the stages,  but
recedes at  an early period (abortive  pocks),  or else  it passes
rapidly and imperfectly through the several phases of develop-
ment, resulting in the production of more or less dwarfed forms, 
376
CURSCHMANN.—SMALL-POX.
The abortive retrogression of the points of efflorescence may occur
at various periods.  Aside  from those cases where  the entire
disease terminates at the outbreak of the initial exanthem, there
are also other, though rare, instances  where merely papules  or
vesicles develop, and which are soon followed by desiccation.
   When  the pustules of varioloid run  through all the stages, the
ordinary small red spots develop  into conical, somewhat acu-
minate papules, at the summit of which little vesicles with clear
fluid contents appear, often within twelve hours (reckoning from
the beginning of the eruption).  The vesicles rapidly increase in
size, till they are as large as a lentil.  Sometimes they are umbili-
cated,  and sometimes not, according  to  their location  and ar-
rangement.  Towards the end of the third, or by the fourth day,
their contents are often slightly purulent, and a red areola makes
its appearance, usually without any noticeable swelling of the
surrounding skin.    Frequently the contents of  the vesicles do
not become wholly purulent, but remain rather of a sero-purulent
character.  Such pocks are usually of small size, often  not ex-
ceeding that of  a  pin-head or a lentil.  They exhibit a broad
red areola, ordinarily of an elliptical form, whose long axis usu-
ally corresponds with the cleavage lines of that portion of the
skin.
   From the fifth to the seventh day (of the eruption), and even
earlier in  less-developed forms, desiccation begins.   This often
proceeds irregularly as regards its occurrence in different regions
of the body, corresponding to the irregularity in the appearance
of the eruption.  The majority of  the pustules  merely  dry up
without previously bursting,  forming brownish crusts,  which are,
thinner and smaller than those of variola vera; inasmuch as the
skin is not very  deeply involved, the scabs fall off sooner than in
true variola, sometimes leaving slightly pigmented hyperemic
spots, which, however, soon entirely disappear.
   Variations  in  the degree of development  of the  points  of
efflorescence are often exhibited upon  the same individual, and
where  this is the case the pocks on the  face are usually much
more  perfectly developed than on the remaining parts of the
body.  Likewise with regard to the number of the pocks different
cases  present extreme variations, sometimes a single pustule  or 
                           SYMPTOMS.                       377

 but a very few appearing, with almost  no disturbance of the
 general condition (Variolois localis), and  again a tolerably copi-
 ous eruption may occur (especially on the face), accompanied by
 a mild suppurative fever.
    The great variability manifested by varioloid has led to the
 description and special denomination of a vast number of forms,
 for which the older  authors were especially famous.   We find,
 for example, a variol. acuminata, globulosa, crystallina, lympha-
 tica, fimbriata, verrucosa,  siliquosa,  miliaris, pemphigosa, etc.,
 while in the majority of instances there was no occasion for any
 special nomenclature.1  We will only allude to a few of these
 terms, which designate certain of the commoner or more interest-
 ing modifications.
    By the term variolois verrucosa we understand that class of
 cases where the eruption does not develop into large, well-formed
 pustules, but remains in the form of solid, conical papules, which
 have a small vesicle at  the summit  containing  fluid.  When
 this has dried, and the scab has fallen off, the solid part of the
 pock remains for a long time, having the  appearance of a warty
 (verrucous) elevation of the skin.  This unsightly, though easily
 treated form, most frequently occurs on the face.
   The form which is characterized as variolois pemphigosa is
 comparatively rare.  In this the small pustules develop into large
 irregular bulle (without the fanlike meshwork), with sero-pur-
 ulent contents.
   A somewhat commoner variety of the eruption is termed
 variolois miliaris.   Here,  upon diffusely reddened and some-
 what swollen  portions of  skin (more  generally in  the initial
 exanthemata), yellowish  vesicles of the  size of a  millet  seed
 ("miliare") are developed, which progress no further, and fin-
 ally disappear by simply  drying up.  This form  is  more  fre-
 quently  seen in conjunction with completely developed pocks
 than alone by itself.
   Where the retrogression of  the pustules occurs  in such a
manner that  the  contents  are absorbed,  leaving  empty shells
   1  Hebra, as a matter of curiosity, presents a still greater number of  forms, with
full reference to his authority for them.  Looking at this host of terms, we can scarcely
ridicule the Chinese, who have described forty varieties of small-pox. 
378
CURSCHMANN. —SMALL-POX.
which contain only air, the  term variola  siliquosa is nsed.
This rare form generally occurs upon the trunk and the extrem-
ities.1
   The mucous membranes  are also very frequently affected  in
varioloid,  although  decidedly less  upon an average  than  in
variola.  Difficult deglutition, hoarseness, stoppage of the nose,
photophobia,  and lachrymation are quite common  occurrences.
At times simple  redness  and swelling  of the membrane is pres-
ent, without the  characteristic papules, but in other cases these
may likewise  be thickly set.   Secondary phlegmonous processes
are extremely rare  in varioloid, while the diphtheritic changes
observed in malignant forms  of  variola scarcely ever occur  in
genuine cases.

                 Complications  and  Sequelae.

   There is no well-marked  dividing line between the complica-
tions  of small-pox  and  the local affections belonging  to  the
disease.  In describing these complications, therefore, we shall be
obliged frequently to repeat previous remarks, and also to omit
some  things which are described by other writers.
   We have already cursorily described the most important com-
plications  due to changes in the  skin.  The multiple abscesses,
which are  often formed during the period of desiccation in con-
fluent small-pox, and in severe cases  of the discrete form, are
especially  painful and  protract  the  convalescence.  Extensive
phlegmonous  processes also, and  erysipelas,  are not uncommon,
but gangrene  of  the skin is  rare, except as an occasional occur-
rence in the scrotum.  In the face, besides brownish  spots  and
cicatrices, acne pustulosa of an obstinate type may continue for
a long time.  It  is  produced  by narrowing  or occlusion of the
ducts of the sebaceous glands.
   The nervous  system  and the  organs  of special sense are
   J In this connection I would mention a form of variola vera which is sometimes
described and said to be very malignant.  It is called Variola emphysematica, for the
reason that from the very outset air instead of pus is contained in the vesicles. This is
said to be due to septic influences and almost without exception terminates fatally.  I
am not acquainted with this form from personal experience. 
COMPLICATIONS AND SEQUELAE.
379
especially prone to be the seat of complications.  We do not
include here the temporary  delirium  common  to most severe
cases, but rather those more permanent psychical disturbances
which continue after the disease has run its course.  Anatomical
lesions of the brain are not  common,  although meningitis and
acute oedema  sometimes  occur.   Sometimes we observe symp-
toms  pointing to  the  existence of circumscribed encephalitis,
such as aphasia, of which I  have myself seen two cases.   Par-
alysis of the extremities and  of the bladder, from complications
existing  in  the spinal cord, have  been frequently observed.
Westphal has studied these cases carefully, and shown  that
the symptoms are often due  to numerous circumscribed foci of
inflammation in the gray and white matter of the cord (myelitis
disseminata).  Whether epilepsy  ever occurs as a real sequela of
small-pox, I think very doubtful.
   In the eyes we see, in most severe cases, conjunctivitis.   This
is often made more severe by the cedema of the lids, the inability
to open  them, and the consequent retention of the secretions.
Pustules may be formed on the palpebral conjunctiva, and more
rarely on the ocular conjunctiva and  cornea.   Some observers,
as Gregory,  deny their occurrence in  the latter situations.  If
the cornea does become diseased, perforation, iritis, and suppura-
tion of the  globe may follow.  In hemorrhagic small-pox hem-
orrhages in the retina sometimes  occur and produce sudden
blindness.   It is worthy of remark that Hebra, in o,000 cases of
small-pox, only saw eye complications  in one per cent.
   We have  already  noticed  that the  hearing often suffers.
Chronic suppurative otitis, and caries of the bones, with  par-
tial or complete deafness,  are not  infrequent.
   In  severe cases ulceration of  the mucous membrane of the
nose, followed by adhesions, may take  place,  but it  is a rare
occurrence.
   The joints may become  diseased.  Painful  swellings,  effu-
sions of serum and pus, inflammation of the cartilages and of the
bone itself may occur.
   Bronchitis accompanies almost  all cases of  small-pox, and
can hardly be called a  complication.  In  some cases,  however, it
leads to catarrhal pneumonia and pulmonary phthisis.  Croup- 
380               CURSCHMANN.—SMALL-POX.

ous pneumonia is not infrequent, but death from sudden oedema
of the lungs is rare.  Pleurisy and pericarditis are tolerably fre-
quent complications.  I have seen  ulcerative endocarditis in one
case of confluent small-pox.
   Diphtheritic inflammation of the soft palate and pharynx is
said to be a frequent complication ; but I believe  that confluent
pustules with irregular ulceration are often mistaken for it.
   Severe inflammation of the larynx, ulcers of its mucous mem-
brane,  perichondritis,  and necrosis of the cartilages produce
chronic hoarseness, or even complete aphonia.  We have already
mentioned that death  may be caused by acute oedema  of the
glottis.
   Inflammation of the salivary glands seems to have been more
frequent in earlier epidemics  than  in  those of later years.  The
older authors considered it to  be  an  unfavorable symptom.   I
have seen it but  seldom, and then it seemed  to  be of little
moment.
   Complications from  changes in the abdominal viscera are not
frequent.   I have never seen peritonitis, unless produced by  a
local cause.  Sometimes there is persistent diarrhoea, which may
continue after the disease has  run its course.  Sydenham  speaks
of a  variola dysenterica.
   After  severe cases  of  small-pox the patient is left much
exhausted and weakened for a long time.  In  such  cases I  have
seen slight oedema entirely due to the anemia.   In other cases
dropsy may be due to chronic nephritis, but this is  in my expe-
rience a rare sequela of variola.
   More  has  been said concerning pycemic symptoms  in the
period of suppuration and desiccation than is warranted by facts.
I have  seen  two  unmistakable cases of this kind,  in which
abscesses in the liver and lungs were found at the autopsy.

                         Anatomy.

   Our knowledge of the real nature of small-pox is  still unsatis-
factory.  At the present moment the fashionable parasitic theory
is invoked to explain the nature of small-pox,  as of many other
diseases.   Inasmuch as opinions in regard to the etiological sig- 
ANATOMY.
381
nificance  of  inferior  organisms  in diseases  have  not  yet been
thoroughly  sifted,  we  cannot  now,  even  provisionally,  accord
them an altogether definite value in the case of small-pox.

   The present aspect of the question demands, however, an incidental exposition.
One of the most valuable papers on this subject is by F. Cohn.1  He found in the
fresh lymph, taken from vaccine and small-pox pustules, small rounded bodies pos-
sessed  of  molecular  movement and  measuring less than .001 mm.   When these
rounded bodies were watched for some time, keeping them at a uniform temperature
of 35° C, they became segmented and formed small chains and masses.  Cohn con-
sidered these bodies, which had been already described by Keber,2 as organisms of
the lowest grade.  He named them Microsphaera, belonging to the family Schizo-
myceta, and to the group Bacteriacia.   He considers these organisms to be probably
the vehicles of contagion, certainly not mere chance products.
   Besides Keber, other authors before Cohn, namely, Klebs,3 Erismann,4 and Wei-
gert,5 had seen these same bodies in the contents of the pustules.  Ziilzer (1. c.) lays
particular  stress upon the presence of these bodies in the wall and lumen of the
blood-vessels.   He says that in the "fulminant form " of variola they infiltrate the
walls of the small arteries, and may even fill completely the smallest arteries of the
skin.   He  believes that  these living thrombi are active causes in the formation of
purpuric spots and pustules.  The  arteries and the tubules of the kidneys are, he
says, filled with the same bodies, while in the other viscera they are seldom seen. In
the blood  also, during the first three days of the disease, he has demonstrated the
microspheres (but only in purpura variolosa).
   These observations render it undoubted that bacteria are constantly found in vari-
ola, but they hardly warrant the conclusion that they  are the vehicles of the conta-
gion.   Nor do I think that experiments made by inoculation with filtered lymph,
as done by Chauveau,6 much increase the probability of this.   There  are too many
technical difficulties in  the way of  such experiments.   A more convincing  method
would be to follow the growth and development of these bodies during the succes-
sive stages of the disease, and to observe the relationship between their growth and
number and the intensity and varieties of the disease.
   For the present, therefore, we consider all such observations merely as material
which may be of use  at some future day to assist in elucidating the  problem of the
contagion of small-pox.

   Until very lately our  knowledge of the changes in the skin,

   1 Virch. Arch., Bd 55, S. 229 ff.
   2 Virch. Arch., Bd. 42.
   3 Handbuch der path. Anat., S. 40.
   4 Sitzungs bericht der K. Accad. der Wissenschaft.  Math, naturw.  Kl.  1868.
   & Centralbl. 1871., No. 39.
   ' Compt. rend., T. 66, p. 359. 
382               CURSCHMANN.—SMALL-POX.

and of the development and structure of the pustules, was very
uncertain,  and it is  evident that this depended largely on  the,
tendency of earlier writers to  theorize instead of accurately ob-
serving.
   In regard to the changes in the skin, and particularly to  the
development and growth of pocks themselves, which is the next
matter for our consideration, great obscurity has prevailed until
quite recently.  The rambling discussions  on rather common-
place matters—such  as the umbilication  and the so-called false
membrane  of the pock, which have lasted almost to the  present
time, show that the fault of the earlier investigators  was, a pro-
pensity to generalize rather than simply to observe.
   The study of the different forms of eruption which appear in
variola and varioloid shows, as already stated, that there  is no
real difference in their structure and development.   On the con-
trary, the  different  varieties are only due to  modifications in
their manner and duration of development and of retrogression.
The  first trace of the pock, a simple  red spot, is produced by a
circumscribed hyperemia  of  the papille, which (according to
Barensprung)  is  continued through the entire  thickness of  the
cutis.  The papule which is formed in place of this red spot is
produced by a peculiar change in the  epidermis.  It differs from
otlier papules, which  are due  to circumscribed swellings of the
cutis.x  if we examine a papule, we find the cells of the rete Mal-
pighii enlarged and granular, especially the cells situated between
the outer epidermis  and the layer of cells immediately covering
the papille.  By the  swelling of these cells the outer layer of
epidermis is pushed up, and flat,  solid papules are formed.   The
next step is an exudation of clear fluid from the papillary layer;
this  fluid separates the altered cells spoken of above, and lifts up
the outer epidermal  layer.  Thus the papule is converted into a
vesicle.  The  vesicle then becomes larger by the continued exu-
dation of lymph and the swelling of more cells.  The exudation
does not, however, separate the  altered  cells from each other.
They are separated in small groups, which are compressed by the
exudation into membranous  and fibrous forms until they look
   1 It is still undetermined how far the papillae  are changed in the formation of the
pustules, whether in all cases or only in the severe ones. 
ANATOMY.
383
like a  network  infiltrated with lymph and filling up the cavity
of the  pock.  The  epithelial  character of this network can be
made  out  in every part,  notwithstanding the  alteration of  the
cells by pressure  and  maceration.  This view of the real nature
of the network in  the pustules is one of  the most important
advances  in the histology of  small-pox.1  While these changes
are  taking  place  in the  epidermis,  the  corresponding  papille
become swollen  and infiltrated with  serum, while their blood-
vessels are dilated, tortuous, and surrounded by new cells.
  a Outer layer of epidermis. ». Middle layer, c Cylindrical cells of the rete Malpighu restmgimmedxate.y
upon the papilla,  Reticulated cavity of the pock, containing pu-orpuscles, with the ep.hehal Re-
work, e. Purulent infiltration of the middle layer of the epidermis.

    In many pocks, as has been said before, soon after the forma-
tion of the vesicle, and advancing with it, a central depression or

   • ThisviewTf"the^tructure of the network was first demonstrated by Ampitz and
Basch  (Virch. Arch., Bd. 28, p.  337 et seq.), whose essay opened the path to a cor-
rect understanding of  the anatomy of the pock.   Barensprung, as is  well known,
attributed a partitioned structure only to confluent pocks, while denymg it to the other
varieties  The older authors considered this reticular structure to be fibrinous. 
384
CURSCHMANN.—SMALL-POX.
 "umbilicus" is seen.  This central depression usually occurs in
 pocks in which a hair follicle or the duct of a sweat gland can be
 seen.  Since the epidermis is continuous with the sheath of the
 hair follicles, when a vesicle is formed about  such a follicle  its
 centre will be held down, and the surrounding epidermis will be
 more elevated than in the portion continuous with the hah- folli-
 cle.   The ducts of the sweat glands have  the same relation to the
 epidermis and act in the same way in holding down the centres
 of the vesicles (Rindfleisch).   In a pock where  there is neither
 hair follicle nor  sweat  gland it is evident that some more resis-
 tant portion  of the tissue may in  the same way hold down the
 centre of the wall of the vesicle. Auspitz and Basch explain the
 formation of  the umbilicus in another way.  They teach that the
 periphery of  the  pock swells more rapidly and  thus becomes
 more voluminous than its centre.
   When the pustule is fully ripe the umbilicus disappears by
 the stretching or destruction of the tissue which held down the
 centre of the vesicle.   When desiccation commences, an umbili-
 cus may again appear from  the earlier drying of  the centres of
 the pustules.  This also takes place in pustules in which there
 was before no umbilicus.
   When the pock is fully ripe, the  subjacent papille, which
 were  at first  swollen,  become flattened.   This  condition may
remain after the scabs  have fallen off, and then give rise to shal-
low depressions in the skin.   But these depressions are quite
 different from cicatrices.   In confluent variola, sometimes in the
 discrete form, and  occasionally in varioloid, the papille beneath
the pustules  become involved in the  inflammation.  Pus cells
accumulate in these papille, compress the blood-vessels, and pro-
duce  partial  or total necrosis of the tissues.  This condition is
indicated  by  great swelling  and congestion of the skin around
 the pustules.   We find in the latter, besides pus  cells, fragments
of the destroyed papille.  But some portions of the papille may
still  remain alive,  and thus hold the scabs on for a long while.
The  extent  of the ulcers formed  by this destructive  process
determines the extent and shape of the cicatrices.
   Of the different varieties of pocks  enough has  been said in
treating of varioloid.   I have convinced myself that in "variola 
ANATOMY.
385
verrucosa"  the wart-like  papules are  produced  by an early
growth of the papille.
   There is nothing specific in the formation of the hemorrhagic
pocks.  Erismann,1 Wagner,2 and Wyss 3 have proved that the
bleeding has no connection with the hair follicles.   The  hemor-
rhagic eruption is seen in different individuals in different stages
of development, according to the period of  the disease at which
the patient  has died.   The only difference  between the hemor-
rhagic pocks and the ordinary forms, in corresponding stages of
the eruption, is that their contents are bloody instead of serous
or purulent.   Besides the hemorrhagic pustules we usually find
larger or smaller hemorrhages in the tissue  of the cutis.  In the
less  severe cases the papille  are  sometimes free  from  hemor-
rhages, and the latter are only found in the layer beneath; while
in the severer forms all the layers of the cutis and  even the sub-
cutaneous fat may be infiltrated with blood.  This last condition
belongs especially  to purpura variolosa, in which the patient
dies before  a pustule is formed.   In this variety of variola the
hemorrhages reach their greatest  size, they may  even be con-
tinuous over a large part  of the surface of the body.  Wagner
has rendered it probable that the bleeding does not take place
by rupture  of the blood-vessels,  but  by  transudation  of the
blood through their walls (diapedesis).  No definite changes in
the walls of the vessels to account for these changes have yet
been discovered.
   The  internal  organs undergo  different  changes in variola
vera,  in purpura variolosa, and in variola hemorrhagica, as Pon-
fick has very recently shown.
   On the mucous membranes in variola vera, we find specific
pustules, diffuse  purulent infiltration of the middle epithelial
layer, and catarrhal, croupous, or diphtheritic inflammation.
The intensity and extent of the changes are often in direct rela-
tion to the changes in the skin, and not infrequently are devel-
oped before  the latter.
   Those mucous membranes are most frequently attacked which
          1 Sitzungsbericht  der Wien. Ace. 1868.
          2 Die epithelialen Blutungen.  Arch, der Heilk.  Bd. IX.
          • Arch. f. Derraat. und Syph.  Bd. III., S. 529.
      VOL. II.—25 
386
CURSCHMANN. —SMALL-POX.
are the most exposed to contact with the air.   In the nose the
process is  almost constant, and is  hardly less so in  the  mouth
and tongue.   The tongue is frequently deprived of  its epithe-
lium over  large tracts.   The tonsils, the  soft palate,  the pos-
terior nares and pharynx, and the lower ends of the Eustachian
tubes are frequently swollen and infiltrated with pus.1
   In the trachea pustules are found as far down as  its bifurca-
tion, and at this point they are often  numerous, sometimes con-
fluent.  The pustules may even extend down into the bronchi of
the second and third order (Wagner).  The mucous  membrane
is, at the same time, swollen, bluish-red, and often partly covered
with a dirty-gray matter.   The  small  bronchi exhibit various
grades of catarrhal inflammation,  and usually contain yellowish,
bloody, or thin mucus.  Catarrhal pneumonia is also of frequent
occurrence, and may be succeeded by pulmonary phthisis.
   In the  oesophagus pustules are  formed, but almost  exclu-
sively  in its upper portion.   In the stomach and intestines we
only find catarrhal inflammation and small hemorrhages.  In
the  intestines  there  may be  ulceration  of the follicles,  with
swelling of the mesenteric glands.   It is very  doubtful  if real
pustules are ever formed in the stomach and intestines,  although
they have been described by the older authors (Robert,  Epi-
demic  in Marseilles).  They are only seen  in the lowest part of
the  rectum, close to  the anus.   In the vulva  and vagina there
may be pustules  or  diphtheritic  inflammation.   In the urinary
bladder pustules  are never  found,  nor in the  urethra,  except
close to the meatus.
   True pocks on serous membranes are fables belonging  to
antiquity; but congestion,  inflammation, and ecchymoses are
common.  The pleura is frequently affected in this way, menin-
gitis occurs rarely, peritonitis probably not at all.
   The liver,  the kidneys, and  the spleen  undergo morbid
  1  L. c.  This author gives us valuable data regarding the condition of the ear in
variola, based on 168 cases.  He found morbid changes in ninety-eight per cent, of this
number. Pustules were present almost always on the external ear, less often at the
beginning of the cartilaginous portion, while in the bony portion and tympanum only
hyperemia  and swelling were found.  These latter changes were also sometimes found
in the middle ear, where pustules are never formed. 
MORBID ANATOMY.
387
changes  of  great  consequence.   Concerning these changes we
find somewhat various statements by different authors.  We
find sometimes granular swelling of the liver and kidneys, some-
times acute fatty degeneration resembling  that  produced by
phosphorus poisoning.   In other  cases  these organs  may  be
found unchanged, either when death takes place so early that
there is  not time  for degenerative changes, or so late that the
cells have passed through the condition of granular swelling and
returned to their  normal condition.  Fatty degeneration is the
more advanced condition in which granular  swelling may termi-
nate.  In pustular variola the bile is usually pale and thin.
    In the hemorrhagic variety of pustular variola I have found
such degenerations of the liver, kidneys, and spleen as the rule ;
but in purpura variolosa Ponfick has shown that the absence of
these lesions is a well-marked characteristic, a fact confirmed by
my own observations.   In this variety of variola the  liver is
usually of normal size, of  dark color, and of very hard consis-
tence.
    In variola vera the spleen is much swollen in those who die
early in the disease, and its pulp is soft and of a light red color.
In those who die later it is more frequently unchanged.  In the
purpuric variety  the spleen  is  small, hard, dirty,  dark red,
sometimes with large white or yellowish follicles (Ponfick).
    It seems to me wrong, on account of these differences in the
condition of the abdominal viscera in variola vera and purpura
variolosa, and on account of the hemorrhages, to  class these two
varieties as distinct diseases.  In  purpura variolosa the patients
die very early, so that we  see lesions belonging to a very early
stage of the disease.  If we obtained autopsies  in an  equally
early stage of the disease in variola vera we should see different
conditions from  those to which we are accustomed.
    When  the liver  and  kidneys are far  advanced in fatty
degeneration the walls of the heart are yellow, flabby, and brit-
tle.  But in purpura variolosa the organ is  contracted, firm, and
brownish red (Ponfick).
    The brain and spinal cord are usually unchanged, although
sometimes they are congested and oedematous.
    In the hemorrhagic form of variola, besides the lesions men- 
388
CURSCHMANN. —SMALL-POX.
tioned, we find large or small hemorrhages in nearly all the vis-
cera.  We  find ecchymoses in  the serous  membranes,  and
bloody fluid in their cavities.  Yery large hemorrhages may be
found in the loose connective tissue of the mediastinum, of the
pelvis, beneath the peritoneum and beneath the capsules of the
kidneys.  Some authors are inclined to connect  the hemor-
rhages about the kidneys and beneath the peritoneum with the
pain in the back, which is so severe in some patients.
   We may find hemorrhages in almost all the mucous mem-
branes.  They occur throughout the respiratory passages, from
the nose down to the bronchi.   They  are  also found in the
pharynx,  oesophagus,  stomach,   colon,  and rectum,  less fre-
quently in the ileum (Ponfick).
   In the mucous membrane of the uterus and Fallopian tubes,
and in the parenchyma of the testicles hemorrhages are of fre-
quent occurrence.  The kidneys  usually escape, but the pelves,
calyces, and ureters are almost  constantly the  seat  of  large
extravasations of blood.J
   The liver, spleen, brain, and spinal cord are seldom affected in
this way.   In the lungs infarctions may be found, but  are  usu-
ally of small size.
   Ziilzer describes  as  of frequent  occurrence  hemorrhages  in
the sheaths of the nerves, and explains in this way some of the
nervous symptoms.   Wagner, however,  did  not find this lesion
either frequent or extensive.

                         DIAGNOSIS.

   The diagnosis of variola seems, a priori, a very easy one, and
in well-marked cases with pustular eruption it is so.  But in the
less severe  cases,  especially  in varioloid, when the eruption is
scanty and  undeveloped, the diagnosis  becomes more difficult.
The  disease may then be confounded with syphilitic eruptions
and with acne pustulosa, especially when there is no history of
the previous condition of the patient.
   Even more difficult, and  sometimes impossible,  is the diag-
nosis during the initial and eruptive stages of variola.   And yet
1 Compare Unruh, Arch, der Heilk.  Bd. 13, S. 289. 
DIAGNOSIS.
389
during these early stages the diagnosis is very important, for the
patient is able to communicate the disease to others, and a failure
in detecting it may be followed by disastrous consequences.
   It is of great assistance to find out, in the first place, whether
variola prevails in a given locality, and whether the particular
individual  has been inoculated, properly vaccinated,  or  has
already had small-pox.  We  should also inquire whether the
person has been exposed to contagion.  Of the manifold ways in
which  such an exposure is possible, we have already spoken in
detail in  the section on etiology.
   If now we pass to the consideration of the first stage of variola
we  shall find that  in many cases,  especially  of varioloid, the
early symptoms are so vague, undetermined, and various that no
diagnosis is possible until the characteristic eruption appears.
   If we pass by these irregular forms, and consider the more
intense and regular  symptoms of the early stages, such as are
usual  in variola,  and frequent in varioloid, the  question arises,
How is the diagnosis to be made 1
   In such cases I believe that by a careful observation and con-
sideration of all the circumstances,  we can often arrive at a defi-
nite opinion.   There is only one pathognomonic symptom, and
that is present only in the  smaller number of patients.   It con-
sists in the already mentioned  hemorrhagic initial  exanthema,
situated  principally in  the triangle of the thigh.  The  macule
and diffuse erythemata  without hemorrhages are not of them-
selves characteristic.  Measles is the disease with which variola is
most frequently confounded,  and there is even an erroneous idea
that there  may be a combination of  these two diseases.   Let us
then see  what are the points of difference between them.
   In measles we find, in the early stages, catarrh of the bronchi,
conjunctiva, and nose, a condition which only comes on in a later
stage of variola.  The appearance of the skin during the  stage  of
eruption may, taken by itself, give  rise to doubt.  We may lay
down the rule, that  in measles  the  macule are,  from the begin-
ning, larger than those of variola, and that  they are developed
almost simultaneously on the back and face ;  while in variola
they begin on the head,  and descend step by step downwards  to
the back.  But this rule is only of  much value in the regularly 
390
CURSCHMANN.—SMALL-POX.
developed cases.  Much more important is  the degree of fever.
In variola, during the initial  stage, the temperature ordinarily
rises to 104.9°-105.8°;  while in measles during the corresponding
period, it seldom exceeds 102.2°-104°.   It is also characteristic of
variola that soon after the eruption appears the temperature falls ;
while in measles it continues the same,  or even rises.   This pecu-
liarity distinguishes variola from the other exanthematous fevers,
and especially from scarlet fever.  In this latter disease the early
appearance of  sore throat  helps in the diagnosis.   In  purpura
variolosa, however, the intense red color covering the back before
the hemorrhages appear, may closely resemble scarlatina.  And
even after the hemorrhages appear it may be doubtful if the case
is  not an  example of hemorrhagic scarlet  fever.  And the case
may be still further obscured by the uncertain character of the
temperature in purpura variolosa.
   The diagnosis between exanthematous typhus and variola is,
in their early stages, sometimes very difficult.  The course of the
fever during  this period is hardly a guide at all.   We have in
both diseases the  same rapid increase of temperature, and often
the same maximum.  But when  the eruption appears the tem-
perature falls in variola and does not in typhus.
   In like manner the first attack of relapsing fever may resemble
the initial stage of variola.  The  course of the fever may be the
same in both diseases until the eruption appears.   Sometimes,
also, there may be doubt whether a case  is one of intermittent fever
or of the initial stage of variola.   But in such a case the lapse of
twenty-four hours is usually sufficient to remove the uncertainty.
   In the case of typhoid fever mistakes are less frequent.  The
rise of temperature in typhoid fever is regular and characteristic.
Enlargement  of the spleen occurs in both diseases.
   The increased frequency  of respiration, the chill,  and the
fever in the  initial stage  of variola may  perhaps mislead and
make one  think of pneumonia.   But in  such a case physical
examination will remove all  doubts, except in cases of circum-
scribed hepatization without physical signs.
   The initial stage of variola is not  likely to  be  mistaken for
acute miliary tuberculosis.  In the latter  disease the ophthal-
moscope may assist in the diagnosis. 
PROGNOSIS.
391
   Meningitis may  resemble quite  closely the  initial stage of
variola.  In  both diseases  we have intense headache,  vertigo,
delirium, coma,  and convulsions.  Basilar meningitis, however,
may be recognized by the local symptoms belonging to it.  Cases
of meningitis of the convexity extending over both hemispheres,
and without  localized  symptoms, may give rise to much doubt.
Cerebro-spinal meningitis may usually be distinguished by close
examination, and by its etiology.
   From the different forms of ephemeral fever the initial stage
of variola can usually be distinguished by the higher tempera-
ture.   But in the irregular forms of varioloid the  distinction
is sometimes difficult.  In the same way, the  early stages of
varioloid may be mistaken for acute catarrhal gastritis; while
in a regular case of variola such an idea would hardly occur.
   To mistake  the  severe  lumbar  pain in the early stage of
variola for simple lumbago, is an error almost unpardonable.
   In pregnant women we must  take care not to confound the
pains belonging to the initial stage of variola with labor pains ;
and, on the other hand, we must not forget that abortion  and
miscarriage are frequent results of variola.

                         PROGNOSIS.

   The prognosis of  variola must be considered in several different
aspects.  We must  first regard the  disease in general—its varie-
ties and its  different  epidemics—then the  separate  cases  and
symptoms.
   It is well known  that small-pox was formally more dangerous
and more dreaded than it is at present.  In former centuries no
disease was more dreaded, or destroyed more victims.   It  has
been calculated that in the last century from 7-12 per cent, of all
the deaths were due to variola.  At  the present day, in countries
where vaccination is  regularly  practised, the  proportion  has
fallen to 0.7-1 per cent.,1 and would probably fall even  lower if
revaccination were more systematically and generally practised.
The best proof  of this is, that among infants, in places where
   1 In Prussia, according to Engel, the mortality from small-pox in the years  1816-
1860 was 0.7 per cent, of the entire mortality. 
392
CURSCHMANN.—SMALL-POX.
 vaccination  is  compulsory,  the  mortality  from  small-pox is
 almost nothing, while before Jenner's discovery, on  an average,
 one-tenth part of all the children died from this disease.  It is
 only after the age when the protection of the first vaccination is
 exhausted, that, at the present day, we see the disease becoming
 formidable.  When, at  this age, revaccination is compulsory, as
 in the Prussian army, its prophylactic effect is as great as that of
 the first vaccination.
   But though, at  the present day, the mortality from small-pox
 is so much diminished, yet we find differences in the intensity
 and extent of different epidemics.  That  even in the worst epi-
 demics the mortality is so much less than formerly,  depends on
 two conditions, both  intimately  connected with  vaccination.
 First,  the immunity of  vaccinated children from the disease;
 second, that among adults varioloid is much more frequent, and
 even variola runs  a   milder  course.  From  varioloid  alone
 healthy adults hardly ever die.   The few deaths which do occur
 from it are in persons weakened by age or  disease.   Since, then,
 the mortality is almost  exclusively dependent on the  existence
 of variola vera, we may state that  in general the mortality of a
 given epidemic  is less in proportion as the number of varioloid
 cases is greater.
   In variola vera the mortality is  still very great; in some epi-
 demics (for example the one in 1870-71) equal to that of former
 years.    In some  epidemics the  mortality is increased by the
 larger  number of  hemorrhagic  cases.  The well-marked cases
 of this variety are usually fatal.   Purpura variolosa is always
fatal,  while variola hemorrhagica pustulosa,   in  exceptional
 cases when the  hemorrhages occur late and in small quantity,
 may terminate favorably.

   Of 850 patients under my care 235 suffered from variola vera.  Of these 46 were
hemorrhagic, and all died.  Altogether there were 99 deaths, about 42£ per cent.
If the hemorrhagic cases are excluded, the mortality of the other varieties was 28£
per cent.  This is a high percentage, and was due to the character of the patients__
hospital cases from the poorer classes.  An average percentage can only be given
approximative^;  it varies between 15 and 30 per cent.

   At  the present  day  some  epidemics are severe,  others are 
PROGNOSIS.
393
mild.  The  principal reason for the periodical outbreaks of the
disease is the neglect of general vaccination and revaccination.
   The mortality is usually less at the end of an epidemic than
at its  commencement.  But the maximum of the extent of  an
epidemic, and the maximum of its  mortality do not always cor-
respond.  More frequently the mortality is greatest at the time
when the extent of the disease begins to decrease.
   The season of  the year  has some influence  on the course of
epidemics;  they are generally more dangerous in summer than
in winter.   Fortunately we  no longer have many opportunities
of confirming this experience of the older observers.
   The prognosis of individual cases depends on a great  variety
of conditions.  The  age  of  the patients is  of much importance.
In infancy  the mortality is enormous.   Even  including chil-
dren up to ten years old,  the mortality  in the epidemics ob-
served by me  was as high  as fifty-eight per cent.  In  old age
also  the prognosis is worse, even as early  as the fortieth year.
In adult life the prognosis is worse in women than in men, for in
the former  pregnancy,  childbirth,  abortions, and  miscarriages
are dangerous complications, and often develop the hemorrhagic
form of  the disease.  It is thought by many that the mortality
is somewhat greater in women  than in men, independently  of
these complications.   In men, however, intemperance adds  to
the fatal cases. Drunkards are very apt to  suffer from  hemor-
rhagic variola, and delirium  tremens is a very fatal complication.
In other cases the viscera are  so much altered by chronic alco-
holism that the patients die from degrees  of the disease which
other persons  pass  through  safely.   Overworked and   badly
nourished persons also seem to me more prone  to die from this
disease.
   The constitution and physical condition of the individual also
have their effect on the prognosis.   Robust and healthy persons
will  naturally  endure a much greater degree of disease than
those enfeebled by scrofula, syphilis, or  other chronic  diseases.
Persons  who  are convalescing from acute diseases,  such  as
typhus, pneumonia, etc., die easily.
   The question next arises how far we can  regulate our prog-
nosis by the character of the disease and the separate symptoms. 
394
CURSCHMANN.—SMALL-POX.
The severity of the initial symptoms is not a safe guide for the
prognosis.  This stage has no direct relation to the intensity of the
succeeding stages.  Sometimes a very severe initial  stage passes
on into a light form of varioloid.  If, however, the initial stage is
mild, we may reasonably look for a moderate eruption.  Yery
severe and continued lumbar pain is usually considered a  bad
symptom, and it does in fact frequently precede the hemorrhagic
form of the disease.  In my opinion  the initial exanthema does
furnish a prognostic  sign of  some importance.  The assertion
that it  only  precedes varioloid is not  true.  According to my
experience it is rather the pure erythematous eruptions, after
which we may expect varioloid or light variola.  The number of
the pustules is then frequently in inverse proportion to the
intensity of the initial exanthema.  On the other  hand, if the
initial exanthema has the  hemorrhagic form, especially if it ap-
pears in the triangles  of the thigh and arm (axilla), then we may
almost always expect variola vera.
   In the stage of full development the  character of the pus-
tular eruption determines the prognosis.   Varioloid is very sel-
dom fatal; confluent  variola  is very dangerous; semi-confluent
variola, or discrete variola with very numerous pustules, are of
doubtful result.  Any one with large experience of small-pox
must be convinced that many patients die simply from the  der-
matitis.  In the confluent and other severe forms death often
takes place during the stage of suppuration.  In other cases the
patients  survive until the period  of desiccation, and  then die
from inanition, or from furunculosis, erysipelas, or some other
severe complication.
   Next to the lesions of the skin those of the mucous mem-
branes are of the greatest importance in prognosis.   Diphtheritic
affections, oedema of the glottis, bronchitis, and pneumonia are
all dangerous complications.   In infants the pustules of the
mouth and pharynx may seriously interfere with swallowing.
   Symptoms of grave cerebral disturbance, delirium, convul-
sions, and coma are dangerous.  They may induce sudden death
with apparent collapse.
   The frequent complications of small-pox add to the mortality
of the  disease according to their character and intensity.   We 
TREATMENT.
395
must never neglect to watch closely for them, as the patients fre-
quently do not complain.
   When variola terminates in recovery, the duration of the dis-
ease varies with its intensity and with accidental relations.  In
varioloid  the  duration varies from  a  few days to a month.
Variola vera,  even in  the  milder  cases, hardly terminates in
recovery before five to  seven weeks.  The duration of  the con-
fluent, semi-confluent, and severe discrete forms can hardly be
reckoned beforehand.  The numerous complications and sequel e
protract the disease  even as long as several months.   Many
patients, without any severe  local  affections, are so prostrated
that their recovery is very slow.  This is said to be especially
the  case with  the hemorrhagic patients, although in  my own
experience these latter cases all died.

               TREATMENT AND PROPHYLAXIS.

   The office of the physician in regard to small-pox is manifold.
Besides the treatment of the disease in its various stages and
varieties there is much to be done in the way of prophylaxis.
   Against  the  spread of small-pox we possess a  certain and
reliable barrier in vaccination, by the use of which the disposi-
tion to the disease can be almost entirely destroyed.
   We will  speak first, however, of the special treatment.
   Are we able to exert any influence on the disease in the early
stage preceding the eruption ?  Is it possible in infected persons
during the stages of incubation and invasion to cut short the dis-
ease or to modify its course ?  Many attempts have been made
to answer these questions affirmatively, but as yet without much
result.   The first idea was vaccination, and this was employed
by some in the ordinary way;  by others subcutaneous injections
of vaccine lymph have been made, it is  said with good results.1
I must, however, advise great skepticism regarding these asser-
tions.  Of the subcutaneous injection of lymph I have no experi-
ence ;  but that ordinary vaccination  during the stages of  inva-
sion and incubation cannot stay the disease, has  been proved to
me by  chance observations and direct  experiments.  On the con-
1 Furley, Lancet, May 25, 1872. 
396
CURSCHMANN. —SMALL-POX.
trary, I have seen, in cases in which vaccination was practised
after infection with variola, vaccine pustules and small-pox pus-
tules  developed side by side.  It is,  in my opinion, very doubt-
ful whether vaccination can even render the course of the  dis-
ease milder.
   The old attempts to cut short the  disease by sweating, vomit-
ing, purging, blood-letting, etc.,  are hardly mentioned  at  the
present  day.  On the contrary,  such  remedies are  used with
caution, even for the relief of symptoms.
   The  assertion lately made (Stiemer), that by large doses of
quinine given during the stage of  invasion the course of the  dis-
ease can be  shortened and  modified,  is  contrary to my large
experience.
   We  can do nothing during the stage  of invasion  except to
regulate the condition of the patient  and  treat  special symp-
toms.  The patient should be kept  in a large, well-ventilated
room, at a constant temperature of 60°-67° F.   During exten-
sive epidemics the large number of patients may render this  im-
possible.  There is  still a popular idea that  in small-pox  and
the other exanthemata there is some special  virtue in keeping
the patient hot  and sweating, and we may sometimes find diffi-
culty in overcoming this prejudice.   The patient should be kept
quiet in bed and given  easily digestible food.   Pure water is
the best beverage, but lemonade, acid and mucilaginous drinks
and Seltzer water, with or without milk,  may be given.  High
grades of fever may render necessary the use of quinine, or digi-
talis,  or of cooling baths or sponging.  If  the headache is severe
and the face flushed,  iced compresses  and ice-bags usually afford
relief.  Pieces of ice and Seidlitz powder may be of use to relieve
the vomiting and retching.   When these are not effectual I have
seen good results from the use of aq. amygdalarum and hypo-
dermic injections of morphine.
   When  the eruption appears, the measures to be adopted  will
vary according to the form of its appearance.
   The  milder  forms of  varioloid usually demand no interfer-
ence, and in some even the patient hardly needs to be kept in
bed.   In severe  variola, on the contrary, the eruption itself, the
symptoms, and the complications demand our attention. 
TREATMENT.
397
   It is unnecessary for us to speak of the specifics which from
antiquity to the present day have been advertised and forgotten.
The  last of these specifics is  the antiseptic,  "parasite-killing"
medication, for which carbolic acid is the fashionable agent.1
   The methods of treatment proposed for the eruption are num-
berless.  They are especially directed to the eruption  on the
face.  Some endeavor to treat  the separate  pustules.   An old
plan, handed down from the  Arabs, is to open the pustules and
evacuate their contents, and  this plan  still  has its advocates ;
but  its only effect is to make the patient rather more comfort-
able.  Some again cauterize each pustule after  opening  it; but
this  is  hardly possible in confluent small-pox, and hardly neces-
sary in the very discrete forms.   The end aimed at by these pro-
cedures, to prevent  the formation of deep  cicatrices, is  never
attained with any certainty.  If the pustules  are superficial their
scars will be slight; if the papille are involved, no  amount  of
caustic can prevent the loss of substance.
   Other attempts have been made to effect a coagulation of the
contents of  the pustules, or to abort them before they reach the
vesicular stage.   For this purpose the tincture of iodine has
been much employed.  I have no personal experience of  its use,
but  reliable authors (Martius,  Eimer,  Knecht)  say that the
results of painting the face with it during the  period of erup-
tion are very striking.   In an analogous  way, during the same
period, solutions of nitrate of silver may be employed with bene-
fit.  Ziilzer believes  that xylol given internally coagulates the
contents of  the  pustules and cuts  short their development.  At
the present time a definite opinion as to the value of this proce-
dure cannot be given.
   French 'authors have thought  that mercury has a  specific
effect on the pustules, and have employed it as  an ingredient in
various salves.  The principal value of this method is in the use
of the fat, and simple inunctions  of oil are equally beneficial.
Mercury has also been used  in the form of plasters, especially
the emplast. de Vigo, with which the face was covered as with a
   ' Thus we find an author claiming that by washing the skin with carbolic soap dur-
ing the stage of eruption the disease was aborted, and supporting this claim by an
experience of five cases ! 
398
CURSCHMANN. —SMALL-POX.
mask.   The good effects obtained by this plan seem to be due to
the gentle pressure exercised on the face, and the action of the
mask as an emollient and a cover.  The same effects are pro-
duced by other indifferent plasters, and by lint soaked in oil or
glycerine.  Painting the face with collodion, as advised by Aran
and Valleix, has not been successful in my hands.
   According to my experience all these methods are far inferior
to the use of cold compresses.  I believe cold and moisture to be
the most efficient agents in the treatment of the eruption.   In all
severe cases the application of iced compresses to the face and
hands, or to any parts where the eruption is abundant, is to be
warmly recommended.   The severe pain is diminished, the swell-
ing and redness of the  skin are lessened, and the  patients are
much relieved.  But no modification of the copiousness  and
development of the eruption is obtained by this plan either.
   In the same way the intense pain often felt in the hands  and
feet may be relieved by wrapping them in cold cloths.  The pro-
longed use of lukewarm hand- and foot-baths may also relieve
this  pain.  I have not seen much benefit from the  use of cata-
plasms.   If the  odor  is very bad, carbolic  acid,  chlorine water,
or otlier antiseptics may be added to the water.
   In the stages of invasion  and eruption, immersion baths may
be beneficial.  But their effect is not as marked as in typhoid
fever, nor do they exert any influence on the course of the dis-
ease.  In the period of suppuration it is very difficult to get the
patient  in and out of  the bath, nor does the latter afford much
relief.   Cold compresses and sponging of  the body are more
easily used.
   When the mouth and pharynx are much involved, astringent
gargles  are indicated; of these I recommend a weak-solution of
the liq.  ferri sesquichlor. To relieve the pain and difficulty in
swallowing, mucilaginous drinks, decoctions of althea, etc., may
be of service,  as may also chlorate of potash, diluted  chlorine
water,  and weak  solutions of  iodine.   Sometimes antiseptic
gargles,  carbolic acid and permanganate of potash, may be of
value.   When there is acute oedema of the glottis we may give
an emetic,  if the patient is strong enough, or we  may employ
local scarifications or tracheotomy. 
TREATMENT.
399
   When the disease is fully developed the diet should corre-
spond to the degree of the fever and the condition of the patient's
stomach.  If the patients are weak, bouillon with eggs, Liebi°*' s
beef-tea, and even wine should be given.  The condition of the
mouth may  render many fluids objectionable, on account of the
pain they give.   In varioloid the appetite may be good in the
period of eruption, and such patients should not be kept on an
absolute fever diet.
   Complications are to be treated according to general rules.
   General blood-letting is usually badly borne in small-pox, and
may produce sudden  collapse or give rise to the hemorrhagic
diathesis.
   In severe delirium  and in delirium tremens the chloral hy-
drate would be of great use if it were not for the affections of the
pharynx and larynx;  but these  affections may be dangerously
irritated by this drug.   I have seen acute oedema of the glottis
produced in this way.   The chloral should be given therefore by
the rectum  (chloral hydrat. 6.0-8.0 ad mucilag. acacie, aq., aa,
30),  or  we may use bromide of  potassium with opiates, or the
latter alone, especially subcutaneously. Patients who are deli-
rious need  close watching, or very disagreeable accidents may
occur.
   If the patients are weak, or fairly in collapse, quinine,  cam-
phor, wine,  or  alcohol should be given.  A very good prepara-
tion is  the Stokes' Cognac mixture:  Cognac opt., aq. dest., aa,
60, vitell. ov. No. 1, syrup, sacch. 25.0.   A tablespoonful every
two to three hours.
   During the stage of  decrustation warm baths employed every
day, or every other day, give great comfort to the patients, and
assist in the falling off of the crusts.   Inunctions with any kind
of fat will alleviate the itching.
   Abscesses in the subcutaneous tissue must be opened early
and freely, for if the skin over them is too much stretched and
thinned, it is a long while in returning to its normal condition.
   When the crusts have fallen off we can do nothing to prevent
the formation of cicatrices.  But in variola verrucosa I have used
with great benefit the tincture of iodine, painted on, as a remedy
against  the warty nodules which  are left on the face. 
400
CURSCHMANN. —SMALL-POX.
   We are  almost  powerless against  the hemorrhagic form of
small-pox.  Acids, quinine in large doses, ergot,  liq. ferri ses-
quichlor.  are of no effect.  Tonics and irritants also, although
they have been warmly recommended, do but little good.  When
there are hemorrhages from the different cavities of the body, we
must employ the different styptics, injections of ice-water, cold
compresses,  or  tampons, although their  beneficial effect  is very
slight.  Transfusion, also, from which so much was hoped, has
as yet disappointed us.   But I should advise further attempts
with this method.

                        Prophylaxis.

   The prophylactic measures against the spread of small-pox
are much more  important than the treatment of the disease.  The
measures to be  adopted are founded on an exact study of its eti-
ology, and of this we have already written at length.
   In the first place, the sick should be strictly isolated, a plan
not always  easy to carry out.  Isolation is proper even in the
stage of invasion, for the disease is then infectious.  Among the
poorer classes, who live in crowded rooms and houses, we should,
if possible, remove the sick to hospitals.  The nurses and attend-
ants should not be allowed to see other persons, or,  if they do,
should change their clothes and be thoroughly aired and cleaned.
Physicians,  also, should remember that they may carry the con-
tagion.
   Far more important, however, is it that every one likely to be
exposed to the  contagion should be at  once revaccinated.  This
should be done even to persons who have been already exposed
to contagion, as it is always possible that they may not have been
infected, although exposed.
   Patients  who have recovered should not be allowed to see
other persons until all the crusts have fallen off, for these latter
are very apt to  carry the contagion.
   The bodies of those who have died from small-pox are capable
of conveying the disease,  so are the  clothes,  beds,  and  other
effects of  the sick, and the contagion may cling to  them  for a
long time.   All such articles are  to be destroyed,  or disinfected
by heat, chlorine, sulphur, or long exposure in the  open air. 
VACCINATION.
401
                             Vaccination.

   All attempts  to check the spread of the disease by isolation
and disinfection are of  but little value in  thickly  populated
countries and cities, for such attempts can never be completely
carried out.
   So deeply was this felt that  inoculation  of  the disease itself
was first resorted to as a prophylactic measure.   Afterwards this
unsatisfactory procedure was replaced by Jenner's discovery of
vaccination.   By vaccination the two great disadvantages of inoc-
ulation  are  avoided, the  danger of the procedure,' and the fact
that inoculated persons can communicate small-pox to others.

   We  must recognize Jenner as  the discoverer of vaccination, one of the most
important advances  in medicine.  Although before him the cow-pox and its rela-
tion  to  small-pox had been recognized in different places,2 and vaccination had
even been practised in Europe, in isolated  cases, yet to him belongs the honor of
establishing vaccination  as a recognized preventive of  small-pox.   The industry,
the straightforwardness, and  the critical acuteness  of Jcnner's investigations may
serve as models.  Jenner began in 1776 to study scientifically the traditional  belief
of the country people of his  neighborhood, that cow-pox was a safeguard against
small-pox.  In  1796 he  made his  first vaccination  on  man, and in  1798 he pub-
lished his first important paper on the subject.
   Jcnner's experiments  met,  at first, with some  opposition, but  soon overcame it.
In England, France, and Germany numerous experiments were made with vaccina-
tion,  and it was found that small-pox could not be produced, even by inoculation,
in vaccinated persons.   In 1799 the first public institution for vaccination was
established  in London, in 1800 the  new  method was introduced into France and
Germany, while now it is practised throughout the civilized world.
   A word with  regard to the variola of the lower animals.   In
various domestic animals, and in many others which come much

   1 The mortality from inoculation was about two per cent.
   2 A.  v.  Humboldt  asserts that among  the mountaineers of Mexico the protective
power of cow-pox against small-pox has been recognized and acted on for a long time.
In Europe, Sicker, in  1713,  Sutton and Fewsfer, in 1765, called attention to this pro-
perty of vaccine. A school teacher in Holstein, named Plett, vaccinated three boys in
1791.  In Jenner's home, in Gloucestershire, it was a traditional belief among the
country people that persons who acquired  cow-pox by milking cows affected with the
disease were safe from small-pox.   It was on  this  experience that Jenner commenced
his researches.
            VOL. II.—26 
402
CURSCHMANN. —SMALL-POX.
in contact with mankind, certain eruptions are observed which
have many features in common with the variola of the human
species.  Of  especial  importance among  these  are  the  small-
pox of horses, and particularly the cow pox}  The horse-pox is
usually seen  upon  the foot-joints of horses,  while the cow-pox,
variola vaccinia, is almost exclusively observed upon the udder
and teats of the cow.  In both cases the eruptions, as a rule,  are
purely local, for exanthemata involving the entire body are of
extremely  rare occurrence in these animals, and are probably  not
of the same nature as the former.  The horse-pox is very closely
related  to  cow-pox, and  Jenner states that  the latter  is some-
times due to the  accidental transmission of the virus to  the
udder of the  cow from the hands of a milker who  has been tak-
ing care of horses affected with the variolous disease.2
  The horse-pox can  very probably  be  inoculated upon  the
human  subject with the  same effect as vaccinia,  and this prac-
tice is  objected  to merely because horses have other kinds of
sores upon  the  foot-joint, which might occasion  disagreeable
mistakes sometimes.
    Respecting the origin of variola vaccinia, which is  by  no
means a frequent disease, we have as yet no very certain knowl-
edge.   A  "spontaneous"  development is accepted by  many,
upon no  very  strong evidence,  however.  The  inoculation  of
human  small-pox  lymph upon cows produces variola vaccinia,
the same as  after  inoculation from  the horse-pox, and if a sus-
ceptible person is vaccinated  from a variola vaccinia acquired in
this way,  merely local pustules will be produced without any
general eruption following.   However strongly these circum-
stances speak in favor of the identity of human and cow-, or
animal-pox,  for  which many  writers very  zealously  contend,
they do not  absolutely prove it, and hence, for  the present, we
   1 Besides these two forms  the sheep-pox is also of some importance. This is said to
run a more severe course than the cow- or horse-pox. Moreover, pocks have  been
observed in goats, pigs, asses, dogs, and indeed in monkeys. The pocks that occur in
any one of these animals appear to be capable of successful inoculation upon all of the
others.
   2 From cows that had been infected in this manner  Jenner made a number of vac-
cinations upon people, wherefore his enemies declared that he had performed his inocu-
lations from bad cases of horse-pox. 
VACCINATION.                     403
can only admit the probability of the supposition that variola
vaccinia is small-pox, so  modified by the nature of the soil that
it  retains its  tendency to strict  localization, even when re-en-
grafted upon the human species.
   Although,  in  accordance with  the method of Jenner, vacci-
nation was originally performed with cow lymph,  vaccinia  is
now almost universally transmitted from one person to another
through many generations, only the first individual in the series
receiving  the  virus  direct from  the  cow.   The  vexed ques-
tion as to  the superiority of this  "humanized" lymph  over
the actual  contents  of the cow-pock has  not as yet been set-
tled.   To attempt  to decide  the question  at present  would be
unjust to both sides.  Two  objections are  urged against the use
of cow lymph ; first, it is claimed that vaccinations with it fail
more frequently than with humanized lymph ; and secondly, that
the local symptoms are much more violent  than where the latter
is  used.  The objection has been made to humanized lymph, on
the other  hand, that its protective power becomes gradually
weakened after it has passed through several generations.'  We
must reject all such assertions as are based  upon general impres-
sions, and are not supported by extended statistical  investiga-
tions.   The investigations  thus far made lack both  exactness
and scope, for, unfortunately, in no  country at present are vac-
cination and revaccination so carefully managed, or under such
perfect control as would be desirable.  As  the question  now
stands, there is no sufficient reason  why we  should give up the
use of  humanized lymph  for true vaccine matter direct from the
cow, and  the  former is much more  easily obtained.   We shall
recur   later to certain objections to vaccination, which relate
especially to the  use of humanized lymph.
   If  we watch the processes which  take place locally after vac-
cination, we shall perceive in their course  and development an
unmistakable  resemblance to the pock of  true  human variola.
To begin with, we have here also a period of incubation, although

   1 Some have lately made the  assertion that  since Jenner's  time the lymph has
gradually deteriorated, and  in view of this supposed fact, Coste has quite recently
made the somewhat singular proposition, that vaccine lymph be taken from cases where
variola and vaccinia are simultaneously present in the same individual. 
404
CURSCHMANN.—SMALL-POX.
of far shorter duration.  Two, and  still more often three, days
elapse from the time of inoculation before the spot of efflores-
cence begins to develop.  The first apparent symptom is a red-
ness and slight swelling of the skin, which preserves the form of
the original wound.  By the next day the summit of the papule,
which has  meantime considerably increased in  size,  shows  a
little  vesicle,  filled with a clear liquid, which now gradually
grows larger and larger.  As the  circumference of  the efflores-
cence increases, an umbilication appears, like that in the genuine
variola pustule, and this also assumes the shape of the original
wound (round or elongated, according as punctures or incisions
were  made), and  this is due to the fact that at the point where
the wound was situated a firmer adhesion to the subjacent parts
has taken place than in the peripheral portions, which latter are
therefore able to  extend considerably, as the amount of the con-
tained fluid increases.   The pustule attains its greatest extent
about the seventh or eighth day, and at this period contains  a
clear liquid which, just as in the variolous pock, does not wholly
escape as soon as a puncture is made,  but oozes out in the form
of a  small drop.   This is  due to the fanlike construction of the
meshwork, which is the same as in the  true variola pustule, and
is dependent upon the same causes.   After the eighth or ninth
day the contents  begin  to grow cloudy, and by the eleventh or
twelfth the previously  pearl-colored, somewhat pellucid  pock
has become entirely yellow, while in the centre, just at the loca-
tion of the original wound, the  crust formation has  begun.
While the pustule is at its highest development the surrounding
skin  is more  or less swollen and red.   The inflammatory areole
of the separate pustules  often run together, so that the latter
then  appear to rest upon an uniformly reddened  and swollen
base.
   At this time fever occurs, which is proportionate to the inten-
sity of the local symptoms, and is accompanied by the ordinary
derangements of the general system which are usually associated
with  it.  At the  commencement of desiccation the local, inflam-
matory, and the general symptoms rapidly disappear.  The dry-
ing begins, as already stated, in the middle of the pustule, com-
mencing with a thin scab,  which gradually increases in thickness 
VACCINATION.
405
and peripheral extent until about the nineteenth to thetwenty-
first da}', and then falls off,  leaving behind a scar which at first is
slightly red,  but  afterwards is white and  radiated, or striated.
These scars, as should be distinctly understood, are in themselves
not at all characteristic, and it is only from their situation and
arrangement, and on account of their uniform size, that we are
enabled to surmise an artificial origin.
   In spite of the efforts of its opponents, no unprejudiced per-
son  at the present day can any longer be in doubt as to the
efficacy and eminent practical value of vaccination.   In countries
where it has been introduced, and in a measure systematically
carried  out,  the number, the intensity,  and the extent of small-
pox epidemics have been  notably diminished, and in a  manner
which of itself renders the idea of mere coincidence inadmissible.
In this  connection nothing could be more convincing than the
exceedingly  interesting and graphic account  which  Kussmaul1
gives of the mortality from variola, in Sweden, during a period
of one hundred  years, in  the latter half  of  which  vaccination
was universally practised.   Moreover, for Germany,  France, and
England a somewhat similar decrease in the small-pox mortality
might be demonstrated.  If, notwithstanding all  these  proofs,
we  for  the moment entertain  the supposition, improbable as it
is, that this decrease in the epidemics is a matter of mere acci-
dent, it at once falls to the ground as soon  as we proceed fur-
ther into detail.   We see,  first of all,  that where vaccination is
regularly practised in very early life, the mortality  of children
from small-pox,  instead of being as enormous as amongst those
not vaccinated, is almost nil.  We notice further, that where the
vaccination  of adults,  as  for example in the Prussian army, is
performed with regularity, epidemics  of the  disease no longer
occur.   With these facts before us the idea of mere coincidence
is out  of the question.   The trial of vaccination in the  Prus-
sian army has conclusively  demonstrated the  efficacy  of the
measure, to  test which we have only to compare the  relative

  1 Kussmaul, Zwanzig Briefe iiber  Menschenpocken- und Kuhpockenimpfung. Frei-
burg, 1870. We would very warmly recommend a perusal of this eminent work. It
presents, in an unpretentious popular form, a mass of scientific matter combined with
critical observations. 
406
CURSCHMANN.—SMALL-POX.
 immunity of soldiers during great epidemics of small-pox with
 the mortality in classes of the same general age in the civil com-
 munity where vaccination is imperfectly carried out.
   Although most persons after having had variola  vera  enjoy
 for the remainder of their lives a complete immunity from  the
 disease, the protection which vaccinia affords  against  small-pox
 is only of a limited duration.  The exact length of this period of
 insusceptibility  cannot be stated ; in  the first place because it
 always varies in different individuals, but especially because its
 own  limits are never sharply defined—the disposition always
 returning,  but very  gradually.  In  general,  the duration  of
 immunity may be stated at from eight to ten  or twelve years.
 In order  to maintain a  state of perfect  immunity  after this
 period a  revaccination is required, and this should then be
 repeated  at  every expiration of the  above-mentioned period
 throughout the remainder of life.  It is only by the careful and
 universal  performance of  revaccination that Ave  can  insure the
 most  complete effect of vaccination in permanently  decreasing
 epidemics  of  small-pox.  Were revaccination performed with
 even  approximate thoroughness, the statistics of the  mortality
 amongst those vaccinated, in comparison with those  not vacci-
 nated, which  now  occasionally  supply an  argument  to the
 enemies  of vaccination,  would  be  far  more  favorable.  At
 present, when the term "vaccinated"  is used  in any table of
 statistics,  unfortunately we can only tacitly surmise that in the
 list of those properly  so classed very many were included the
 date of whose last vaccination was very far removed, and conse-
 quently that their susceptibility had long since been renewed.
 Under existing circumstances it would be  much more accurate
 to place opposite the  number  of  those  not  vaccinated the
 number of those who  had been successfully vaccinated within
 a comparatively recent period (say within eight years).  I ascer-
tained to my entire satisfaction, with regard to over  one thou-
 sand small-pox patients whom I examined with reference to this
point, that, although many of them had been  vaccinated, it had
been done either improperly or too long before  the date of the
attack ; not a single one met the strict requirements of an effec-
tive vaccination. 
VACCINATION.
407
   Besides inefficacy, all  manner of directly injurious effects
have been attributed to  vaccination.   That such effects  may
follow  vaccination  there  can be no doubt, but  it  is idle to
regard these as  any sufficient reason for rejecting vaccination.
We should rather endeavor to ascertain how numerous and how
great the possible grounds of objection  are, and to what extent
they may be avoided.
   But even vaccination, it is said, makes the children ill, and
in many cases has, in fact, been the direct cause of  death.  If
caution is exercised in  vaccinating, that is, if the operation is
not performed upon  too  young, feeble, or sickly children, nor
during the period of dentition, nor at very unfavorable seasons
of the  year, the bad  results  will be so extremely rare that, in
comparison  with the advantages of the method, they will appear
of trivial importance.  Healthy  children,  if  not too young,
simply manifest, during  the few days that  the pustules are
at their  highest development,  certain febrile disturbances of
the general system,  during  which  the temperature  sometimes
reaches 104° F.   But these  symptoms quickly pass  away, as
desiccation commences, without leaving any permanent ill effects
behind.  The  occurrence  of erysipelas, however, is  something
more serious.  This may  spread from  the point of vaccination
over a region of variable  extent, and in certain cases  ma)' prove
of very great danger.  But, compared with the millions of vacci-
nations that terminate  favorably, the number of cases which
become dangerous  or fatal in this manner  is extremely small.
Were we to neglect  vaccination on this account, it  would be
about as  wise as though  we should refuse to travel by railroad
for fear of  possibly running off the track.  Pseudo-erysipelas,
lymphangitis, and inflammatory swellings of the axillary glands
are of still more rare occurrence than vaccinal erysipelas.
   Aside  from the  vaccination diseases proper, those objections
to vaccination, based upon the supposition of  its leading to per-
manent derangements of  nutrition or of the general  health, or
upon the idea that it may afford an opportunity for the trans-
mission of still other diseases than those mentioned above, have
met with  but slight acceptance.
   In healthy children those  disorders of nutrition or  of the con- 
408              CURSCHMANN.—SMALL-POX.

stitution which  result from  vaccination never remain  for  any
length of time after the accompanying febrile symptoms  have
passed away.  If just after  this, however, the children should
seem  to be considerably affected, though even  this is rare, they
recover rapidly,  and are generally quite well after a few days.
But if, on the other hand, children who are already delicate, or
have  an hereditary disposition to scrofula, are  vaccinated at an
improper time, their doubtful condition of health at this tender
age may  thereby, as from  any other febrile disease  of  like
intensity, receive a permanent shock, and the scrofulous  ten-
dency may be thus  hastened in its development.   There is no
doubt that in the latter case phthisical and tuberculous pro-
cesses, which are so closely akin to  scrofula, may now and then
be developed.  But in  all  this  we discover no reason why we
should abandon  the practice of vaccination, but simply a motive
for previously examining the condition of health of those to be
vaccinated with the greatest exactness and circumspection. If, in
case the children are  delicate, or evince any special morbid ten-
dencies, we wait until  they are somewhat older and more strongly
developed, vaccination may usually be  performed  upon them
from  the second to the fourth year without any injurious result.
During small-pox epidemics delay is of  course  unjustifiable
even in these  instances.  At such times the apprehension of the
above accidents,  which never happen indeed, except in a very
small number of cases, is quite overshadowed by the threatening
dangers of the disease.
   Scrofula and phthisis are cited as amongst  the very chief of
those diseases which may be  directly transmitted to  healthy
individuals by means  of the lymph.   But not the slightest evi-
dence is adduced in support of this assertion.  We have already
admitted that in a small number of cases these conditions may
arise  indirectly,  and where,  in some  other  instances, these
extremely common diseases  have chanced  to  occur, the oppo-
nents of vaccination, partly blinded by their over-zeal, and some-
times not without design, have had recourse to the deceptive
"post hoc, ergo  propter hoc."
   The possibility of the actual transmission of a disease through
vaccination has  thus far been  demonstrated  in  but a single 
VACCINATION.
409
instance, and that is syphilis.  Could the opponents of vaccina-
tion show that this occurs with any degree of frequency, or is
with difficulty prevented, vaccination would  thereby receive a
severe blow.   But here, fortunately, lies the weak point in our
opponents' deductions.  In the first place, those cases where the
actual  inoculation of  syphilis has been  verified are so exceed-
ingly rare that the objections based upon them are consequently
materially  weakened.   The force of these objections  is still
more impaired by means of the evidence, almost always present,
that the unfortunate result was due to actual  carelessness, or to
an  oversight easy to  be avoided.  Nearly all of the  unhappy
occurrences of this sort are not the fault of vaccination, but of
its  improper performance.  Our experience regarding the inocu-
lation of syphilis admonishes us, therefore, not to throw aside
from mere timidity one of  our most valuable safeguards from
small-pox, but to endeavor to ascertain how we may avoid this
undeniably  serious accident.  The most radical means to avoid
it would be  to vaccinate with lymph directly from the cow, and
to this we should resort under certain circumstances.   We have
already spoken, however, for practical reasons, in favor of the
ordinary use of humanized  lymph, and in the great majority of
cases can find in the danger of inoculating  syphilis no sufficient
reason for giving up this method.  Of course great caution and
care is very necessary in this matter.   We are forced to confess
that at present carelessness and  negligence,  especially in the
procuring of  vaccine  matter, are too  common.  Particularly
objectionable  is the common custom  of using  for vaccination
lymph which is brought into market,  preserved in various ways,
when nothing is  certainly known as to its origin.  Only  such
lymph should be used as either comes  from  a well-conducted
institution, or is obtained by the physician himself directly from
suitable cases.  In the latter case the vaccine  matter should not
be taken from an adult if it can be avoided.  Only in the most
pressing cases is  this allowable.  Kespecting the  children, it is
advisable to select lymph  from such as are not too young, in no
case before  the expiration of five months,  and still better after
the first year.  If congenital syphilis were present, it is to  be
supposed that some distinct manifestation of this would show 
410
CURSCHMANN.—SMALL-POX.
itself within the first  year, or, indeed, as a rule, within the  first
five  months.   It is furthermore  advisable  to  vaccinate, when
possible, only from those children whose parents1  state of health
is  known,  and on  this account to avoid illegitimate children.
The  particular caution to examine  carefully the  entire body of
the children from whom lymph is taken for the purpose of vac-
cination does not  appear so superfluous as one might a priori
imagine, when it is remembered  how  often "the busy practi-
tioner"  merely exposes the arm, or the upper  portion of  the
body before taking the vaccine matter.'
   According to an hypothesis of Viennois', it has been thought
that the transmission of the disease might certainly be avoided,
even in vaccinating from syphilitic children, if the clear lymph
alone were used, with no admixture of blood.  The lymph, ac-
cording to V., is never the vehicle of the syphilitic poison, while
the latter is invariably contained in the blood.  That so absolute
an assertion is untenable has been proved by experiments, and is
confirmed by experience.  It appears to be a fact, however,  that
bloody or cloudy purulent lymph is more dangerous than  that
which is perfectly clear.   Moreover,  we would call  attention
especially to the fact that not in all, indeed in but a small num-
ber of the cases vaccinated from syphilitic children, is  there dis-
ease transmitted.   This may partly be explained by reference to
the  above-mentioned  qualities of the lymph (whether clear or
mingled with blood), but more frequently the cause of the immu-
nity is not apparent.   It is  not easy to  solve this doubt,  since
experimental  investigations are precluded, from the very nature
of the case, and the few chance cases which are available to obser-
vation are fortunately extremely rare.
   It is also frequently asserted that other, non-syphilitic erup-
tions arise in consequence of, or are transmitted with, vaccination.
It is not uncommon to observe a macular or diffuse erythema, or
even urticaria, making  their appearance,  usually  just as  the
vaccine  pustules are at the height of their development,  or dur-

   1 The case of Dr. H., of  Holfeld, so often quoted by way of condemnation, offers
an apt illustration of this point.  The trial at that time revealed the fact that H. had
simply exposed  the arm of the syphilitic child from whom the vaccine material was
taken. 
VACCINATION.
411
ing their desiccation.  The dependence of these upon vaccination
cannot be denied, yet no reasonable person would oppose the lat-
ter on account of such insignificant occurrences.
   The belief that healthy persons, who are not already predis-
posed to them,  may be attacked  by chronic cutaneous erup-
tions, especially eczema, in consequence of vaccination, is utterly
unfounded.   In those who are so predisposed there  is no doubt
but these eruptions may sometimes, though rarely,  occur.  The
eczema then first shows itself generally in the neighborhood of
the point of vaccination, and extends  from there over a greater
or less portion of the rest of the body.
   An objection which shows a great  want of discernment, but
which has been frequently urged, is that since the general intro-
duction of vaccination, as it is claimed, certain other epidemic
diseases, particularly  scarlet fever and measles, have  become
more frequent  and more malignant.  The absolute number of
deaths from  these diseases may have been somewhat increased,
but this is by no means true of their relative number.   This is
readily explained by the fact that in consequence of vaccination
a large number of individuals, who otherwise would have died
of variola, remain alive, thus leaving a larger number for measles
and scarlet fever to attack.  A similar objection which has been
raised  in connection with typhoid fever, may be disposed of in
the same way.
   In regard, to the performance  of vaccination, a number of
points are to be observed with especial care. Above all we should
be very particular in procuring the lymph which is to be used,
taking it  only from perfectly healthy children,  and from those
vaccinated for the first time.   We find, it is true, that the possi-
bility of transmitting diseases  in vaccination  is far less than is
generally supposed, and that we can assert this  possibility with
perfect certainty only of syphilis.   But in a procedure which so
many contend against, and which, especially in  the  eyes of the
laity, is so objectionable, even the appearance of error must be
most scrupulously  avoided, not only  for the personal interest
of the physician, but in the interest more especially of  a good
cause.  The early years of infantile life are threatened by a mul-
titude of dangers, aside from this, and should any  unfortunate 
412
CURSCHMANN. —SMALL-POX.
accident occur, the laity are generally very eager to trace its
source to the vaccination, and especially to circumstances con-
nected  with its  performance.   AVe  have already  mentioned
that lymph taken from syphilitic children, and employed in vac-
cination, does not always  transmit the disease, and  Bousquet,
who intentionally vaccinated with  such  lymph, has never ob-
served infection  follow.  Concerning the proper  age at  which
vaccination should be performed, and the necessity for a care-
ful examination  of the child  from whom the lymph is taken,
we have already said all  that is requisite.  Vaccination from
adults should be avoided,  and especially from  those who have
been  vaccinated  more than once, since  in  the  latter case the
lymph is much  more apt to operate with uncertainty.   But
during great epidemics, when there is a lack of vaccine virus,
necessity may oblige us  to  resort  to even this doubtful source.
This was the case in many places  in the epidemic of 1870-71.
   The  best time for taking lymph from  the  child is  on the
seventh or  eighth day after vaccination.  We should select such
pocks as are well developed, and it should be borne in mind that
in order to obtain an abundant supply it  is not sufficient simply
to puncture the vesicle, but the epidermis over it must be incised
for a considerable extent (on account of the  fan-shaped  struc-
ture). Before and after the seventh and  eighth day it is much
more difficult, if  not impossible, to procure  the lymph, and it is
decidedly less reliable in its action.
   It is always best in the performance of vaccination to carry
the lymph directly from one arm to another.   Often, however,
this  is impossible, and on  account  of the frequent necessity of
waiting  a long time after  obtaining the  lymph, before using it,
its power of retaining its  properties becomes of  great service.
With proper means of preservation the lymph retains its activity
for a long time.   The most unsuitable method for preserving it
is that which was formerly very generally employed, namely, of
allowing the lymph to dry upon little  rods.   A much  better
method,  and one that is at  present much more common, consists
in preserving the lymph in capillary tubes which are hermeti-
cally sealed at both ends (by fusion or with sealing-wax).   Mid-
ler has  the great credit of having  discovered the fact that by 
VACCINATION.
413
mixing vaccine matter with glycerine in certain proportions, the
activity of the former is not diminished, so that we have here a
means of  increasing the volume of the lymph when the quantity
is small  or when there is an unusual demand for it.  This dis-
covery is  of  great value,  since the certainty of  success after vac-
cination,  apart from the quality of the lymph,  is dependent  to a
certain extent upon  its  quantity.  The  lymph  and glycerine
mixture  appears  to keep quite as well as the unmixed lymph.
The objection frequently made, that vaccinia  develops with less
certainty and completeness  after  this  method, I am able to re-
fute from personal observation.  I have never  seen better devel-
oped vaccine pustules than at the Berlin Vaccine Institution,
where  such lymph is employed ; and after my  own numerous
experiments  I can assert that the certainty of result is not at all
less than after the use of  the pure lymph.
   Muller usually mixes the lymph carefully with two parts of glycerine and two
parts of distilled water (by means of a small brush in a watch-glass), and preserves
the liquid  in air-tight capillary tubes.   This mixture, according to M., can be still
further  diluted (one part to eight) without suffering any  perceptible loss  of its
efficacy.  Beyond this its activity is lessened in proportion to the- degree of its dilu-
tion. Reiter ' obtained a feeble action with dilutions consisting of one part of lymph
to two  hundred of distilled water, and  he  ascertained that, as a rule, in order to
obtain any effect a greater quantity must be employed the more the virus is diluted.
   The direction generally given to avoid any admixture of blood with the lymph
originated in the idea, formerly entertained, that dyscrasiae were capable of being
transmitted with the blood; but at the present time it is only with regard to syphi-
lis that  any importance is to be attached to the precaution.  Where  this disease is
out of  the question  the admixture of a drop of blood does not signify. Reiter's
ingenious experiments have shown even that vaccination may be successfully per-
formed from the bearer of vaccine pustules using nothing but the blood, though the
activity of the latter is far less of course than that of the lymph, being about as one
to twelve.

    As regards those who are to be vaccinated, no less caution is
necessary in their choice than  in  the selection of  the children
from whom the lymph is taken.   When small-pox epidemics do
not render vaccination imperative, it should be performed only
on such children as are robust and not too young.   They should
be from four or five up to twelve months of age, according to cir-
1 Bayr. arztl. Intell.-Bl. 1872, Xo. 15. 
414
CURSCHMANN.—SMALL-POX.
cumstances, should not present at the time any other  morbid
symptoms, and  not be teething.   The period of weaning also is
a particularly unsuitable time.  A rigorous season of the year
and times when epidemic diseases prevail among children should
likewise  be avoided if possible.   In the case of weakly children
and such as have a special morbid disposition to scrofula, phthisis,
etc., it is generally well to postpone the vaccination  until they
have become stronger, since in such children  vaccine, like any
other intercurrent disease,  is liable at the  critical period of inci-
pient development to occasion a derangement of nutrition which
may be of long continuance, if not permanent.
   In the vaccination of adults such great caution is of  course
unnecessary.
   We now come to speak of the mode in which vaccination
should be performed.  It  is  generally done upon the arm, and
usually on both sides.   In girls just that portion of the upper
arm (which, by  the way, is of rather limited  extent) should be
carefully selected which will  be concealed by the  future even-
ing toilet.  The method,  still much in  vogue,  of vaccinating
children  in the  situation of nevi upon the face or some other
conspicuous part, with the  purpose of simultaneously accom-
plishing  two ends, appears to me of rather doubtful utility.1  In
order to  introduce the vaccine matter into the  skin, a number of
punctures or scarifications  are made with a vaccinating needle or
lancet, which has  been previously  moistened with the  lymph.
Where vaccine matter is to be had in  sufficient quantity, it is
purely a matter  of custom whether  punctures or  incisions  are
made.    If, however, the supply of virus is deficient,  and it has
been necessary to  dilute it with glycerine  to the utmost possible
extent in order to make it suffice for  the number to be vacci-
nated, then the method  by  incision  is  decidedly  preferable.
Reiter has established this  point  by convincing  experiments.
When lymph diluted in a  certain way was brought into contact
with the skin by means of punctures, incisions, or by rubbing it

  1 In one case, to be more fully described elsewhere, a cicatrix of the  face (resulting
from vaccination of a nsevus at the age of two years) was shown with great probability
to be the starting-point of a lupus that developed at the time of puberty just in this
place. 
VACCINATION.
415
over a vesicated spot, the best effect was produced in the last
case; from  the punctures not a single  pustule was produced,
while after  the incisions  a few characteristic  signs manifested
themselves.
   If vaccination  is made with incisions, from  four to  six
usually suffice for each arm.  These should not  be  too  close
together, in order  to prevent the  pocks, and if  possible their
inflammatory areole also, from afterwards coalescing.  Too deep
incisions are inadvisable on account of the copious bleeding, by
means of  which the vaccine virus  might be washed out of  the
wound.  This danger, however, appears  not to  be as great as is
generally  imagined.  The  precaution not  to  cover the wound
after vaccination until the blood has entirely dried, seems some-
what superfluous.   The blood has often been intentionally wiped
away from the wounds without the  result of vaccination being at
all impaired.
   After the vaccine pustules have  developed  they should be
relieved from  any pressure or friction.  Not so much because
their destruction at a certain stage  might lessen their protective
influence,  as for the sake  of not adding any traumatic effect to
the already existing inflammatory symptoms.
   If no pocks are formed after vaccination, the attempt should
soon after be repeated—in the course of  the following  month at
least—with all the necessary precautions.  The failure of vacci-
nation may depend upon several reasons.  In the first place, and
this is especially true of  revaccination,  the individual in ques-
tion at the time of the vaccination may not have been susceptible
to the  virus, and hence we may conclude that  he  was also not
disposed to variola.   Or else the vaccination itself was  defective,
either on  account  of some fault in its performance or from  the
use of inactive lymph.  The latter possibility should be particu-
larly borne in mind in case lymph was used that had been pre-
served for some  time, instead of  the vaccination being made
directly from arm to arm.
   In those cases, too, where at the point of vaccination, instead
of the normal vaccine pustules, other lesions—macular erythema,
pustules, vesicles,  or abscesses (erroneously termed spurious vac-
cinia)—make their appearance, the  repetition of the vaccination 
416
CURSCHMANN. —SMALL-POX.
 with other lymph, and if possible from arm to arm,  is absolutely
 necessary.   It will generally be found that the cause of failure is
 to be attributed to the quality of the matter employed, though
 in revaccinations the reason is quite as apt to be due to  a want of
 susceptibility to the vaccine virus.

    A weapon of defence against the scourge of small-pox so powerful as vaccination
 should not be left to the pleasure of the individual, but the State has the right and
 the duty to look after its most thorough performance.  As in other spheres, where
 for the attainment  of  a result perfect  co-operation is requisite, so our experience
 in regard to vaccination teaches that instruction and admonition  alone are almost
 powerless in the struggle against negligence, deficient sense of duty, and evil dispo-
 sition which oppose this useful  measure at every step.   Those acquainted with  the
 subject therefore have long since been of the opinion that to the attainment of  the
 desired end legal compulsion is absolutely necessary.   The authority of  the  State to
 effect this is unquestionable in the minds of those free from prejudice, for the effec-
 tiveness  of the method is  beyond all  doubt.   Indeed, even since vaccination has
 been very imperfectly employed against the decimating plague, the average length
 of life has undergone an evident increase.   Compulsion is furthermore justifiable on
 the ground that a certainty of success is impossible so long as a few individuals are
 not subjected to the operation, since from the extraordinary contagiousness of small-
 pox these become conveyers and diffusers of the poison.  Even if vaccination were
 to be considered in the light of a sacrifice, the  State might  under certain circum-
 stances demand this from the few in the interest of the community, and upon this basis
 establish a large number of State institutions.  But even the selfish pretext that vac-
 cination is injurious becomes, as we have seen, in so far untenable as the great num-
 ber of the formerly accepted dangers of vaccination  have been shown to be wholly
 imaginary, and the unquestionable  harm which  only rarely  occurs  can  be  certainly
 avoided by means of caution and  experience.
   We, therefore, greet with  pleasure, in spite of its many imperfections,  the law
 which the Imperial Diet has recently passed (April 8th, 1874) concerning vaccination.
 According  to this law every child that has not already had small-pox must  be vac-
 cinated before the termination of the calendar year  following the year of its birth,
 and every pupil in a public or private institution is to undergo revaccination within
the year in which his twelfth birthday occurs.  For the most convenient and cheapest
methods  of carrying out this plan, for the procuring of good lymph  and its free
distribution to physicians, as well as for accurately recording the results of vaccina-
tion, both in isolated cases and  for general statistics, the law makes the most ample
provisions.  The paragraph of the previous statute which was designed to regulate
the revaccination  of adults  at the outbreak of small-pox epidemics was unfortu-
nately rejected by the Diet.   To repair this  mistake, and as soon as possible obtain
the necessary addition to the vaccination law, is  an important task for those conver-
sant with the matter. 
    ERYSIPELAS.
(ROTHLAUF, ROSE, ST. ANTHONY'S FIRE.)
ZUELZER. 
 
ERYSIPELAS.
1560-1700.   A.  Ellinger,  Dissert,  de  erysip.  Leipz.,   1560.—Heurnius,   Diss.
    Leyd.,  1596.—Schoen,  Diss.  Basel,  1605.—Burmeister,  Diss.  Basel, 1615.
    —Schilling, Diss.  Lips.,  1621.—Kiiffer,   Diss.   Argent.,   1640.—Mooeling,
    Diss.   (pvaiTrfXayvuvaaia.   Tubing., 1621.—Michaelis,  De rosas vero  ac  legi-
    timo  erysipelate.   Leipz.,  1655.—Metzger, Diss, historia?  erysipelatis.  Tub.,
    1666.—Vehr,  Diss.  Altd.,  1661.—Schenk,  Ordo  et  methodus tract, et cur.
    febr.  erysipelat.  Jen.,  1666.—Schneider,  Diss.  Wittenb., 1568.— Wedel,  Diss.
    Jen.,  1682.—Sydenham,  Oper. univ.  Lond., 16S5.  p. 310.—Dessali,   Diss.
    Leyd., 16%4,—Mappus, Diss.   Argent.,  1700.—1701—1800.  Jacobi, Diss, in-
    aug.  Erfurt.,  1711.—Zabel, Diss.   Lyon., 1717.—Fr. Hoffmann, De febr. ery-
    sipelacea.  Halae, 1720.—de Pre, Diss. d. Erys.  (vulgo  Rothlaufen.)  Erfurt,
    1720.—Goelicke, Diss.   Frankf., 1786.— Charlcville,  De erysipelate pustuloso.
    Halle, 1740.—67.  G.  Richter, De erys. Diss.  Getting. (Opuscula medica, 1744.
    I.)—Juch, Diss, de  erysipelaccis inflammationibus.   Erfurt, 1752.—Aurivillius,
    Diss.  Upsala,  1762.—Hermann,  Diss,  de  rosa.   Argent,  1762.—Monro, The
    Diseases  in the Brit. Military Hosp. in Germany.   Lond., 1764.—Schweder, De
    febrib. erysipel.  Gott., 1771.—Dale,   De  erysipelate. Edinburgh  1775.—
    Bureau, On the Erysipelas which is called St. Anthony's Fire.  Lond.,  1777.—
    Gregory,  Lect.  on Fev. and Inflamm. Edinb., 1777.—Luther, Diss. Erfurt, 1780.
    Hellbach,  Diss,  de erysip.  Erfurt, 1780.—Gulbrand, Observationes de  erysipe-
    late.  Acta reg.   societal,  med.  Havn.  I.—J. J.  Aerts, Diss.  Lovan.,  1782.
    —van  der Belen,   Diss.   Lovan., 1782.—Gourlay,  Diss.   Edinb.,  1782.—
    Kyper, Inst. med. de erysip.   Montpellier, 1783.—Hoffinger,  De volatico s. de
    erys.  erratico.   Vindob.,  1789.—Gulden,  Med.  Prat.   Trad,  de  Bosquillon.
    Paris,  1789.—M. Culley, Diss.  Edinb., 1790.—Amman,  Diss, de  erys. ejusque
    ab inflammatione diversitate.  Hard., 1790.—Thierens, Diss.    Lugd. Bat, 1790.
    —Fowle,  De febr.  erysip.  Edinb., 1791.—Gergens,  De erysipelatis febrisque
    erysipelatosae causa materiali.  Mogunt.,  1792.— Winkel, De cognoscendo et cu-
    rando  erysipelate.  Erl.,  1794.—Feme, De diversa erysipelatis  natura.  Frankf.,
    1794.—J. P. Harmand  de  Montganvy, Precis med. et curatif. de malad. erup-
    tives, connues sous le nom de rose epidgmique, qui  regnent dans le dSpartement
    de la  Meuee.   Verdun,  1793.—Engelhart,  Diss.  Lundse,  1797.—1800-1820. 
420
ZUELZER. —ERYSIPELAS.
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—Legueule, Diss.  sur.  sur l'6rys.  Paris, 1805.—Grube, Diss,  de erys. neona-
torum.   Wittcnb.,  1807.—Terriou,  Essai sur  l'erys.  Paris,  1807.—Closier,
Diss, sur  l'erys., ses varietSs et son traitement.   Par., 1809.—Mariande, Essai
sur l'erys. simple.   Par., 1811.—J. R. Sourisseau,  Diss.  Essai sur la nature et
la traitement  de l'grys. bilieux et du  phlegmon  aigu.  Par.,  1813.— Willan,
Hautkrankh.,   dtsch.  v.  Friese.  Bresl.,  1816.—1821-1840.  Alibert, Precis
theorique et pratique des maladies  de la peau.   Par., 1822.—Bayer, ib.—Ch.
Bell, Transact,  of  the  Soc. for the Improvement of Med. Knowledge.  V. II.—
Bibes,  Mem.  de la  soc.  m§d. d'emulat. T.  VIH.—Schmitt, De  erys.  neona-
torum.   Leipz., 1821.—L. Borchard,  Die Blasenrose.  Carlsr.,  1825.—Leon,
New York Med.  Journ.,  1827.    April.—Rostan,  Cours  de  m6d.  clinique.
Paris,  1827.  II.—Arnott,  Lond. Med.  and  Surg.  Journ., 1827.—Durand-
Fardel,  Malad. des Vieillards.—Lawrence, Observat. on the Nature and Treat-
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Frank (J. P.),  Prax. med. univ.  prsec. I. 2. 116. 1828.—Sabatier, Propositions
sur l'erys. conside're principalement comme moyen curatif dans les  affections
cutanees  chroniques.  Par.,  1831.—Bayard,  New York  Med. Journ.,  1831.
May.—Costallat,  These  de  Paris,  1832.—Marjolin, Lecons,  1833.—Hilden-
brand, Inst. Pract. Med.   Vienn., 1833.— Wolff, Graefe u. Walther's Journ. V.
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Piorry, Clinique de la  Pitig, 1834.—Stoltz,   These  de  Strassbourg,  1835.
— Ozanam, Traitg   d.  malad.  epid.  Paris,  1835.—Lepelletier de  la Sarthe,
These  de  concours.   Paris,  1836.—A.  Brinnet,  Journ.  des  connaiss. med.
chirurg.   1839.  Nr. 7.—Fuchs,  Die  krankhaften  Veranderungen  der  Haut.
Gott,  1840.—1841-1860.  Fenger,  De  erys.  ambulanti.   Havniae,  1842.—
Sutton, Hall, and Dexter, Ber. lib. d. nordamerik. Erysip.-Epid.  Canst. Jahres-
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Causes, and Treatment of Erys.  Lond., 1845.—Blandin, Epid.  d'erys. trauma-
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the Treatment  of  Erys. by Numerous Punctures.  Lond.  Med.   and Surgic.
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la convalescence ou la  pgriode ultime des maladies graves.   Arch. gdn6r. 1847.
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de ridentite de ces deux  maladies.   Paris, 1849.—Higginbotham, Edinb. Mod.
and Surgic. Journ., 1849.   (Advocating external use of nitrate of silver.)—Mor-
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1850.—Spengler, Deutsche  Klinik,  1850.  p. 395.  (Collodium.)—Gallway, On
Unhealthy Inflammation.   Lond.,  1850.—Hill,  Monthly Journ. of Med. Science,
1850.— Erichsen, Lancet,  March,  1851.— Walsh, Dublin Hosp. Rep.,  1851.— 
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Gaz. m6d. 1866.—Durozier, Gaz. des  h6p. 149.—Anstie, Lancet.  17. Novbr.—
Eulenburg, Centrbl. f. d. med. Wissensch. p. 65—Blockberger, Quelques consid-
erations sur l'grys.  These de Paris.—Deblieu,  Quelques consid. sur l'etiologie,
le traitement et la nature de l'grys.  These de Paris.—Michel, De l'erys. dans la
convalescence a l'asile imperiale du Vesinet.   These de Paris.—1867.  Daude,
Traitg  de l'erys. epidem. Paris.—B.  Withers, Americ.  Journ., p.  280 (Recom-
mending Potas. Iod. internally).—Liebermeister, Dtschs. Arch. f.  kl. Med. III.
569.—Lbbel, Ber. d. Rudolphstiftg.—Bartscher,  Journ. f. Kinderkrankhtn.  I.—
Gueneau de Mussy, Gaz. des hop.  Nr.  10.—Emil  Ponfick,* Dtsch. Kl. Nr. 20
ff.—1868. R.  Volkmann und F. Steudener, Zur patholog. Anatomie des Erysip.
Centralb. f.  d.  med.  Wissensch.   Nr. 36.— Volkmann,  Art. Erysipelas.  In v.
Pitha and Billroth's Handb.  der allg. u. spec.  Chir.—Griscom, Med. and Surg.
Rep—Mettenheimer, Dtschs. Arch. f. Kl. Med. p. 203.—Pozzi, Gaz.  des hop. 47.
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Gaz. de Paris, 44. 45.—Colin, Gaz. hebd. 31.—Mathis,  Rec. de mem. m(jd. mil.
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Das Verhalten der  Eigenwiirme  in  Krankheiten.    Leipz.—Kbnig,  Arch. d.
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l'anat et de la physiol.  3 p.  26. Maiet Juin.—Tutschek, Bayr. arztl. Intell.-Bl.
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face.  Paris.—Huter  Centralbl. 5. (Subcutaneous Injection of Carbolic Acid).
—Aufrecht, lb. 9. The same. 
DEFINITION.
423
                         DEFINITION.

   Erysipelas  is an acute febrile disease characterized by a
peculiar inflammation of the skin, which is accompanied by more
or less severe general symptoms, headache, loss of appetite, nau-
sea, aud sometimes vomiting, and  by disturbance  of the intel-
lectual functions, with occasional delirium.  It begins at the site
of some injury to the skin or external mucous membrane, gener-
ally suddenly and with chills, and is accompanied by swelling,
redness, heat, pain, enlargement of the neighboring lymph-glands,
and often by the formation of  blisters,  and it is disposed to
extend rapidly over large portions of the skin.  It generally ends
in desquamation of the cuticle,  speedy resolution, and perfect
recovery, prolonged occasionally by the formation of cutaneous
abscesses.  The only dangers are the inanition which  follows
long-continued  fever in weakly  persons, and  the secondary  in-
flammations of  the lungs, pleura, and peritonseum.  Laryngitis
and oedema of the glottis may also sometimes bring on  a  fatal
ending.
   The duration of the fever corresponds precisely to the contin-
uance of the cutaneous affection, which lasts upon one  and the
same part from three to four days ; if it  extends  farther, how-
ever, and attacks  various portions  in  succession,  the duration
may reach several weeks.   The disease is disposed to attack the
same person repeatedly; it is contagious and inoculable; and
arises spontaneously under conditions not accurately determined.
It occurs, for the  most part, sporadically, or as a limited epi-
demic within the walls of institutions.

                           HISTORY.

   Erysipelas has occurred in a  sporadic form, according to the
statement of Hirsch,1 at all times, and, with the exception of the
tropics, in all regions of the earth's surface alike.

  Its frequency in particular regions may be approximately shown by the following
facts: In the whole of  England, in the years 1862-1867, erysipelas was recorded
              1 Handb. d. histor. geograph. Pathol. I.  p.  243. 
424
ZUELZER—ERYSIPELAS.
as the cause of death in 3,904  children, under five years, and in 4,731 older persons
(Farr) ; in Paris there  died, on the  average, in the years 1865-1869, about  350
persons annually; while according to my own computation some 200 cases received
medical treatment in Berlin during six months of the year 1870.

   The disease  rarely attains any special  frequency, and never
prevails in epidemic form amongst an entire community.  Many
writers have expressed  the opinion that it occurs with especial
frequency, either in sporadic or epidemic form, as a forerunner or
companion of epidemic variola, scarlatina, or diphtheria ; but the
observations of recent years,  which have been rich in epidemics
of all sorts, have failed to show such a connection.

   Hirsch l describes under the names erysipelas typhoides, malignum or gan-
grsenosum, an  extensive epidemic which prevailed throughout a great part of
North America  in the  years 1841-1854.  This affection, however,  as Hirsch him-
self states, is to be regarded merely as an acute infectious disease closely related to
diphtheria, the local symptoms of which, so far as they were manifested in  the form
of deep-seated inflammation of the subcutaneous cellular tissue, were much more
nearly akin to diffuse phlegmonous inflammation (the  so-called pseudo-erysipelas)
than to true erysipelas, from which it is entirely distinct.

   On the other hand, the disease has always prevailed not unfre-
quently in epidemic form in enclosed establishments, where great
numbers of persons live together in hospitals—especially the sur-
gical—in  foundling  and insane  asylums, in military  lazarettos
and prisons,  and  in  ships.  Epidemics in  surgical wards  have
been often described  by authors, and Volkmann has collected a
great  number of  them.    Every injury,  even  the slightest, the
opening of abscesses, vesication, leech-bites, may serve  as the
starting-point of erysipelas within the  sphere  of the  epidemic.
The following epidemics are likewise deserving of notice :

   Rayer describes, according to the statements of Calmeil, an extensive occurrence
of erysipelas of this sort in the Paris hospitals, in the year 1828 (especially in those
for the insane), where at that time patients were  often treated by revulsive applica-
tions upon the skin.   "For  six months," he writes, "the hospitals have been
crowded with  patients affected with erysipelas.  The affection shows itself upon
any part of the body, sometimes upon a sound one, but oftener in the neighborhood
of some cauterized portion of skin.  Similar cases were observed in the Bicgtre,
St. Louis, and Charite  hospitals, and the number of them at certain times was so
lL. c. II. p. 432. 
ETIOLOGY.
425
great that the disease became a true epidemic.  Schonlein mentions in his lectures '
an extensive epidemic, which he observed in the hospital at Zurich, in 1836.   " The
affection was characterized in the beginning by traces only of desquamation accom-
panied by the appearance of pale red spots, which quickly disappeared again. The
true erysipelatous redness was  not  markedly developed until after the use of the
cold plunge-bath.  At  the same time there was considerable disturbance  of  the
sensorium ;  some lay in sopor; while most were delirious, and did not know where
they were;  leaving their beds and desiring to go to their work; seating themselves
in the middle of the ward to evacuate their bowels, as if they were in the privy."
   According to Gintrac's description, there was  also an  extensive epidemic  of
erysipelas in the hospital St. Andrg,  at Bordeaux, in the spring of the years 1844
and 1845.  "Both in the private as well as  in the surgical wards did every vesica-
tion, every  incision, every cauterization serve  as the starting-point of an attack.
Eleven cases on the face and scalp occurred ' spontaneously,' six in consequence  of
the use of a vesicant; while the same result followed  venesection upon the arm."
The same hospital was again the scene of  a severe attack  in 1863, according  to
Pujos, in which all the cases assumed a typhoidal form.  " At this time there was
not a single case of pyaemia, while during the previous year eleven fatal cases had
occurred."
   Trousseau states that in the year 1858 a severe epidemic of puerperal fever pre-
vailed in the Maternite at Paris, and that at the same time a very grave erysipelas
was developed among many of the wounded in the surgical division.  In recent
times these  epidemics appear to occur less frequently, although Volkmann observed
a severe outbreak of the disease in the surgical clinic at Halle in 1868, where in the
summer nearly seventy of the patients in the  various wards were attacked by it.
In the  military  hospitals in Berlin, in 1870 and 1871, there occurred 170 cases of
erysipelas (1.7 per cent.) among the 9,972 wounded (v. Steinberg).   About one per
cent, of those sick with typhus were thus affected.   More recently,  also, reports
have been published by Loysel, of an extensive outbreak of erysipelas at Cherbourg,
in 1872, and by Savory,  at St. Bartholomew's Hospital, London.


                               ETIOLOGY.

    As the term erysipelas is used  even at the  present  day with
great diversity of meaning, it is necessary, before proceeding,  to
define  the basis upon which this treatise rests.
    Medicine, as distinguished from surgery, has  always confined
itself,  on  etiological grounds, to   cases described as idiopathic
erysipelas, erysipelas verum  s. spontaneum s. exanthematicvm
(erysipele medicale of  the  French), especially erysipelas of the
head  and face; while  cases  occurring  among  the  wounded  or
         1 Schonlein's klinische Vortrage von  Giiterbock.   Berl.  1842, p. 431. 
426
ZUELZER.—ERYSIPELAS.
after operations have been distinguished from  it as erysipelas
nothum s.  spurium s. traumaticum (erysipele chirurgicale), or
e.  nosocomiale (Hirsch).   The latter term has been used with
excessive latitude, so that it is often applied, and especiaUy by
English physicians, to phlegmonous and other inflammations of
the skin and subcutaneous cellular tissue which tend to spread
quickly over large surfaces.  Both, as distinctly accepted forms,
lead to a very different interpretation.
   Opinions about idiopathic erysipelas have diverged widely in
three directions since the eighteenth  century.   Bromfield,  Fr„
Hoffmann,  Kicheraud, and some others attributed it to  a status
biliosus; Boyer referred  its  cause to the saburral  state ; while
Lamotte  designates as such  a stopping up of the pores of  the
skin which prevents the escape of  acrid material separated from
the blood.
   On  the  other  hand, Eichter, of  Gottingen, was the first to
regard  erysipelas as an inflammation of the lymph vessels.  Sub-
sequently many  physicians  were inclined to  the  theory of  a
simple  inflammatory process ; while Borsieri declared it to be an
inflammatory condition due to the production of acrid fluids in
the  body.  This  theory,   in consequence of  the  authority of
Broussais,  who looked upon  erysipelas  as  an "inflammation
franche et pure,"  led  to  the extreme  use of  antiphlogistic
methods of treatment, as with other infectious diseases.
   By far the greater number of  physicians, however, were dis-
posed to place erysipelas  among the acute exanthems.

   Sauvages regarded it as an  exanthematic inflammatory process produced by
corrupt and acrid juices.  According to Cullen's view, it arose in consequence  of a
materia peccans developed within the body,  which, in proportion to the amount of
fever,  was deposited, after the manner of other exanthems, upon the surface.
Cazenave, Biett, Schedel, and, later,  Rayer, considered it absolutely as an acute
exanthem.  "It is the exanthematic character of  the erysipelatous process,"  says
Canstatt,1 "which gives it its specific individuality and distinguishes it from other
kinds of dermatitis. The true erysipelas develops, like all acute exanthems, from
within outwards, in consequence of some peculiar though little known transforma-
tive or toxic process in the blood, the local and critical expression  of which shows
itself mostly upon the outer skin, in the form of an erysipelatous stasis."  Schonlein
1 Handb. d. medic. Klinik 1847.  II. p. 230. 
ETIOLOGY.
427
went still farther: he was led, in consequence of the resemblance which the appear-
ance of the erysipelatous fever bears to urticaria, scarlatina, variola, and so on, to
include all these processes in one common family of the erysipelatous diseases.
   These  views, so  generally  accepted at that time,  were first
opposed by Trousseau,  who  regarded erysipelas as the visible
manifestation of  some  intensely  active  and  specific noxious
agency working from without, at first locally, like diphtheria,
and  only secondarily infecting the whole organism.  The brief
period of invasion, the frequency of relapse, the peculiarity of its
constantly starting  from  some definite  point,  and finally  the
course of the disease, protracted sometimes in wandering erysip-
elas  for weeks and  even months, afford  sufficient characteristic
marks by which it may be distinguished from the infectious dis-
eases known as the acute exanthems.
   In  accordance  with these views Trousseau makes no farther
distinction  between the so-called  idiopathic and the  traumatic
erysipelas, inasmuch as he believes that every erysipelas is trau-
matic, that is, that it  is never developed except as the result of
some previously existing wound or injury.
   In fact,  opinions with  regard to  the difference  between  the
forms of erysipelas described as  distinct, rest  wholly upon  the
manner in which  the  entrance of the poison is supposed to be
effected.  That the poison  in both forms is identical there can be
no doubt;  numerous observations, of which several examples are
given below, show that the so-called idiopathic erysipelas occurs,
under similar conditions,  as well through  contagion from  the
traumatic form as by its epidemic prevalence in enclosed  institu-
tions.  The type  of the disease itself also, according to Volk-
mann, presents in  the two forms  no  remarkable difference,
when it is considered that in  the one  it  mostly attacks  persons
reduced  by severe injuries, prolonged suppuration, and the like,
while in the other relatively healthy people are affected.  To  set-
tle this question,  we have only to furnish evidence that in  the
latter, as well as in erysipelas  traumaticum, the invasion of  the
morbid poison depends upon  a previously existing injury of  the
integument, to show that  the skin affection is not to be consid-
ered as the result of any preceding general poisoning.
   Clinical observation teaches the strict dependence of the  gen- 
428
ZUELZER.—ERYSIPELAS.
eral symptoms upon the local process.  The fever runs its course
parallel with the  steadily progressing or receding inflammation
of the skin, and deviates from it in relatively few cases in conse-
quence of severe complications.
   Inoculation also shows that the  whole morbid process  can
only be developed by infection through  the injured cutaneous
covering.
   The most various wounds of the skin, and  at all periods of
their existence, may serve as the  starting-point for erysipelas,
however, as Volkmann shows in a very comprehensive manner.
It is observed as well in severe and fresh wounds after operations
and accidental injuries as in unimportant  and slight cuts, in
trivial fissures and abrasions of the skin, and even in leech-bites  ;
also in suppurations and  inflammations of considerable, as well
as in those of trifling extent, in wounds in process of granulation
as well as in those completely healed.
   In cases of so-called idiopathic erysipelas of the trunk  and
extremities, scarcely an  example  can be found,  according to
Volkmann and others, where it has not started from some local
disturbance, such as a scratched pustule or the  like.
   With regard to erysipelas of the face and head, such accord-
ance of observations is, it is true, not obtained.  Trousseau found
indeed in all his cases slight ulcerations or suppurations of the
cavities of  the nose or mouth, or  in the ear  or tear passages, as
the  starting-point of the  process,  and many later observations
yield the  same result; yet in many  of these descriptions there
remains in this connection a gap, which may in  part, it is true, be
regarded  as the  result of defective  examination,  inasmuch as
slight injuries upon the scalp or in the facial cavities may easily
escape observation when  the parts are highly  swollen in  the
course of the disease.  B. Konig found, for instance, in thirty-
three cases of spontaneous erysipelas,  a slight injury as the start-
ing-point in nineteen of them, while in the  others the examina-
tion was hindered by the great swelling of the parts.
   The fact that erysipelas begins  by preference at the orifices
of the body and at the points of junction between the skin  and
mucous membrane, that is, at points which  are most exposed to
all kinds of irritation, speaks strongly, too, in  favor of the the- 
ETIOLOGY.
429
 ory.   Observation,  moreover, shows that the process may  be
 continued from the cutis to the mucous membrane, that is, may
 affect it secondarily or take just the reverse course.
    Positive evidence,  too, may be  derived in all cases from the
 so-called  habitual facial  erysipelas, where the inflammation al-
 ways attacks the same portion of skin, and generally also starts
 from the  same point; it is impossible to prevent these recur-
 rences until the chronic and generally scrofulous inflammations
 of  the nasal mucous membrane, the lachrymal sac, the ear pas-
 sages,  and so on, from which they start, are healed.
    In  support of  the  theory of an idiopathic erysipelas  as the
 result of some general  affection, it has also been stated that many
 acute diseases, especially many that are infectious, show a pecu-
 liar disposition to it.   Wunderlich, too,  distinguishes the fol-
 lowing forms of erysipelas : that produced by local disposition ;
 that connected with disturbances of the stomach and intestines ;
 that which slowly wanders ;  that  form, especially the primary
 and spontaneous,  which  is analogous  to  the acute exanthems;
 that produced by pysemic  infection ; the glanders-erysipelas;
 and finally that form  which occurs in  the last stages of  illness
 and precedes death only a few days,—forms of erysipelas which,
 according to his own views, are unmistakably distinct affections,
 and have little in common besides the form of dermatitis and
 their name.   Many of  them should certainly be distinguished as
 phlebitic,  pyamiic, or specific affections  of another sort.   The
 classification of the others offers little difficulty, when their etio-
 logical conditions are  considered.   The occurrence of erysipelas
 as  a specific affection  in  typhus, for instance, can no longer be
 considered strange, now  that  Hunter's1 doctrine,  that two so-
 called  specific  affections  cannot  coexist in the same organism,
 has been refuted.
   The complication is, however, by no means so common as to
establish a relationship between erysipelas  and the specific blood-
poisoning.

  In the course  of typhus  exanthematicus, Murchison* mentions among 14,476
  1 Hunter's Works.  Ed. Palmer, 1, p. 313.
  2  Treatise on the Continued Fevers of Great Britain.   2d Ed.  Lond., 1873. 
430
ZUELZER. —ERYSI PEL AS.
patients only 92 cases of erysipelas (1:159) ; whilst I have observed it but twice in
229 cases.  It may occur at any period of the disease, frequently even in the latest
stages of convalescence ; it begins generally upon the nose or on one ear, especially
if otorrhcea coexists; or starts from abscesses in the eyelids or upon the  scalp.  In
one of my cases the suppurating point  of insertion of a Pravaz' syringe was the
starting-point; in the other, infected from this, it was the catarrhal affection of the
nasal mucous membrane.  In typhoid fever it showed itself in about one per cent, of
Murchison's cases, mostly the facial form, in connection with otorrhcea.  Among 84
cases I have observed it only three times, and Zuccarini eighteen times  in 480 pa-
tients, especially in those who were suffering from ulceration, suppuration,  or hemor-
rhagic infiltration of the mucous membrane accompanying catarrh of the mouth, the
antrum Highmorii, or the cavities of the nose, sphenoid, and middle ear.  Zuccarini
was able to demonstrate in fatal cases that the dermatitis had  developed exactly
over those parts most diseased.   Among the French, erysipelas as a complication of
typhoid fever seems to occur, as in general, disproportionately oftener; at least in
six to eight per cent, of the cases of Louis  and Chomel.   In recurrent typhus Murchi-
son describes only four cases of erysipelas among 1,671 patients.  In variola, also,
it is not very frequent;  in 700 cases, I saw it only seven times, in four of which it
started from abscesses and  bed-sores, and in the others from markedly suppurating
pustules which were deeply seated in the corium.  In the single case mentioned by
Volkmann also, its starting-point from an excoriated pustule was  unmistakable.

    When erysipelas  occurs in  the  course  of other non-specific
diseases, especially in dropsical  swellings  as the result of renal
affections,  to which attention has been  called by  Imbert-Gour-
beyre, and in diseases  of the heart,  its connection with  more or
less considerable injury is easily established.   And in  general,
persons who are  relatively  healthy  and strong  seem to be dis-
proportionately less  subject to  erysipelas  than those who are
weak  or convalescent  from  serious diseases, especially  such as
have  been greatly  reduced by scrofulous  affections,  long-con-
tinued suppurations, or by syphilis.

    The special  etiology  of erysipelas can be given only within
certain limits, on account of the insufficient data  at our  com-
mand.
    With regard to sex, it is almost universally stated in the text-
books that the female is  more frequently attacked than the male.
This relation,  however,  does not seem  to  be  everywhere the
same; for, in  opposition  to the  French  and German  reports,
Hinckes  Bird enumerates, among 260 cases, 147  males and only 
ETIOLOGY.
431
113 females.   Of the fatal cases in England between the years
1862 and 1868, the male  sex numbered 56  per cent, (compare
my Wochenblatt fur med. Stat. u. Epid. 1870-72).
   As  to  age, leaving out of view the earliest days of existence,
when the vulnerability of the skin readily conduces to erysipel-
atous inflammation,  it is the prime of life, the period from the
twentieth to the forty-fifth year (Volkmann),  which is, according
to general acceptance, especially concerned.  Among 12,556 per-
sons, who died of erysipelas in England in  the years 1862-68,
31.1 per cent, were in  their first year, 5.9  per  cent,  were under
five, 2.9 per cent, under fifteen,  4.2 per cent, under  twenty-five,
12.4 per cent,  under forty-five,  20.9 per cent,  under sixty-five,
about  as  many under eighty-five, and 1.4 per cent, were still
older.   It appears, therefore, that the period beyond the for-
tieth year exhibits the greatest predisposition to the disease.
   Any special predisposition connected with  definite kinds of
business or occupation cannot be determined.
   As to the season of its  occurrence, authorities differ widely.
Haller found on  analysis of the cases which were observed in a
period of  ten years, in the General Hospital of  Vienna, that the
majority occurred in April and May, October and November.
Chomel and  Blache  obtained the same results.  Lebertl states
that it  occurs most frequently in January and April; while
among  the  fatal  cases observed  in  England,  in 1862-67,  the
greatest number, 30  per cent., occurred  in January, February,
and March, 25 per cent, in spring  and autumn, and  20 per cent.
in summer.   In Berlin, according to my estimate, the number of
cases in 1870 increased from December to May.   In the military
hospital  of  that  city  the  majority of Ritzmann's  cases (87),
occurred in  the months of November  to January (50), while in
the spring and autumn months  the disease was less common (6
on  an  average).   Hirsch believes that erysipelas is especially
prevalent  in times  of  marked   changes in temperature and
weather, and in damp weather.   The condition of the soil seems
to him of  less importance, while  Naumann is  of the opinion that
the disease is more frequent upon stony and sandy soils.
1 Handb. d. prakt. Medicin.  1871.  II. 
432
ZUELZER.—ERYSIPELAS.
                         Exciting Causes.

    Among the most important of the exciting causes of  erysipe-
las must be mentioned its contagiousness.   Opinions concerning
this  point,  however,  vary  widely.   English  physicians have,
since  the  time of  Graves, declared their  belief  in it;  and  in
France, too, where  at  the Academy of Medicine it  has been the
subject of frequent discussions, influential voices have  spoken in
favor of it;  whereas in Germany the question has been but little
considered,  and only the  latest works offer any evidence of its
contagiousness
    From the   not inconsiderable amount of material  thus far
collected, it follows in support  of this view that erysipelas does
not occur in the form of  extended epidemics,  but  that, on the
contrary, the  cases seldom remain  single,  but  often occur  one
after the other in succession.   Starting from the first case, the
disease often spreads to those in its immediate presence—nurses,
relatives, and  physicians—and  where, moreover, such infection
cannot  be  regarded as the result of a  pervading,  local cause.
The following instances will serve as evidence of this :

   (1.) Wells (1798) describes the following  chain of  cases.  An old man was
attacked with erysipelas faciei; one after the other his wife, the housekeeper, their
nurse, and his  nephew were attacked within  a month, all of whom had come in
contact with him.  (Among the instances of DaudS,  Case 4-5.)
   (2.) Blackett: l After an erysipelas faciei of  a patient, his whole family were
affected in succession.
   (3.) Graves narrates among others a case in which a young man who was taking
care of his mother, affected with  erysipelas, was himself likewise  attacked by the
disease.  (Daud6, Case 11.)
   (4.) Lawrence :  A man with a seton in his neck was attacked with erysipelas of
the part;  his child and wife, who shared the bed with him,  were affected, the first?
with erysipelas cruris, the latter with erysipelas faciei.  (Daud6, Case 9.)
   (5.) Martin: A fatal case of facial erysipelas in a young woman after abortion.  A
few days after, the husband, and a lady who had taken care of the deceased, were
attacked with the same disease.  (Daudg, Case 12.)
   (6.) Fenestre, 1861: Puncture of a suppurating bubo and subsequent erysipelas of
the part;  fourteen days  afterwards a neighbor of  the patient was attacked with
1 Lond. Med. and Phys. Jour.  Vol. 55. 
ETIOLOGY.
433
erysipelas faciei,  and two days  after his death a third  man, who had recently
entered the hospital, was likewise affected.  (DaudS, Case 16.)
   (7.) Fenestre:  Erysipelas in a hospital patient, starting from amputation of the
finger; four days afterwards two wounded patients lying by the  side of the first
were attacked, the one with erysipelas faciei, the other with erysipelas manus;  eight
days subsequently a third patient with fistula ani, and nine  days later a fourth, a
case of cancroid of the nose treated with caustic, were affected, the latter terminat-
ing fatally.  Both of the last two lay in the same hall and opposite the  first case.
The almoner of the institution, who had taken care of the original patient, fell sick
with erysipelas on the following day  and died, and his father, who came to visit
him and  remained two days with him, was also attacked with it and died.   (Daud6,
Case 7-9.)
   (8.) Gosselin:  A rapidly fatal case of erysipelas in a new-bom infant   The
mother was attacked with the disease, in a scratch upon the leg, two days after its
death.  (Daude, Case 21.)
   (9.) Daudg: A woman, who was convalescent from erysipelas, visited a female
friend suffering from it, and was herself in two days again attacked with it.
   (10.)  Ob6: In Piorry's division of  the Hotel Dieu, two girls, one suffering from
odontalgia, the other from angina simplex, were placed in beds near a case of ery-
sipelas faciei.  Two days later both were attacked with the same affection.   (DaudS,
Case 26.)
   (11.)  Trousseau: A fatal gangrenous erysipelas penis et scroti, following a forci-
ble dilatation of the orifice of the urethra.  Twenty-four  hours after his  death the
wife was attacked with erysipelas faciei, following sore throat, and the servant girl,
who  had taken care of him, was seized with angina and erysipelas palpebr. on the
same day.
   (12.)  Trousseau: Erysipelas mammae developed in  an American lady after the
opening of a phlegmonous abscess in the nipple.  Her husband, who was absent,
returned, and in two days a severe erysipelas developed from a slight scratch  upon
his leg.   Ritchie x and others narrate similar cases.

    To these and numerous similar  cases may  be  added others,
which  prove  positively that the disease may be directly trans-
ported  into places which have been previously free from it.

   (1.) Bernutz:  In November,  1864,  a patient with eczema lab. was discharged
from the St. Louis,  in Paris, because erysipelas had broken out  in the hospital.
Four days later she was received into the Hop. de la  PitiS,  where the disease did
not exist, with erysipelas faciei.  On the following  day her neighbor, who lay
opposite, and another patient were both attacked with  the same form of the  affec-
tion.  (Daude, Case 32.)
   (2.) In February of the same  year an old man with  erysipelas entered Gosselin's

                        1 Brit. Med. Journ., 1871.  II.
            VOL. II.—28 
434
ZUELZER. —ERYSIPELAS.
division of la Pitig.   The assistant physician, as well  as several patients, were soon
attacked with the disease.
   (3.) Cornil: In January, 1862, a  person  with erysipelas entered the Hopital
Beaujon.   Several days  afterwards two patients, convalescent respectively from
typhus and variola, and one with pericarditis,  were successively attacked with facial
erysipelas, and prior to this no case had occurred in the ward.  (Daude, Case 25.)
   (4.) Larcher :  A patient with erysipelas faciei was the first case of this disease in
the Hop. Cochin, in April, 1864, and he died  in a few days.  After his death an
old man with retentio urinas, who was placed in the same bed, was attacked with the
disease.
   (5.) Martin: In February,  1863, a  man in the H6p.  de  la Pitie,  from whose
femur a sequestrum had been  removed, was, two days subsequently,  attacked with
erysipelas, for which  he was transferred.  Three days later three other patients in
the same ward were similarly affected.  The first man was carried to a ward where
erysipelas did not exist, but in three days two other patients, and twelve days sub-
sequently still another were attacked  by it;  all of  them had injuries of various
kinds which served as starting-points for the disease.
   (6.) Labbg: In  December, 1857,  an epidemic of erysipelas  prevailed  in  the
surgical wards of the Charite\  A woman with panaritium was attacked in the part
with it, and was transferred to the medical division, in which the disease had  not
hitherto occurred.  She  died, and  her next  neighbor,  with acute rheumatism,
became affected;  and subsequently  erysipelas spread throughout  this  division
also.
   (7.) Pujos: After  a  wound  in the foot a huntsman was attacked with ery-
sipelas cruris  gangrenosum, which proved fatal.  His brother, who took  care of
him, died with e. fac. et  cap.  His daughter  was attacked with  e. migrans of  the
arm and breast, starting  from a slight burn upon the  hand, and the nurse, with e.
faciei.  The woman also  who  washed the patient's linen was affected with  an ery-
sipelas of the hand.
   (8.) Arlt:1 A patient with erysipelas faciei was received into the  Ophthalmic
Division  of  the  General Hospital at  Vienna.  His neighbor was  immediately
attacked with the disease; and on the removal of the first case to another  ward a
still further infection followed.
   (9.) Ritzmann:  In the Berlin Military Hospital ten  cases were observed in
1870-71, infected through other cases, which  were  in the florid or desquamative
stages.
   (10.)  Broadbent:  2  On the 28th of June, 1871, a  man with erysipelas  cap.  was
admitted to St.  Mary's Hospital, where there had been no previous cases.  A  few
days subsequently, three cases  occurred in the ward in which the patient lay.

    In addition to the contagion from patients,  erysipelas seems
"Oesterr. Med. Jahrb 11, p. 147.         ! Brit. Med. J., 1871, 2, 94. 
ETIOLOGY.
435
to be capable of spreading from the  dead body ; at least two
cases have been  observed  by Maclagan 1 and  Rogez (1860)  in
which those who  made the post-mortem examination of patients
dying of erysipelas were affected with it, although their hands
showed  no injury,  and after  a certain period of incubation,  so
that direct inoculation could be excluded.
   With regard to  the way in which erysipelas is transferred
from a patient to  a healthy person, no direct  observations exist.
The question also as to the stage in which the disease is most
infectious has  not yet been  solved, although some instances
show that it is contagious as well in the florid as in the desqua-
mative  period.   The  action  of the poison  does  not  seem  to
extend  over great  distances, since any great number of healthy
persons  are never attacked simultaneously from one  patient,  as
in typhus, for instance, but the disease progresses successively
in hospitals from one bed to another.  In the Berlin Military
Hospital, according to Ritzmann, it travelled in six cases directly
from one bed to the next; and Savory observed, during a great
epidemic in St. Bartholomew's Hospital, in 1872, that the disease
almost always attacked the patient lying next  the one previously
affected.
   Campbell mentions a very remarkable case communicated to him verbally by
Goodfellow, which I quote from Volkmann: " In the course of an epidemic of
typhus, which prevailed in the fall of  1833, erysipelas also  constantly showed itself
in the fever hospital, spreading, as a rule, from bed to bed. The most striking
example of this propagation was in a large ward containing seven beds upon one
side and  six upon the other.  The patient lying in the second bed upon the former
side was attacked with erysipelas.  Then the patients  in bed No. 3, and in No. 1,
were simultaneously affected, and afterwards the one in No. 4, and subsequently all
the patients were attacked in regular order upon that side up to and including No.
7.  From this point the erysipelas extended to the opposite side of the ward, begin-
ning with the bed at the same end as No. 7, and wandering back from bed to bed.
without missing a single one, until No. 12 was reached. The patient in bed No. 13
was alone spared.

   The poison of  the disease offers considerable resistance to the
action of disinfectants, and appears capable of remaining active
also for a long time.   In several epidemics, for instance, in the
1 Edinb. Med. Journ., 1837. 
436
ZUELZER.—ERYSIPELAS.
year 1822, in the infirmary at Montrose, which Gibson observed,
they were obliged  to  evacuate the affected ward, as no means
availed  to check the  spread of the erysipelas when introduced.
At the  present day also it  is shown by many epidemics (one in
the surgical clinic  at Halle,  in 1868, described by Volkmann, in
the Paris hospitals, in the Berlin  Military Hospital, in St. Bar-
tholomew' s Hospital at London, and others), that the most care-
ful and thorough  measures  do not suffice to control the spread
of the  disease where  it is  impossible to immediately isolate
those first attacked.
   The  poison of erysipelas, which, according to the examples
quoted, effects its  spread by contagion, that is, diffuses  itself
through the air to  a certain  distance, is also to a decided extent
inoculable.  The serous  fluid  of the vesicles and of the oedema
of the skin and subcutaneous  cellular tissue seem to  be  espe-
cially infectious by direct  transfer.  The earlier attempts by
Willan, who inoculated with the fluid contents from the vesicles
of erysipelas,  and  produced only a red  and painful  (but not
spreading) inflammation of the skin similar to erysipelas, as well
as those of Martin, from which only a temporary inflammation
of the inoculated places resulted, are to be regarded as negative
evidence of little account.  It has not unfrequently happened
also  that vaccine  matter has  been taken  from children who
immediately afterwards have been  affected with erysipelas, and
used without bad result.
   On the other hand, Doepp1 communicates a very remarkable
case of a positive  character.   Lymph was taken from a child
that was attacked the day afterwards by vaccinal erysipelas, and
nine other children were vaccinated with it.   All  of  them had
erysipelas.
   The disease has also been frequently communicated by dress-
ing wounds with the  aid of instruments  which had previously
been employed  for the  same purpose in  erysipelas.   Ritzmann
shows the probability of such an origin in many cases which
have occurred in the Berlin barracks, and, with many other sur-
geons,  laments  the powerlessness of  the measures  employed
1 Mitthlg. aus d. Arch. d. Ges. corr. Aerzte in Petersb. 1840.  Schmidt1 s J. 30, p. 184. 
ETIOLOGY.
437
against a  direct  transference,  a colportation, of  the infecting
matters by means of instruments, lint, and other dressings.
   Direct  transference  is also positively proved by experiments
upon animals.  Some of the earlier  attempts, like those of Pon-
fick, were  only partially conclusive;  but  lately Orth has suc-
ceeded in demonstrating, in a series of twenty-three experiments,
that erysipelas can be successfully inoculated from man to the
lower animals.
   The  fresh contents of the bullae  of erysipelas bullosum in man, the expressed
oedematous fluid from the portions of skin affected with erysipelas in the rabbits
used for experimentation, as well as the pus formed at the point of inoculation,
and the blood of the affected animals filtered  through linen, were found to be
actively contagious.   If any of these fluids became putrid, their action was some-
what retarded, but did not  fail.  An artificial infecting fluid  also, which was
obtained by the cultivation  of the serum, containing abundance  of bacteria from
the bullae, in Pasteur's solution (10  per cent, sugar, 0.5 per cent,  phosphate of
ammonia), was found to be effective.

   As the  most characteristic appearances of successful inocula-
tion, Orth noticed an affection of the skin, accompanied by a
rapidly increasing  fever,  beginning in  small spots, with cede-
matous infiltration and sharply defined  redness, and once  even
with  the  formation  of bulla3, which extended with more  or less
rapidity.   The parts first reddened became  paler  after a time,
and generally assumed a more yellowish hue, or  in the most
acute  forms  of  infection,  a green, gangrenous color.  In  the
affected parts various large infiltrations of the skin and subcu-
taneous cellular  tissue were found, the young cells, of  which
they  consisted,  forming  abscesses in the  deeper layers,  where
they were most abundant,  but less  frequently in the upper lay-
ers.   This form of disease, which may farther be  produced by
inoculation from infected to healthy  animals, differs manifestly
from  the  phlegmonous and  rapidly suppurating  dermatitis in
putrid  poisoning;  there a  minimum  amount  of  the infecting
fluids  (1-2  cc.)  sufficed,  while  for  this poisoning  relatively
larger  quantities are  necessary;  moreover, in  contrast  with
putrid poisoning, the artificially cultivated fluids were effective.1
   i Lukomsky's essay (Virchoio's Archiv, 60, 3. and 4. Heft) may also be referred to,
confirming the truth of these  statements.  His observations are also important in this 
438
ZUELZER.—ERYSIPELAS.
   I deem  these experiments of Orth's as  conclusive, moreover,
because they produced  appearances  identical  with  erysipelas
occurring spontaneously upon domestic animals,  swine, horses,
sheep, and  the like.1  At all events, they  serve  to confirm clini-
cal experience  concerning the  possibility of successfully inocu-
lating erysipelas.
   From the observations above quoted, it seems very probable
that a great number  of the cases  of erysipelas arise from con-
tagion, or by direct inoculation.
   The isolated, single cases, however, which occur  among peo-
ple without any connection with one another,  and  those cases
which in one and  the same locality appear in multitudes and
simultaneously, can only be referred  to an autochthonic origin.
The following instances illustrate  the affection as it occurs in
this rare manner:
   (1.)  Trousseau observed in a private house a regular epidemic, which affected
simultaneously nearly every tenant, even to the concierge.  Dkect  transference of
the disease seems scarcely probable in such cases.
   (2.)  Daude" relates the following instance: At the end of November, 1864, a
merchant in Paris was attacked with facial erysipelas, and was taken care of by his
wife and maid-servant  The cook did not enter his room, but eight days after his
recovery was attacked with the same form of the disease.  On the same day two
operatives, who had no connection with the first patient, were affected with  the
disease.  Twenty-one persons, of  whom  eighteen were  girls or women, were
attacked one after the other.  At the same time numerous other cases occurred in
the city and environs.

   Some authors would  refer the sporadic cases to a "pysemic
infection,"  the relationship of  which to erysipelas is maintained
on  various  grounds, especially from a surgical  point of  view.
Roser, for example, regarded many cases of erysipelas occurring
in hospitals as the  expression of a mild miasmatic pyaemia, and
Pirogoff could not  conceive of  erysipelas without pyaemia, or of
the latter without erysipelas.  Not to  mention the fact that the
latter expresses himself like Volkmann,  who  declares against

respect, that it is not merely subcutaneous injections, but also the mere painting of the
fluids, taken from parts affected with erysipelas, upon wounds, which will produce a
similar inflammation.
   1 See Spinola, Path. u. Ther. fiir Thierarzte.  Berl., 1863.  p. 28. 
ETIOLOGY.
439
such  a connection, and  extends the conception of "traumatic
erysipelas," probably after the custom of many  English  phy-
sicians, to phlegmonous  inflammations as well, numerous obser-
vations do not show any such relationship.   In the epidemic at
Bordeaux,  for instance,  where, according to Pujos, thirty-four
per cent, of those affected died, no  case of pyaemia occurred.
In Volkmann's Military  Hospital at Trautenau (1866) there were
pyaemic affections, but no erysipelas ; and Ritzmann shows that
in the Berlin Military Hospital, in 1870, pyaemia occurred during
the first months of  its  occupancy  with great frequency, while
the cases of erysipelas exhibited a frequency very different from
it in point of time as well as duration.
   Hitherto no  one  has succeeded in discovering the  noxious
influences which lead to the spontaneous development of ery-
sipelas  in certain localities.  There has been a disposition to
connect it with the crowding together of many persons in con-
fined  institutions, but this opinion is not sustained by experi-
ence ; for the  disease, which it is true  never dies out in many
old and unwholesome hospitals, often  occurs  very extensively
in the most modern establishments, which fulfil every claim of
cleanliness.   Erysipelas is indeed relatively  rare  in  prisons,
transport-ships,  and  even in  military  hospitals,  where great
numbers of severely wounded, with suppurating wounds, lie
crowded together under  the most unfavorable circumstances.
In the Crimean  war,  for instance,  while  pyaemia and  hospital
gangrene were claiming  numerous victims, it was scarcely ever
observed by the  English ; and in the war of 1866, Volkmann did
not see a single  well-marked case in  Trautenau and other hos-
pitals, where about 1,000 wounded were quartered.  During the
war of 1870-71 it occurred very infrequently, according to my
observations, in some of the lazarettos established in France, but
in the well-situated  military hospitals  in Berlin,  on the  otlier
hand, it attacked two per cent,  of the wounded (v.  Steinberg).
   In other cases the cause of the disease has been sought in the
pollution of the soil,  as in the frequent overflowing of the cellars
of the Hotel Dieu by the Seine,  for instance ; and yet this theory
is unsupported by any considerable number of observations.
   Several  instances seem  to me nevertheless  to point to more 
440
ZUELZER.—ERYSIPELAS.
definite local causes.   Volkmann's treatise narrates that in the
Middlesex Hospital, for a long  time, those patients  exclusively
who lay in two beds, standing next each otlier, were constantly
attacked one after the other with erysipelas, without any farther
infection occurring in the same ward.  It was finally discovered
that a pipe from the privy,  which was situated  in  the wall
between these beds, was defective ; it was repaired,  and the ery-
sipelas disappeared.   Ten years afterwards erysipelas  began
again in the same beds ; and, mindful of former experience, the
pipe was examined, and again found defective; on mending it
no new case occurred.   An entirely similar instance was observed
in the surgical division of the Berlin Charite, where the disease
occurred only in certain beds which stood  directly  above a
defective privy pipe;  after  repairing it the erysipelas disap-
peared.
   To these cases may be added a very important observation by
Konig. During a slight epidemic,  at the clinic at Rostock, it was
noticed  that only wounds  from  recent operations, and indeed
upon  such  patients  only as  had been operated upon in the
operating theatre, were attacked with erysipelas.  The  cause o|
this infection  was finally suspected to be the use of the pillows
of the operating  table, which were saturated with blood ; and
in fact after their removal the erysipelas disappeared.   This
theory received farther support by the following experiment:
The pillows were extracted with water for twelve hours, and with
this rabbits were  inoculated.   One attempt was without result;
in the other there was developed from  the point of  inoculation
upon the back a diffuse dermatitis, which spread over the belly,
produced oedema of the praeputium, bullae and crusts upon cer-
tain places, and disappeared, after twelve days.
   These observations are not yet numerous enough to afford a
basis  for positive judgment  concerning the noxious influences
which give rise  to autochthonous erysipelas;  they may, how-
ever,  be  regarded as an important starting-point  for  farther
investigation. 
PATHOLOGY.
441
                        PATHOLOGY.

   Symptoms.—Erysipelas generally begins suddenly with chills,
less frequently there may be a feverish condition for  a day or
two beforehand.
   The first local symptom  is a feeling of warmth, tension,  and
pain in the skin, which  soon shows oedematous  swelling,  and
becomes red.  The redness  is at first pale and in spots, it  then
becomes diffused and more  intense, and disappears on pressure
with the finger, to return again when this is removed. The swell-
ing reaches a high degree early, especially in places where the
skin is attached to the underlying parts merely by loose cellular
tissue.   On account of the great stretching which it undergoes,
the skin appears  smooth and shining.  At the  same  time the
painfulness of the affected part increases, and it is intensified by
pressure, which leaves a pit  in the swollen skin.  The  lymph-
glands in the neighborhood swell  more or less, but  return to
their natural  size immediately on the disappearance of  the
cutaneous inflammation.
   Most frequently it is  the skin of the face and head which is
affected, less often that of the extremities and  trunk ; and slight
or more severe injuries of the openings leading to the cavities of
the body, of  the  nostrils, eyelids or meatus of the ear, or of the
mucous membrane of the nostrils or throat, serve as the starting-
point.
   The  redness and swelling reach  their highest degree of devel-
opment on the  second  or third day,  and  in facial  erysipelas
patients at this time are greatly disfigured, and  are scarcely to
be recognized ; they can  with difficulty open the oedematous and
prominent  eyelids.  On  the third  or fourth day the parts  first
affected  become gradually paler, the  swelling and painfulness
diminish, the skin  becomes wrinkled, desquamates in branny
scales or larger flakes, and only retains a slight  yellowish or
brownish color which soon disappears.
   The progressive course of the skin affection is especially char-
acteristic of the disease.  While the erysipelatous inflammation
is still in the stage of eflaorescence,  or  already subsiding at the
part first affected, it spreads at uncertain intervals to the neigh- 
442                ZUELZER.—ERYSIPELAS.
boring parts, and there reaches its height at correspondingly later
periods.   On the side where it is  advancing, the redness which
elsewhere runs gradually into the color of the neighboring skin,
is generally marked by a sharply defined and often wall-like ele-
vated edge.  The course of  its extension is often  preceded by
peculiar tongue-shaped projections beneath the cutis.
   Erysipelas faciei et capit.  is limited  mostly to a more or less
extensive portion of the skin of the head and face, and seldom
descends over the neck to the trunk.  Upon the latter, and upon
the extremities, it often wanders over large surfaces.  The course
of the disease is,  therefore, in the  first  case, only three or four
days, or one, two or more, seldom  three weeks ; but in the latter
situations it is often much longer,  and in some cases it reaches
a duration of several months.
   In proportion as the oedematous  swelling of  the skin ad-
vances, and to the more or less acute progress of the disease, the
epidermis is often raised in  smaller or larger bullae, which are
filled with a serous fluid of  a  yellowish < ? bloody tint.  These
subsequently burst and dry up, or form crusts.
   Simultaneously with the cutaneous inflammation, the temper-
ature and the pulse-rate rise rapidly and considerably, the former
even to 41° C. [= 105.8° F.]  and upwards.   The patients com-
plain of  headache,  prostration, loss  of appetite,  and  often  of
nausea, vomiting, and great thirst.  The tongue is thickly coated,
and, when the fever is high, dry; the hepatic region is often pain-
ful to pressure ;  and the urine scanty, turbid, and often albumi-
nous.  The sleep is uneasy, disturbed  by wild dreams, and  in
erysipelas of the head and face often wholly absent.  Not unfre-
quently delirium is present.
   The mucous  membranes bordering upon the affected skin—
those of the nose or throat, of the ej^es, vagina, etc.—are almost
always, and often in a high degree, affected secondarily by the
inflammatory process, which also is primarily developed  upon
those superficially situated,  and may,  by extension to deeper
parts, especially in the air-passages,  give  rise to grave distur-
bances.  Erysipelatous angina renders  swallowing difficult, and
by extension not infrequently leads to laryngitis, bronchitis, and
even pneumonia. 
ANATOMICAL CHANGES.
443
   The  termination is almost always in recovery with persons
previously healthy and strong.  The fever, which runs parallel
with the cutaneous inflammation, ends simultaneously with  it;
the other symptoms quickly abate ;  only convalescence is occa-
sionly disturbed by numerous abscesses, which often appear for
weeks after  the cessation of the fever.  The patients exhibit a
strong disposition to  relapses, which sometimes return more or
less periodically.

                    Anatomical Changes.

   Inasmuch as erysipelas is seldom fatal or accompanied by
severe  chronic  affections, the number of post-mortem examina-
tions in uncomplicated cases is very small; most of them concern
cases which have been complicated by other affections, and where
death has been  caused by the latter.  On this account our know-
ledge of the anatomical changes peculiar to erysipelas is but lit-
tle advanced, and the various statements which have  been col-
lected, by Daude and Ponfick for example, differ widely from
one another.  Excluding the conditions which belong to the com-
plicating affections, of most diverse character, the following may
with probability be referred to erysipelas.
   Inflammation of the mucous membrane of the throat is often
met with in facial erysipelas ; with this is connected, at one time,
inflammation of the mucous membrane of the nasal, frontal, and
Highmorian cavities (Zuccarini), at another time, of the larynx
(often in such cases with severe oedematous swelling), and of the
bronchi and the lungs.  (Cases by Wutzer, Avery, Hebra, Fen-
estre, Labbe, Peter, Trousseau.)
   Independently of this, hypostatic congestion and croupous
pneumonia are found at times (Thoinnet, Trousseau, Ritzmann,
and others).   Serous and purulent pleurisy is described by Law-
rence, Velpeau, Daude, Ritzmann, and others, and anterior medi-
astinitis by Lawrence and Ponfick.
   Enteritis in the lower portion of the duodenum was found by
Lawrence, Hebra,  Bennett, and others ; considerable hyperaemia,
with intestinal hemorrhage, by Bayer ; small duodenal ulcers in
the neighborhood of the ductus choledochus,  by Malherbe and 
444
ZUELZER.—ERYSIPELAS.
Larcher ; and peritonitis by Trousseau, Hebra, Wilks, Ritzmann,
and others.
   The  spleen is unanimously described as enlarged, softened,
and often liquefied (Ponfick), while with regard to the condition
of the liver the statements are entirely at variance.
   The  kidneys were always found  by Ponfick in a state of
parenchymatous nephritis.
   Heart.—"The statements of Sevestre concerning the frequent
occurrence of endocarditis  and pericarditis have not been sus-
tained by dissections, the latter only having been found twice in
the dead body.
   Meningitic affections seem to occur only  as  the result of
wounds or other complications.
   The  blood was found by Hebra, when death occurred at the
height of the disease, bright red and  thin, but when the patient
died after  any considerable  exudation,  thickened; by  Pihan-
Dufeillay it was  found dark-colored  and thin; by  Ponfick,
dark, thin, and varnish-like.  According to  Virckow, the propor-
tion of fibrine is increased.
   In contrast with these meagre and dissimilar statements, there
appears as a uniform condition, according to Ponfick's observa-
tions of eleven cases, a more or less marked  parenchymatous
degeneration of the muscular tissue of the  heart and vessels, as
well as  of  the extremities and trunk, and  of the liver and kid-
neys ; also softening and hyperplasy of the spleen.
   The affection of the skin has been studied more thoroughly.
   According to Biesiadecki' sx  beautiful investigations  of the
facial form of the disease, which agree with those of Volkmann
and Steudener, simple erysipelas, like phlegmonous inflamma-
tion, affects the  skin in its whole thickness and the subcutane-
ous cellular tissue.
   The rete Malpighii is dried up in the dead body almost  to a
horny layer or crust, and when removed there remains attached
to the swollen papillae only the  deepest  row of cells, which are
loosened in  their connection, and, like the epidermal cells of
hair follicles and  the outer  layer of the sebaceous glands, are
much swollen.
1 Sitzungsber. d. K. Acad, der Wissensch. zu Wien.  1867. II. p. 231. 
ANATOMICAL CHANGES.
445
   All the layers of the corium and of the subcutaneous cellular
tissue  are oedematous, swollen, and penetrated by large, finely
granulated,  white blood-corpuscles.  The  meshes of  the  con-
nective tissue in which these cells are embedded are very decid-
edly separated by them and by the fluid which uniformly perme-
ates the tissues.  In proportion as the cells are massed together
in quantity,  the individual  fibrillae lose their sharp outline,
become broader, swell up, and finally leave behind only a homo-
geneous matter, which is faintly colored by carmine.   In this
way an abscess is formed, situated most commonly at the tips of
the papillae, and traversed only by solitary and often torn elastic
fibres.
   The blood-vessels  are enlarged,  and filled with corpuscles;
their walls, however, are unchanged, and sharply defined against
the surrounding masses of cells. Only in the proximity of  the
abscess formation does their contour disappear, and beyond this
their course is marked only by  a brown mass of decomposed
blood.   As soon as the skin becomes  pale, however, after  the
second or  third  day, according to Volkmann  and Steudener, a
rapid destruction of the escaped elements begins.  In the subcu-
taneous cellular tissue there  are very soon to be found only
masses of cells in a state of finely granulated disintegration, and
a few  hours  afterwards  often only granular  detritus.  In  the
upper layer of the cutis only the lymph vessels are thickly filled
with the uniform granulated cells or surrounded with large col-
lections of them.  A portion of them are, perhaps, taken up by
them;  but the most of them,  however, rapidly perish, for in a
day or two afterwards there is often not a trace of the affection
to be found in the skin.
   We now come to  the above-mentioned  numerous  observa-
tions upon the extensive occurrence of globular bacteria (puncti-
form bacteria,  Ehbg.;  microspheres,  Cohn) without spontaneous
movement.  They were first  discovered by Huter, then by Xep-
veu, Wilde, Orth, and Wahlberg, everywhere in the  inflamed
tissues, and especially abundant  in the oedematous parts, much
less so  in the blood.

   On  reviewing these results,  we find little that  is specifi- 
446
ZUELZER.—ERYSIPELAS.
cally characteristic.  The parenchymatous changes of the large
glands and of the heart have been recognized,  since Liebermeis-
ter's observations, as conditions which are common to every sort
of severe febrile affection.  The intense cutaneous inflammation,
with the abundant oedema, occurs also in phlegmon.  The slight
differences consist only in the relative integrity of the peculiar
parenchymatous tissue, in the absence of destruction of  the fat
cells,  of the liquefaction of the intercellular substance,  and in
the rapid  restoration  of  the normal condition in erysipelas
(Volkmann).   The bacteria  also, which  are described, offer  no
morphological peculiarities.
   The anatomical changes, therefore, will not suffice to  answer
the often proposed question, whether erysipelas constitutes  an
independent disease,  or is only a simple  inflammation  of  the
skin without  specific  character, as  Hebra  and  lately Klebs
(Handb. der pathol. Anat.) regard it.  In fact, Virchow,1 Hey-
felder, and others are of  the opinion, that in addition to the
infectious form  there  may be a non-infecting erysipelas, pro-
duced by  thermal, chemical, or mechanical influences, which
possibly may become infective secondarily, and then for the first
time assume a specific  character.
   In  considering  the  anatomical changes, we must also at the
same time have regard to the course of the affection.  The most
important  distinctive  feature in erysipelas,  besides its fuga-
city,  is  its disposition to  spread  only  by creeping uninter-
ruptedly  onwards without  making jumps.   This peculiarity
finds  its anatomical  expression, if I may so speak, on the one
hand in the direct continuation  of the inflammatory process to
mucous membranes  which  are  in  direct connection  with the
affected portions of  skin, on the other hand  in the absence of
more grave changes, especially those of  a pyaemic character, as
large abscesses at the height of the disease, embolus and infarc-
tion,  diffuse inflammation  of serous and synovial membranes,
and the intestinal affections so common in  septic poisoning.
(That  pyaemia and erysipelas do not exclude  the coexistence of
each other, is shown by some observations of Ritzmann, in which
the latter was complicated with pre-existing pyaemia.)
1 Ueber Lazarette und Baracken.  Berlin, 1871. 
ETIOLOGY.
447
   In comparison with this,  no inflammation of the skin pro-
duced by external thermal or otlier irritants shows this pecu-
liar  method  of  spreading.  A more or less extensive, diffused
phlegmon and lymphangitis,  such as many observers at least
have in view, does not run its course without  leaving  behind
it corresponding local changes.
   But is the exciting cause,  the morbid poison of erysipelas,
that always  runs a uniform course,  varying  only in intensity
and  extent, is it  constantly the same, or may, perhaps, products
of decomposition of various kinds, or animal poisons, produce
the same affection ?  Billroth admits the latter theory, although
he has abandoned his former  distinction between an erysipelas
which is produced by self-infection in consequence of secretions
retained  and decomposed in wounds,  and one which  is the
result  of infection from without.  Observations in the  French
war, where great numbers of  wounded were crowded together,
showed him  that erysipelas was developed under  such circum-
stances less frequently than was to be  expected  according to
such theory.  The question may  be considered as settled  up
to a certain point by the inoculations which  have been  made.
The  specific  poison  always  yielded (Orth, Lukomsky, and,
apparently also,  Konig) a well-marked erysipelatous inflamma-
tion, even when only small quantities were used.  Putrid infec-
tion, however, which, according to my own and numerous other
experiments,  requires relatively large quantities of the  infect-
ing material,  produces  sometimes extensive suppurations  and
abscesses  of  the cellular tissue, but (with the  single  excep-
tion  of a case by Ravitsch) no affection  resembling erysipelas.
(From  the additional experiments which  Orth has in view, we
may expect further advances in our knowledge of this subject.)
   In what substance we are to seek the morbid poison has not
yet  been  positively determined, but a  contemplation  of the
observations in hand leads to several established points.
   We have  to  consider  a  disease  which is inoculable  and
contagious, and  may under given circumstances exist sponta-
neously, as well  as a fixed poison  which can also  diffuse itself
through the air.  The affection starts from some solution of
continuity of  the skin or superficial mucous membrane ; upon 
448
ZUELZER. —ERYSIPELAS.
more deeply situated parts, the stomach or lungs for example,
it never arises primarily.  As soon as the irritating action of the
poison begins, the inflammation of the skin spreads outwards,
step by step, from the affected  part,  halting,  according  to
Pfleger's investigations, at places where mechanical obstacles or
the resistance of pressure stand in its way,  or turning aside
for them, and returning again,  indeed, to the part  previously
affected, without leaving behind any serious disturbances even
after  frequent  relapses.  This process can  with difficulty  be
explained otherwise than as produced by  an irritation which is
always present within  the sphere of the existing  inflammation,
and which is constantly being  pushed forwards mechanically.
Every fluid would behave under the same conditions of pressure
just as does the oedema, which plainly carries the irritant along
with  it.  The lymph-vessels, also,  which have  often  been re-
garded as the exclusive  channels for the distribution  of the
poison, are  affected, as will be shown farther on, only in the
same  degree as the other tissues  within the area of the inflam-
mation.
    Matter chemically different, such as the products of decom-
position of  the albuminates, could not give rise to  such  a
condition, even were it considerably increased,  since it would
leave behind it, at the part  first affected, much more  serious
after-effects than erysipelas, which, in spreading, leaves the part
first involved already in process  of recovery.  At  all  events,
under this supposition it could not be explained why the local
affection  limits  itself  to the skin, and why in its spread  it
follows purely mechanical laws.
    We can  think  rather  only of  an agent which is  in  the
broadest sense ferment-like or mechanical in its action,  with an
activity and vitality  of short  duration  only, but  with great
capability of reproduction.   In  the present  state of our  know-
ledge we are led to attach ourselves to the indications presented
by the bacteria, which as carriers,  or exciters, or  at  least as
attendants of the process, are surely found.   In addition to this
result, the  published investigations of Lukomsky  really point
to the same conclusion.  It appears by these that in the animals
experimented on,  the bacteria (micrococci)  were  found only 
ETIOLOGY.
449
during the  existence of the dermatitis,  and that they disap-
peared simultaneously with its expiration.  The products of the
local irritation, especially the  cellular infiltration, disappear in
the same way, or at least only a little more slowly, according to
the above-mentioned investigations of Volkmann and Steudener.
While by this coincidence  a connection of the  affection  with
these  organisms is made probable, some experiments of Orth's
show, moreover, that the oedema of erysipelas is at least weak-
ened in its  infectious  properties as soon as the  vitality of the
bacteria is impaired by the use of carbolic acid and the like.
   After this we are  no longer authorized in rejecting the theory
which regards these  objects as at least local exciters  of  disease.
The strict dependence of the general  symptoms upon the cuta-
neous inflammation  is, moreover, very  remarkable.   Even the
increase  and diminution in size of the spleen proceeds mostly
parallel with it.  A beautiful proof of this was  furnished by
Friedreich,  among others  (Samml. klin. Vortr. 75), in the  case
of a patient with a  wandering spleen, in whom,  by means of
palpation, its enlargement and diminution,  synchronous  with
the course of erysipelas, could be  demonstrated.  Can any irri-
tant be conceived of,  in our present state  of  knowledge,  the
general  and local action  of which begins and  ends simultane-
ously, unless it is sought in the vital process of these organisms ?
   To be sure, it cannot yot be determined in what way the mor-
bid symptoms are brought about.   It  is regarded as possible
that bacteria may produce a matter which  may  act as an irri-
tant both locally and generally ; but such an one would,  if solu-
ble, hardly  confine  itself  within  bounds limited  purely by
mechanical  relations ;  otherwise, however,  the  irritation could
not immediately follow the advance of the oedema.
   It may be conceived, therefore, that  these  organisms may
produce a mechanical  excitement of the cutaneous  nerves by
their rapid increase1 alone.   Such irritations may,  however,  as is
well known,  in addition to the local symptoms, such for instance
as follow the use4 of epispastics,' produce, according  to their
strength, a more  or less prolonged and  considerable  increase of
         1 Zuelzer, Deutsche Klinik 1865.
VOL. II.—29 
450
ZUELZER.—ERYSIPELAS.
temperature, and a corresponding effect upon the vascular sys-
tem.  In favor of this, on the one side, are the  observations of
Naumann, ; on the otlier side the well known  works of Lieb-
ermeister,2  Gildemeister,3 and others,  and the investigations,
moreover,  of Kuntz and Rohrig,4 Paalzow,5 and  Haidenhain
(Pfluger's Arch., III.  504), which show that  a fall of tempera-
ture takes place within the body by irritation of the sensitive
nerves,  cannot be  regarded as standing  in opposition to this.
These investigators were  concerned with different periods in the
course of the experiment,  which, as Virchow suggests (in  his
Arch. 52), may possibly bear the  same relation to each other as
the narrowing of the vessels which accompanies irritation does
to the hyperaemia which follows it.
   This view is supported, too, by the evidence of increased con-
sumption of  oxygen and  production of carbonic acid, as well as
by the  increase in the excretion of  urea, although small,  as
determined by Beneke6 and  others.
   It must, it is true, be granted that the increase in tempera-
ture and metamorphosis of tissue  falls far short of the rise which
takes place in fever.  It is  easily conceivable, however, that an
excitement of the cutaneous nerves of  a  more appropriate sort
than the electric point or  a cold bath affords,  aided by the rapid
emigration of  the  white blood-corpuscles, might give  rise to
much more intense symptoms.
   More positive data in these directions, however, can be ob-
tained only by experimentation.   Many an experiment in thera-
peutics  has been based upon a similar supposition, although the
result does fall short  of  the expectation.   If, then,  our knowl-
edge of  the nature of  this mysterious disease is enriched by the
proof that it is connected with the immigration of these parasitic
organisms, only by a fact which  requires  for its full valuation
  1 Prag. Vierteljahrsschr, 1865.  Pfluger's Arch. 1872.  p. 196.
  2 Prag. Vjahrsschr.  1864. Arch. f. klin. Med. X. ff., Virch. Arch. 52 ff.
  3 Ueber die Kohlensaurenproduction bei der Anwendung von kalten Biidern  etc.
Basel, 1870.
  * Pfluger's Arch.  1871.
  6 lb. 492. 1871.
  c Grundlinien der Pathologie des Stoffwechsels. Berlin, 1874.  p. 117. 
SYMPTOMS.
451
further investigations in a  new direction, it is still a great gain
that a departure may be taken from a definite point.

                        Symptomatology.

   Integument.—The local  affection begins generally with swell-
ing and painfulness  of a  small portion of  skin,  which soon
becomes rose red, and later darker in color, and rapidly increases
in size.  New spots appear near it, which become confluent, and
in a few hours, according to the locality affected, the skin, of the
size of a dollar or the palm of the hand, is colored  deep  red,
swollen, and hot, and the patient experiences a stinging or burn-
ing pain in it.  On slight pressure with the finger the redness can
be made to  disappear  temporarily, and  a pit is left in the dis-
tended skin, which  gradually  fills up  again.   On puncture a
serous fluid mixed with blood is discharged.  Pressure produces
also a lively pain.
   Erysipelas has  the disposition,  moreover, to spread superfi-
cially with greater or less  rapidity (erysipelas ambulans  s. ser-
pens).  It seldom  remains  confined to a  small area (e. fixum),
but often  spreads  from the part first attacked over wide regions
of the skin, from  the head at times to  the neck, from there to
the back and front of the trunk, to the upper or  lower extremi-
ties,  or followrs  the  opposite course, according to its  starting-
point.  Upon the  extremities  it often attacks large portions of
the skin.
   Until very recently no explanation of the apparent irregularity in the method
of its  extension had been discovered.  The early theory of Billroth's, that the ery-
sipelas really followed the  course of the lymph vessels, had not been confirmed.
Only lately has  Pfleger, at Billroth's suggestion, collected observations upon this
point in fifty-five cases.  His results are therefore of special importance to our com-
prehension of the course of the disease, as they show that its  extension is deter-
mined  in accordance with the above expressed opinion solely by the mechanical
relations of the pressure exerted through the cutaneous coverings.

   The advance of the erysipelatous redness in  the skin takes
place in many cases in  the  same way, to use a striking illustra-
tion of Billroth's,  as water spreads in blotting-paper.   The red-
ness and swelling  of the skin is not sharply defined, but gradu- 
452                 ZUELZER.—ERYSIPELAS.
ally passes into the normal skin ; only on one side the border is
generally  formed by an abrupt, wall-like,  and somewhat  ele-
vated edge (e. marginatum), and it is from  this that the exten
sion mostly proceeds,  rounded, tongue-like, subcutaneous pro-
jections shooting out, which are followed by a broader advance.
The appearances are generally complicated,  more particularly
upon  the  anterior and inner side of the thigh and the external
surface of the  thorax, by a redness of the subcutaneous veins
and the lymph vessels, extending  from the  border  of the ery-
sipelas to  the nearest lymph gland.   While, however,  the skin is
movable  over  these,  the  points  or  outshoots, according  to
Pfleger's investigations, lie  apparently nearer the upper surface
of the cutis.   Their extension seems to depend solely upon the
architectural  relations of the cutis over the various parts of the
body.
   The investigations of Langer', Biesiadecki, and others show,
as is well known, that the  main lines of the bundles of fibrous
tissue  in  the subcutaneous  tissue  cross each other  in rhombic
meshes.   If holes are made with a round punch in the skin, they
are drawn out into slits according  to the direction of the longi-
tudinal diagonal of these rhombic meshes, which also determine
the arrangement of the meshes of the networks  of the blood and
lymph vessels, and which designate the direction of the tension
to which  the  skin is subject.  Over all  regions  of the body
where,  in general,  tension  exists  in an  upright symmetrical
attitude, and especially where it is  not uniform, a  great stretch-
ing constantly takes place  in the  direction of  these  slits.   In
their direction, that is, in that  of the greater tension, the spread
of the erysipelas meets with less resistance than in  any other.
The projections,  also, which accompany the extension  of the
erysipelas, push themselves forward according to the lines  of
these slits.  Inasmuch, now, as the  blood and lymph vessel dis-
tricts,  especially on the  extremities, correspond to  these,  the
serous exudation is also pushed forwards in these directions in
consequence of the less resistance.
   In  places where the skin is  of  thicker structure and more
   1 Zur Anatomie und Physiologie der Haut, (1) iiber die Spaltbarkeit der Cutis, (2)
fiber die Spannung der Cutis.  Sitzungsber. der k. Acad. d. Wissensch.  z. Wien 1861. 
SYMPTOMS.
453
 firmly attached to its base, by means of the so-called ligamen-
 tum cutis around the base of the skull, at the condyles of the
 joints, over the crest of the ilium, Poupart's ligament, the spinal
 tibiae, and so forth, and at places, too, where two portions of
 skin  possessing a different cleavage border upon one another
 without crossing,  a  real hindrance to  the  farther extension of
 the erysipelas seems to  be offered.  It progresses with  striking
 slowness  in these regions, halts, or goes around them and leaves
 them untouched throughout its whole course.   Thus, for exam-
 ple, erysipelas, when it starts  from the mamma, remains station-
 ary at a  horizontal  boundary line  on a level with the  xyphoid
 process.   It  confines itself, moreover, generally to the face and
 head,  and  moves, when  it  progresses, only over  the  scalp
 towards the neck, and from thence onwards.  The same  method
 is followed when  the  direction pursued is reversed.   In this
 case it spreads from the scalp  to the ears, thence to the forehead,
 cheeks, eyelids, nose, and  finally to the lips.  The chin remains
 almost always free, even  when the erysipelas  starts  upon the
 head, at the nose, or at the corner of an eye for instance, prob-
 ably because a perpendicular  tension prevails in the skin of the
 chin, while immediately in the neighborhood it ascends towards
 the angle of the mouth obliquely, and extends into the region of
 the cheeks in a horizontal direction.
   The arrangement of  the papillae in the papillary bodies in
 rows corresponding to the folds or furrows in the skin also serves
 as an  obstacle to the direct spread of the erysipelas.  It evades
 the folds, the plica  naso-labialis,  the furrows in  the forehead
 and buttocks for instance, inasmuch as  it pushes itself forwards
 not continuously, but from their terminal angles.
   In portions of  the  skin which are firmly bound down to the
 subcutaneous base the formation of the outshoots fails  more or
 less, and  the progress at such parts takes place  mostly in the
 form of a  broader advance.
   The  unequal rapidity  with  which erysipelas  extends  over
 different parts of the skin also seems to be in conformity with
 these observations.  It spreads most quickly upon the back and
 scalp, upon the  shoulder in the direction of the outshoots  from
behind forwards, and  upon the upper arm and  thigh centri- 
454
ZUELZER. —ERYSIPELAS.
petally.   Over the rest  of the body Pfieger  noticed no special
difference in the rate of its progress ; but it appears to spread
everywhere more  quickly in the direction of  the points  than
perpendicularly to them.  It extends  as well  centripetally as
centrifugally, probably because the oedema which  distends the
cutaneous tissues  to a considerable extent is  constantly pushed
forwards, when greatly increased,  towards  the point  of  least
resistance, that is, parallel with the direction of the cleavage of
increased tension and of least pressure.
   Some descriptions mention cases where island-shaped portions
of the skin, not in direct connection with the main disease, are
affected,  erysipelas erraticum.  In fact, as Pfieger observes, ery-
sipelatous patches several centm.  distant from the borders of
the dermatitis not unfrequently  occur.   In  these cases, how-
ever, the intermediate skin is always painful at some points ; the
process being continuous, therefore,  although in the interval it
has not attained a full development.  There is often found, also,
a zone of  a certain size beyond the reddened portions, where the
skin is painful on pressure.
   Every part attacked by erysipelas exhibits on the second or
third  day its highest  degree of  swelling  and redness.   In the
facial  fprm patients  at  this  time are  greatly disfigured  and
scarcely  recognizable; they are  unable to open the oedematous
eyelids, which are often as tense as a drum, and the external ear-
passage and the entrance  of the nostrils are also not unfrequently
swollen up.
   The serous  infiltration of the skin is of various  degrees.
Sometimes it is  firmly stretched and has a shining aspect, ery-
sipelas glabrum s.  levigatum;  sometimes it  appears, in .conse-
quence no doubt of' the manner of its attachment  to the under-
lying  parts,  warty or wheal-like,  e.  verrucosum,  or, when the
streaked form prevails, e. variegatum.  The epidermis is often,
in consequence of unusually strong distention  and rapid  exuda-
tion, raised up, especially upon the face, in the form of larger or
smaller blebs, according  to  the  size of which the older authors
distinguished an erysipelas miliare,  phlyctaenulosum, vesiculo-
sum, bullosum, and pemphigoides.
   The formation of these blebs has no specific significance in the 
SYMPTOMS.
455
disease.  Sanson indeed is of the opinion that in the forms de-
scribed as e. cedematosum and erythematosum, the swelling may,
with the aid of a lens, always  be found  covered with  small
phlyctenae.  The blebs are filled with a clear, yellowish serous
fluid,  sometimes tinged  with blood, that contains  numerous
bacteria, and is often  gradually made turbid by the abundant
appearance  of pus-corpuscles,  or,  according to Lewin,  by cells
from the rete Malpighii.
   On  the third, fourth, or fifth day of its existence,  the swell-
ing subsides, the redness  fades generally to a light-yellow color,
and the  painfulness diminishes.  The tension in any  blebs that
may be present relaxes,  and their contents are reabsorbed, or
they burst  and dry  up into  lemon-yellow, semi-transparent
scales,  or less frequently into crusts of considerable size, e. crus-
tosum.   Desquamation of the epidermis, in the form of  large or
branny scales,  and wrinkling of the  skin, terminate the local
process.  There often  remain  for  days or  weeks, afterwards a
little a>dema, a certain stiffness, and a slight anaesthesia of the
skin.
   Not unfrequently more or less numerous abscesses are formed
in the  subcutaneous fibrous  tissue after the termination of the
acute process,  which protract the  convalescence for months at
times,  and upon the scalp especially may attain a wider spread.
Landouzy counted as many as sixty-nine upon a patient.  They
do not appear, however, before  the complete  termination of the
dermatitis, which is a  circumstance of importance in  diagnosis,
because in phlegmonous processes the abscesses mainly accom-
pany the course of the disease.  They seldom give rise to serious
symptoms, but are perfectly reabsorbed, as in Orth's experiments
upon animals.  Their origin may probably be traced to the little
points  of suppuration  situated, according to Biesiadecki, in the
tips of the papillae.
   The hairs fall from the scalp, as a rule, during  convalescence,
in consequence of the dropsical  infiltration, by which  the exter-
nal root-sheath is separated from the vitreous layer of the folli-
cle as  far as its junction with the  papilla  (Haight).  The hairs,
however, quickly form again.
   Generally  at  the close  of the erysipelas  the skin returns 
456                ZUELZER.—ERYSIPELAS.

completely to its  normal state.  In certain places, however, the
skin, on the  contrary, undergoes more or less extensive gangre-
nous destruction, as upon the eyelids (Arlt),  the  scrotum, pre-
puce, and vulva ; parts, that is, where the particularly thin and
tender skin, without any firm underlying  tissue,  and  held
tightly at only one edge, is provided with loose cellular tissue,
and undergoes, in the course of  the disease, enormous swelling ;
less frequently upon the  skin  of the  cheeks and the patella
(Heyfelder), where the circulation has been obstructed by great
oedematous distention.  A marked bloody hue of the contents of
the blebs  is  often the first sign of commencing gangrene, which
may at times be  checked  by early puncturing.   Slight defects
are quite rapidly  repaired,  according to Billroth, but larger ones
lead to serious consequences.
   The lymph  vessels are implicated in erysipelas in rather a
specific way.  As in every acute, even non-specific disturbance,
they swell in the neighborhood of the affected part as far as the
nearest glands, and often form  cords and knots  perceptible to
touch or  sight.  If Behier and Mittenheimer  failed to discover
this condition at times, it was perhaps in cases where it wTas con-
cealed by the thick swelling of the skin.   The glandular affec-
tion  is so much  more constant still, that  Blandin and others
regard the whole process as a capillary lymphadenitis.  The
slow  progress, however,  and the limitation  of  the  glandular
infiltration to the immediate neighborhood of the affected por-
tion of the skin, are opposed to  such a view.  Lymphadenitis at
a  distance  from  the affected  part  never occurs, although it
accompanies the progress  of the erysipelas.  The subsequent
course is distinguished from diphtheritic  and similar affections
by the rapid retrogression  of the affected  glands with the ter-
mination  of the cutaneous  affection.   Exceptionally only, three
times in  forty-twro  cases as observed by  Heyfelder, do chronic
infiltrations  remain,  and  suppuration, as  in other specific or
phlegmonous processes,  is very rare.  Colin describes a rare
case of abscess of the parotid.
   These observations substantiate our theory of  the slight viru-
lence of the morbid poison, which seems  to be inactive after a
definite and brief period. 
SYMPTOMS.
457
   The acute irritation  of the  glandular apparatus gives rise to
leucocytosis (Virchow '), which  is  not  very  serious when the
extension of the process is limited ; but in wandering erysipelas,
when  it  affects the whole body  in debilitated  persons, it mav
lead to bad results in consequence of excessive  irritation of the
lymph vessels.
   According to the part affected, we  distinguish an erysipelas
faciei,  capitis,  auriculare,  when it is confined to the  ear and
its immediate neighborhood;  trunci,  resp. mammae,  thoracis,
abdominis,  genitalium,  extremitatum,  etc.  It  affects  the face
and head most frequently, and  next to these the lower extremi-
ties.

   P. II. Bird found that in 260 cases the  face and head were attacked 125 times
(61 males, 64 females), and the extremities  135 times.  In 81 cases of (idiopathic?)
facial erysipelas it affected the right side in 56 per cent, of the females and 50 per
cent, of the males, the left side in 29 per cent, of  the men and 19 per cent, of the
women.  It  started upon the median line  in 13.7 per cent, of the women, and in
11.8 per cent, of the men; upon both sides simultaneously in 5.9 per cent, of the
women and 2.9 per cent,  of the men.  Of Heyfelder's 42 cases, 28 affected the face,
3 the face and trunk, and 11 the trunk and limbs.   In Billroth's surgical clinic at
Zurich,  in the years 1860-70, there were 67  cases of erysipelas of the face, 13 of the
scalp, 45 of  the trunk, 43 of the upper, and 80 of the lower extremities, although
tvvica as many injuries  of the  lower  extremities  as of the head were treated.
Among Ritzmann's cases 84 were upon the lower extremities, 35 upon the upper, 10
upon the trunk, and 13 upon the head, corresponding to  the very small number of
injuries upon  the head  and the very great number upon the lower  extremities.
Pflcger's observations confirm those of Graves, that erysipelas, when it begins at the
middle line, generally spreads symmetrically upon both sides.

   The starting-point of erysipelas is formed, as we have stated,
by injuries  of  the most various kinds,  in the  skin and the
mucous membranes lying near the surface of the body, especi-
ally the points of junction of the  latter with the skin.

   In Heyfelder's 42 cases it was the nose  12 times, tne ear  6 times, eyelid 5 times,
upper lip once, lymph glands twice, mamma once, and in the other cases injuries
elsewhere, of which 5 existed upon the scalp.

   The condition of the mucous membrane is of  special interest.
While it  is never attacked primarily in deeply seated parts by

                     1 Cellularpathologie 1871.  p. 230. 
458
ZUELZER.—ERYSIPELAS.
erysipelas, the process does often take its origin unquestionably
from  portions which lie nearer the surface of the body, whether
it  be  from a scrofulous affection, from a diphtheria of the ton-
sils (Bayer),  from a gangrenous ulcer of the larynx (Laborde),
from  a local inflammation in  typhoid  fever (Murchison),  or
from  a traumatic  lesion,  as  the tearing out of nasal polypi
(Volkmann),  the  wounding of  the vagina during delivery (Her-
vieux), and the like.   Trousseau was even of the  opinion that
facial erysipelas generally started from an angina.
   The extension  of the process to the outer skin takes  place
by continuity of tissue, either directly from the mucous  mem-
brane of the mouth, or through  the  posterior part of the nasal
cavity and the tear-passage, through the lowTer nasal entrance, or
through the Eustachian tube and the external auditory passage.
   The process may also remain wholly confined to the mucous
membrane ; at least this  may be inferred from the  eighteen
cases of angina collected by Cornil, which occurred at the time
of an epidemic of erysipelas at the  Paris hospitals.  Cornil de-
signates,  as the characteristic of  such an erysipelatous angina,
the purple-red, shining, oedematous  swelling of the whole pha-
ryngeal mucous membrane, which looks as if varnished,  while
the tonsils may remain free. Great pain is produced by swallow-
ing, and when the inflammation extends farther forwards saliva-
tion ensues.  The glands of  the  lower jaw and neck are  much
swollen.   Occasionally blebs  are formed,  which quickly dry
upon  the mucous membrane, and leave behind a softened, cor-
roded epithelial layer;  in some cases it runs into gangrene.
   The  diagnosis  from otlier  similar affections designated by
Lewin as pharyngitis  sicca is  seldom possible; it  can only  be
determined with  certainty when the erysipelas  spreads to  the
external skin.  It is probable that many of the observations con-
cerning fever, which precedes erysipelas one or two days,  relate
to cases where the affection has  been limited  for a time to the
mucous membranes.

   In a patient  of Brochu's  ' there existed for five days a severe pharyngitis, with
swelling of the  lymph glands. He was discharged, but returned to the hospital
1 Gaz d. hop. 1874.  13 Jan. 
SYMPTOMS.
459
after a few days with facial erysipelas.  It was only possible by this second obser-
vation to determine the nature of the affection of the mucous membrane.

    Sometimes the disease spreads almost simultaneously over
the mucous membrane and the skin.

   Jules Simon saw an erysipelas of  the face and scalp starting from an angina,
in which the inflammation was so severe that the jaws were closed as in trismus.
The patient could not swallow, was at first hoarse, finally voiceless, and died
delirious on the tenth day, the skin of the face and neck being of a bronze color.
On dissection the posterior parts of the mucous membrane of the mouth were vio-
let red, and that of the pharynx thickened and softened; in the air-passages, the
mucous  membrane  of the epiglottis, larynx, vocal cords, of the trachea and the
bronchi as far as their finest divisions, appeared as red as if soaked in blood, but
free from secretion.

    The mucous membranes bordering upon the skin are also sec-
ondarily  attacked by an extension of the  erysipelatous inflam-
mation.   The mucous membrane of the nasal  and pharyngeal
cavities is found, in  erysipelas of the head and face for instance,
generally hyperaemic and swollen;  sometimes the palate  and
fauces,  and less often the tonsils, are so swollen that swallowing
is difficult (Arnott, Wutzer, Trousseau,  Oppolzer).   Among
sixty-five cases in  Wunderlich's clinic, Blass saw pharyngitis
thirty-two times, and in nine  cases so  severe that without other
serious general symptoms  difficulty of swallowing ensued.
    Semeleder'  found an inflammatory  redness and  swelling of
the  epiglottis and entrance of the trachea,  without subjective
trouble and  change  of voice, which gradually disappeared with
the progressing desquamation of  the skin, but returned with a
relapse.
   Not very  unfrequently the affection reaches a higher degree
and extends  farther.  In  several  instances by Velpeau, Bayer,
Gubler, Dujardin-Beaumetz, and others, an oedema of the glottis
was rapidly  developed, that often rendered tracheotomy neces-
sary, which, however,  was seldom successful.   Lewin found, on
dissection of such a  case, swelling of the arytaeno-epiglottic folds
and of  the posterior wall  of the larynx, with intense redness of
1 Die Laryngoscopie und ihre Verwerthung fiir die arztliche Praxis.  Wien, 1863. 
460
ZUELZER.—ERYSIPELAS.
the vocal cords.  Such processes may become, according to his
views,  the starting-point of new growths upon the vocal cords.
   The erysipelatous  inflammation  of  the mucous membrane,
whether of primary or secondary origin, may also assume a wan-
dering character, and from a pharyngitis extend to the air-pas-
sages farther down,  and even produce pneumonia.   Former
writers regarded this as erysipelas internum.  Without referring
to these, however,  Peter, Trousseau,  Labbe, Jules  Simon, and
others  mention cases where  pneumonia has arisen from an ery-
sipelatous angina through descending laryngitis and bronchitis
of the large, smaller, small, and smallest bronchi.
   Labbe1 describes a case of facial erysipelas which appeared four days after the
beginning of the fever.   During this time the patient had a considerable angina,
hoarseness, and swelling  of the mucous membrane of  the mouth, so that an ery-
sipelas starting from the pharynx was recognized.  The patient died on the eighth
day.  Extensive pharyngitis was found ; the  inflammation extended downwards
over the epiglottis and larynx; the trachea and bronchi were deeply reddened;
pneumonic infiltrations existed at  the  base  of both  lungs, and the bronchial
branches leading thither were acutely inflamed.

   This  possibility of the direct  extension  of the irritation by
continuity of tissue  to  the mucous membrane of parts even
below  the vocal  cords is  peculiar to erysipelas.  In  affections
apparently similar, diphtheria and the like,  the vocal cords more
frequently form the natural limit to  the spread of the inflamma-
tion.
   Organs of Digestion.—Somewhat severe disturbances of the
digestive apparatus show themselves as a nearly constant symp-
tom of erysipelas.   The tongue  is covered with a white creamy
coat, which dries gradually, becomes of a dirty yellow color,
and, when the fever is protracted, blackish and crust-like.  The
taste  is pai>like, the appetite fails,  and  the  thirst  is much
mcreased.   Great  nausea,  and  even repeated  vomiting, often
accompany severe cases, especially of erysipelas of  the face and
head.  These  symptoms led the older physicians to the theory
of a bilious erysipelas ;  and Behier still refers cases where bili-
ous vomiting and a  yellowish hue of the face are present to this
class.  The urine is also said  to be colored by bile at times.
General jaundice, however, is  seldom observed, and Lebert sug- 
SYMPTOMS.
461
gests that  the nausea and vomiting may possibly proceed from
the giddiness of the head in severe erysipelas.
    The liver  seems to be  generally somewhat  enlarged,  and  is
more or less  sensitive on pressure.   The spleen also is enlarged,
but the  swelling  disappears,  as a rule, with the  termination  of
the cutaneous inflammation (Friedreich).
    Intestinal Canal.—The discharges  from the bowels are  not
materially  altered,  but are occasionally diarrhoeal in character;
the cases  of  intestinal  hemorrhage and of ulcers in the duode-
num, however, which rarely  occur,  and which prove fatal from
profuse hemorrhage, are very remarkable.   The various instan-
ces have occurred  in cases of facial erysipelas, which were in no
way  of  great severity.   They  suggest  the  similar  symptoms
which are  occasionally observed  after burns of  the  skin, and
bear the same explanation.

   A case of  this sort, described by Malherbe, was that of a man twenty-four years
old, in whom  the disease ran its course with severe nausea and vomiting.  On dis-
saction, the stomach and  the duodenum were found hyperaemic to a marked degree,
the intestinal mucous membrane elsewhere considerably swollen, and on Kerkrino-'s
folds, fifty  to  sixty ctm. from the pylorus, were several  ulcers, some of  them  as
much as a ctm. in diameter, the borders of which were not swollen.  In two other
cases of Larcher's, in men fifty-two and sixty-eight years old, the disease lasted eleven
days; there was severe bilious vomiting, and  in one case constipation and subse-
quently diarrhoea.  On dissection several ulcers (four) were found around the open-
ing of the ductus choledochus and pancreaticus, and in one case, even a fifth, on the
posterior intestinal wall,  close by the  pylorus, all of quite regular, oval form, and
confined to the mucous  membrane simply.  In the neighborhood were numerous
ecchymoses.  The intestinal glands were not swollen.   Bayer also observed a case
of erysipelas starting from the upper part of the nose after diphtheria of the tonsils,
which extended over the forehead, and on the fifth day of its existence, during a
profuse  intestinal hemorrhage of  which the patient died, disappeared.  There was
found on dissection a peritoneal transudation colored with blood, the peritoneal coat
of the ileum tinged with blood, the contents of the lower part of the small intestine
as far as the valve markedly bloody,  and an  abundance of tar-like matter in the
large intestine.  Bayer is inclined  to refer these appearances to a transitory conges-
tion of the intestinal mucous membrane.  Schonlein states that in times of extensive
epidemics many otherwise healthy persons living  within  the affected district were
attacked by severe diarrhoea, without  the occurrence of any erysipelatous process
upon the skin.

    Kidneys.—The  urine is generally scanty and  turbid at the 
462
ZUELZER.—ERYSIPELAS.
height of the disease, and contains albumen, which, according to
Lebert,  may persist  for weeks  even after  recovery.   In  severe
cases casts and hemorrhagic  elements are found.   Lebert is of
the  opinion that possibly a permanent nephritis is produced by
the  erysipelas, and Despres would even refer uraemic symptoms
to a preceding  erysipelas, an opinion which is not supported by
evidence in our possession.
   Cerebral Symptoms.—-Patients  complain most  of  giddiness
and  of more or less severe headache, which is especially violent
in erysipelas of the  head in consequence of the great stretching
of the skin.  They are excited, anxious, and very sensitive to
external impressions  upon the  organs  of  hearing  and vision.
Sleep is  uneasy, often disturbed by wild dreams, and sometimes
wholly absent.  Mild delirium accompanies nearly all cases in
which a  large extent  of skin is involved, and in erysipelas  of the
head and  face it is not  unfrequently furious, the  patients
shrieking, springing out of bed, and the  like.

   The epidemic described by Schonlein was characterized by severe cerebral symp-
toms of this sort, which generally lasted several  days.   In a patient of Volkmann's
they were so violent that the use of the strait-jacket was required.  A case is men-
tioned by Colin, of a man  twenty-five years old, in which the delirium lasted ten
days,  with coma, subsultus tendinum, and involuntary dejections; the patient, how-
ever, recovered.  Holm reports a  similar case, which relapsed after an interval of
three  weeks, and, like deep-seated affections of  the central nervous system, termi-
nated in a symmetrical gangrene of the distal phalanges of the second, third, and
fourth fingers, with idio-muscular contraction on pressure of the pectoralis major,
deltoideus, and biceps.

   In a prognostic sense  this  condition, which is probably pro-
duced mainly  by the cutaneous irritation, has  no bad signifi-
cance.  It disappears, as a  rule,  simultaneously with the abate-
ment of  the cutaneous symptoms.   In those who have died dur-
ing severe cerebral symptoms, Trousseau and  others have been
unable to discover any considerable  changes in the  brain and its
membranes.  It is possible that the  impediment to the venous
circulation, produced by the  swelling and infiltration of  the
parts, may assist in the production of the delirium in erysipelas
of the head and face. 
SYMPTOMS.
463
   Eecer.—In the majority of cases (in all of Heyfelder's and
in two-thirds of those of  Ritzmann) a more or less severe  chill
(less  frequently  several  milder  ones,  occurring  one after the
other) marks the  beginning of  the  disease.   In other cases
(twenty-seven per cent, according to Ritzmann)  the initial chill
is wanting, especially, according to  Volkmann, in  patients who
have  previously  exhibited considerable febrile  symptoms, and
where also the sudden rise of temperature produced by the ery-
sipelas is very inconsiderable.
   Generally, as in  recurrent  typhus,  the  temperature  very
rapidly,  often within eight to twelve hours, reaches the point of
40° C. [= 104° F.], or higher.   A more gradual elevation takes
place less frequently,  any considerable height not being reached
before the second or third day (Wunderlich).
   Corresponding to  the  remission  described by Thierf elder in
typhoid  fever,  the  temperature  exhibits  at times,  after  the
appearance of the exanthem, a marked depression, which  may
last a certain time,  a day  even,  and then quickly rise again.
Generally, however, the temperature remains at its height, and
even increases during the following  days, so that the  exacerba-
tions  soon mount between 40° C. [= 104° F.] and 41° C. [= 105.8°
F.],  and in some cases even 42° C. r= 107.6° F.], according to
Wunderlich and others.
   The subsequent course of the fever depends  exclusively,  in
uncomplicated  cases,  upon  the  extension  of  the  exanthem.
When the process spreads quickly, uniformly, and to an intense
degree upon the skin,  the fever becomes continuous, with very
slight remissions, which often amount scarcely to  0.5° C. [= 0.9°
F.].   The time of the remissions varies considerably ; they gen-
erally occur  in the  morning, or, when the evening exacerbation
is followed by a  secondary one in  the night, in the later fore-
noon  hours.  In  other cases, especially  in those  in which the
spread of the erysipelas  takes place more slowly, there occur,
after high evening temperatures with frequent secondary exacer-
bations, marked diminutions, not unfrequently accompanied by
perspiration.
   Finally, in those forms where the erysipelas progresses by
extensive and irregular advances, and is protracted for  weeks, 
464                 ZUELZER.—ERYSIPELIS.

the course of the fever is apparently irregular, although proba-
bly parallel  with that of the cutaneous affection.   Correspond-
ing to these  advances, which are broken  by long and  irregular
intervals, it  often appears to be interrupted by very considerable
remissions, and even complete intermissions, which are followed
by more or less rapid and prolonged elevation of temperature.
   The decrease is generally as rapid as the ascent; and in many
cases is preceded by a perturbatio critica (Thomas).   The tem-
perature sinks continuously in a few hours, or in a single night,
to, or nearly to, its normal  standard.  Fluctuations even then
follow at times.   Less frequently the fall assumes a more remit-
ting character, the diminution of temperature being distributed
more or less uniformly over  several days.
   The duration of the fever, exclusive of complications, is deter-
mined solely by that of the exanthem.  Neither the high tem-
peratures nor the duration of the fever are of evil significance as
regards prognosis,  except in  patients previously  debilitated ;
even very high  grades of temperature  are relatively well borne.
Death takes place generally during high fever (Wunderlich);
seldom  at the temperature of  collapse, and  is often,  according
to Wunderlich and  Eulenburg, followed  by  a prolonged post-
mortem elevation of 1.2° C.  [= 2.16° F.] to 1.8° C. [= 3.24° F.].
   Cases occur also of very slight fever, accompanying  an exan-
them of mild intensity, wdiich  may  be regarded as abortive
forms, especially in times when erysipelas prevails.
   The pulse generally corresponds in frequency with the eleva-
tion of temperature, 100  to  120, and not unfrequently 140 in the
minute.  In quality it exhibits nothing especially characteristic,
varying according to  the greater or less strength of the patient.
Many authors (Lebert and others) describe it as especially soft;
and when the erysipelas has existed for a long time, and there are
slight remissions, it is often considerably smaller  and weaker;
and in  many cases also  intermittent and dichrotic.  A marked
increase in frequency after the fifth or  sixth day is, according to
Nunnely and Hinckes-Bird, of unfavorable significance.   After
the diminution  of the fever, its frequency generally falls for a
time below the normal rate.
   The  action of  the heart corresponds with  the pulse.   Great 
COMPLICATIONS AXD SEQUEL.E.
465
weakness  of both is an important indication in treatment.  In
most cases the first sound is accompanied by a systolic murmur
heard most distinctly at the apex, which, according to Jaccoud,
is  independent  of the high  degree  of fever, and disappears
after its termination.  Sevestre observes  that endocardial pro-
cesses sometimes  occur in the course  of severe cases, which per-
sist after the disease is over ;  his theory, however, is based solely
on the systolic murmur.  One of his cases terminated in  fibrin-
ous pericarditis ; and Durozier describes a similar case.

                 Complications and Sequelae.

   Hypostatic pneumonia sometimes occurs,  especially in ery-
sipelas  of long duration (Volkmann).   Some cases  of  severe
croupous  pneumonia belong to a post-febrile stage (Trousseau,
Ritzmann).
   Pleuritic  affections seem to be more common, and it is a
question whether they are to be regarded, like other phenomena,
as the direct continuation of the process to deeper parts.  Law-
rence1, Wutzer, and lately Volkmann,  consider them as  such,
because they appear especially with erysipelas of the chest, and
because a suppurative or  hemorrhagic  inflammation in  the
anterior mediastinum  was also observed under  the same  cir-
cumstances in certain  cases (Lawrence,  Ponfick).   On the other
hand, Daude mentions a pleurisy which complicated  facial ery-
sipelas,  where, as in a case of Ritzmann's, no continuity  of the
process  could be shown.
   Several cases of peritonitis have also been described.  Whether
they are to be regarded as an immediate extension of the inflam-
mation  from  the abdominal walls, cannot be  decided  from the
material thus far collected.  Samuel Wilkes,1 among others,
refers a case under  his  observation to this  cause, and classes
with it another case, in which acute general peritonitis appeared
after a burn upon  the  abdomen.  Ritzmann recently observed a
peritonitis complicated with  pleurisy and  pyothorax in ery-
sipelas of the trunk, without being able  to  decide in favor of
this theory.
                     1 Guy's Hosp. Rep., 1861.
          VOL. II.—30 
466
ZUELZER. —ERYSIPELAS.
   Older  writers,  Martinet,  Parent-Duchatelet, Lietzau, and
others, often regarded a meningitis as an accompanying symp-
tom  of erysipelas cap., which is supposed to arise readily in
consequence of violent suppression of the cutaneous inflamma-
tion  by the use of cold and moisture for instance, that is, by
metastasis or repercussion.  Trousseau, too, looked upon it as a
not infrequent complication of "epidemic"  erysipelas, although
not occurring in the "sporadic" form.  The theory rests, how-
ever,  wholly upon the violent cerebral symptoms during life ;
it  has not  been established by dissection.   Trousseau failed
to find it in  the examination of  persons who  died with cerebral
symptoms.  Exclusive of severe cranial injuries, I find recently
only the case of Rhode, who describes a tubercular meningitis
ending fatally five months after the termination of a facial ery-
sipelas.  It  was apparently connected with  caseous  degenera-
tion  of hemorrhagic infarction of the lung, the relation of which
to erysipelas, however, was not to be made out.  A primary sup-
puration in the immediate neighborhood of the cranial bones, as,
in an instance of  Lebert's, within  the frontal sinus, may serve
as the  starting-point  simultaneously  of  meningitis and ery-
sipelas.
   Pycemia is extremely rare in uncomplicated cases, according
to the data before me.  The evidence which  has been collected
in support of the widely spread opinion to the contrary, appears
to me to have been derived from cases in which the erysipelas
was  associated with severe or extensive  injuries.  The pysemia
here is apparently of  great assistance, because,  in  accordance
with  the view of Volkmann, it appears to favor the destruction
of any thrombi that may be already present, and the destruction
of embolous infarcts.   The great debility after prolonged ery-
sipelas may in such cases also easily give rise to venous thrombi.
   On this  theory the rare cases of multiple inflammations  of
the joints, which occur at a distance from the  seat of the ery-
sipelas, and of which earlier writers (Lawrence, Velpeau, Avery)
furnish some examples, may be referred to pyaemia.
   Despres (Traite de l'Erys.  Paris, 1862) saw a case, in a facial erysipelas that
arose from  an operation for cataract; others, seen by Volkmann and Ritzmann,
affected only the severely wounded. 
COMPLICATIONS AND SEQUELAE.
467
    Besides  these cases,  Ritzmann observed patients in whom an
erysipelas of the extremities in the neighborhood of joints super-
ficially situated (the ankle, knee, and  the like) led to inflamma-
tion of  the same.  Rayer had also made similar observations,
and a recent case from Volkmann's clinic is described by Anger-
hausen.  This is not,  however, as some  believe, an  extension of
the inflammatory process from the skin to deeper parts,  and
to the joint.   Ritzmann draws  attention to the fact rather that
the affection  occurs only as a complication of severe fractures,
especially  those  produced  by  gunshot,  and  attacks  not  the
wounded joint, but generally  that situated nearest  the injured
part.  A great oedematous  swelling as  the result of erysipelas
may, in consequence of the strong disposition  of such injuries
to secondary inflammation of the joints, easily give rise to such,
as may  other relatively slight irritations.
    On the  other hand, extensive gangrene of the skin in conse-
quence  of  erysipelas  not infrequently points to severe pyaemic
and septicaemic  phenomena, generally  of  evil  omen,  of which
literature furnishes many examples.

   Malmsten (Hyg. 21) describes a thrombosis of the portal vein after an erysipelas
gangramosum,  which extended over the abdomen, sides, and back as far as the
axillae upwards, and  downwards over the thigh and scrotum, and caused gangrene
of the latter.  The patient, twenty-four years old, died on the sixth day of the dis-
ease, with typhoidal  symptoms, coma, delirium, and the like.   On cutting through
the abdominal  integuments,  where the erysipelas was seated, the subcutaneous cel-
lular tissue was found swollen, loosened,  and  pervaded with pus, which  had
nowhere collected in masses.  The skin of the erysipelatous half of the scrotum was
gangrenous, with a superficial line of demarcation.  A great quantity of ichorous
matter flowed from the underlying cellular tissue on cutting into it.  In the abdo-
minal cavity were several large spoonfuls of clear serum.  The peritonaeum was
actively injected only upon the last coils of the ileum and caecum, corresponding
to the intestinal mucous membrane at the end of the ileum and caecum.  The spleen
was enlarged, spongy, and  soft.  The liver was greatly enlarged, anaemic,  and
fatty.  The vena porta was  completely distended by a particularly firm, fibrinous
coagulum,  which extended  into its ramifications within the  liver.  This  lay so
loosely in the vessels, that it  could be easily drawn out.  The coats and the inner
surface of  the vessel were normal. Incipient fatty degeneration of the kidneys was
found.

   In a case lately observed  by  Tutschek, a facial erysipelas  led 
468
ZUELZER. —ERYSIPELAS.
to a peculiar stopping up of  the abdominal  aorta at its bifurca-
tion  in consequence of  true thrombosis of the heart.   The rarity
of  the  affection  makes the communication  of the case pardon-
able, even if its explanation is wanting.

   H. W., a soldier, set. twenty-two, was received into the hospital on the 12th of
February, 1873, with an  erysipelas of the right half  of the face, which had started
the day before from a pustule upon the right ear.  There was high fever.  Painting
the parts with collodion was ordered.  The erysipelas extended over the left half of
the face, the back of the  head, and neck, diminishing in intensity.  On the evening
of the fifth day the temperature  was normal,  and  the  pulse,  previously full and
hard, was eighty-four, small and weak.  A slight systolic blowing was heard at the
apex of the heart.   There was delirium.  On the succeeding days the pulse was
stronger, the delirium abated, and the appetite returned.  On the morning of the
tenth day of the disease, the  patient having complained since ten o'clock on the
preceding evening  of a  sudden attack  of  violent burning, tearing and stretching
pains, with coldness of the legs, and difficulty in moving them, the feet, the legs,
and the lower third of  the thighs were found to be stone  cold.  The skin of the
same was covered with purplish  spots, and its sensibility was impaired; the feet
were entirely deprived of the latter and of the power of motion, and passive move-
ments caused intense pain.  There was no  pulsation in the femoral artery.   The
radial pulse was quite strong.  The action of the heart was increased in force, 100,
and the first sound  was  distinct and accompanied by a blowing murmur.    The
patient died twenty-six and three-quarters hours after the  beginning  of the first
symptom of arterial stagnation.   Dissection.—In the left heart, in the depressions
between the columnae carneae,  toward the apex and behind their point of insertion,
were numerous closely attached, firm, yellowish-white, fibrinous coagula, varying in
size from a pea to a filbert, with fringes which floated free  under water ;  some of
them were  less firmly attached,  and could  be easily torn off with forceps.   The
endocardium was normal,  granular degeneration of the transverse fibrillae being
recognized  only in places.  On the free borders of the semilunar valves there Avere
small, detachable coagula  of fibrine.  The  inner surface of the aorta was smooth
and soft.   In the left renal artery there was a small thrombus running into  both
branches of the vessel, which entirely filled up  the  lower  one as far as the renal
substance, but  the upper one only imperfectly.  The lower half of the kidney was
correspondingly enlarged, colored yellow, and in a state of fatty degeneration.  A
thrombus completely filling the vessels was  found in the abdominal aorta and its
branches, beginning five  ctm. above the bifurcation, extending nine ctm. into the
common iliac arteries as far as Poupart's ligament, and several ctm. into the hypo-
gastric arteries.  None were  found in  the  other branches of the aorta.   In the
spleen, which was twice the natural size, there was a wedge-shaped, fibrinous infarc-
tion as large as a walnut.

    The eyes, in  facial erysipelas,  readily suffer  by  sympathy. 
COMPLICATIONS AND  SEQUEL.E.
469
Conjunctivitis and photophobia accompany the  majority  of
cases, but quickly disappear  after the termination of the affec-
tion.   Ulcers  upon  the cornea sometimes occur (Anstie), the
softening and  perforation of which  may lead to atrophy of the
bulb (Wagner).   Cases in  which the erysipelas  proceeds  from
an abscess behind the globe  are the most serious.  In a patient
of Arlt's, iritis  occurred,  with  great  exudation,  followed by
shrinking of the globe after the former was evacuated.   Glauco-
ma (0, neuro-retinitis, and atrophy of the optic nerve and of the
retina are also described.  Certain disturbances of vision, which
occasionally follow erysipelas, are produced, however, according
to Mathis, solely  by movable  opacities of the vitreous.   Gan-
grene of the eyelids, according to the communications of Arlt and
Biermann, is apt to lead to complete suppuration of the globe.
   According  to some observations by H. Weber and  Mugnier,
mental disturbances may remain after the termination of ery-
sipelas, especially maniacal delirium, with delusions or melan-
choly, which offer a favorable prognosis and quickly disappear.
   A peculiar effect is often exercised by erysipelas upon pre-
existing chronic or acute morbid processes in  the  skin.  Caze-
nave, Schedel, Sabatier, and others have observed, that  after
the  termination of  a casual attack of  erysipelas, old  ecze-
mas, lupous affections, and  ulcers upon the legs are  quickly
healed.   In several  cases reported by  Despres, Champouillon,
Mauriac  and  others,  extensive  phagedenic and serpiginous
chancres, and  even chronic abscesses produced by caries of the
bones, which had previously defied all treatment, healed rapidly
during an erysipelas.  Even extensive  non-malignant tumors
may be made to  undergo absorption,  according to the obser-
vations  of  Legraud,  Busch, and  Volkmann, by erysipelas,
although the cure does not  seem to be always permanent.
   Despres was induced by these results to recommend  the arti-
ficial production of erysipelas as a means of cure for phagedenic
ulcers (!).
   On  recent  wounds  also erysipelas often seems to  exert an
influence, although not always one favorable to their recovery  ;
especially, according to Ritzmann, where small wounds still ex-
ist.  In five  of his cases, deeply penetrating wounds, they were 
470
ZUELZER.—ERYSIPELAS.
attacked by gangrene, which they recovered from, however, after
the termination of the erysipelas.
   The explanation of this peculiar influence, which is observed
also in other violent  cutaneous inflammations, in variola for
instance, is possible on the supposition that old infiltrations may
be more easily brought to softening  and resorption by the uni-
form, intense inflammation of  the skin and the altered relations
of tension and hyperaemia in the affected parts.

                         Diagnosis.

   The diagnosis of erysipelas is generally certain as soon as the
eruption has shown itself upon the skin.  The rose-red color of
the painful,  hot, oedematous, shining, and swollen portion of skin,
generally with a sharply defined border upon one side, and start-
ing from the opening of some  natural cavity, or from a wound ;
the similar inflammation of neighboring mucous membranes ; the
swelling of the lymph glands, the rapid and marked elevation of
temperature, the  serious  general symptoms,  and the favorable
ending in desquamation, are sufficiently characteristic.
   On the other  hand, erysipelas occurring primarily upon the
mucous membranes, especially of the pharynx and nasal cavities,
escapes recognition until it has extended to the external skin.
Swelling  of  the glands, and serious constitutional symptoms at
the time of epidemics, should direct attention to this.
   Simple erythema (E. simplex), which is a transitory hyperae-
mia of the cutis, runs its course without marked increase of tem-
perature, without pain and swelling of the skin and glands, and
leaves  no desquamation or  pigment deposit behind.  Erythema
nodosum is  characterized by exudation in the deeper parts of
the skin, particularly in the neighborhood of the bones, which,
however, is always sharply defined in the  form of papules, nod-
ules, or nodes.
   Urticaria is distinguished  from erysipelas by  its peculiar
nettle-like itching, the wheal-shaped eruption, and its simultane-
ous extension over more or less extensive  portions of the body.
   The acute superficial lymphangitis, which is accompanied by
swelling, redness,  pain, and fever, has  a streaked or spotted, sel- 
DIAGNOSIS.
471
dom a confluent, redness;  its extension is always centripetal,
the stretching of the skin is moderate, and the inflamed lymph-
vessels appear like firm cords.  Its termination in resolution is
less frequent than in suppuration.
   The course of diffuse phlegmonous inflammation, often de-
scribed as pseudo-erysipelas, or erysipelas phlegmonosum, exhib-
its at first  high fever, painfulness, redness, and swelling of the
skin and of the glands.  The redness is here much darker, and
nowhere  sharply defined, and the cutaneous swelling is of board-
like hardness, and generally ends in suppuration, in which case
the abscesses in the  subcutaneous cellular tissue quickly become
confluent.
   The differential  diagnosis  of erysipelas from a progressive
and diffuse purulent  inflammation of the cellular  tissue, and
from an  acute  suppurative ozdema, which  spreads rapidly and
extensively from severe injuries,  with  irregular, diffused, and
often dirty redness and oedema, is not always easy.  Of decisive
importance in this respect are the slow increase of the fever, the
rapid development  of  purple or  discolored vascular networks,
the doughy quality of the swelling, and the peculiar ichorous or
gangrenous character of the wounds, while the general condition
of the patients may remain for a long time without serious  sub-
jective disturbances (Volkmann).
   The (Edematous form of charbon (oedema malignum s. car-
bunc.) occurs only in places where the skin is very thin, on the
eyelids, on the  neck, and in the axillae, seldom  on the extremi-
ties.  The swelling  comes on quickly, and  is extensive, so that
the lids,  for instance,  are  often in contact with each  other by
their external surfaces, like two shining, semitransparent pads.
The swelling, however,  soon becomes hard and uneven, and blebs
filled with sanguinolent fluid are developed upon the swellings.
The painfulness is  limited to the swollen lymph-vessels, and
severe  fever  occurs only when  the disease  has  existed for a
longer time.  The affection ends with sloughing, or fatally with
typhoidal symptoms.
   Pemphigus is distinguished from erysipelas  bullosum by its
more or less uniform localization and the fixed character of the
cutaneous  inflammation, wliich progresses  without oedematous 
472
ZUELZER.—ERYSIPELAS.
swelling, and without constant participation of  the lymph-ves-
sels and glands.
    With regard to  the extensive epidemics of ignis St. Anton.
(called after the foundations of this order), which  prevailed in
central Europe in the  tenth and  twelfth centuries, and which,
as Daude states, are described, according to the theory of Cullen
and others, as erysipelas gangrenosum or putridum, no definite
judgment can be given.

                      Stages and Duration.

    A division  of the erysipelatous process into distinct periods
is not practicable.  Every affected portion of the skin is subjected
to a  typical course, in  which the  stages of incubation, efflores-
cence, and desquamation may be distinguished.  Inasmuch, how-
ever,  as the affection does not remain limited to the place first
affected, but advances more or  less  irregularly,  all  stages of the
dermatitis are  generally found simultaneously near  one another,
and accordingly the general symptoms are often  destitute  of
determinable divisions.   On this account the duration of the dis-
ease is also very variable.   In erysipelas of the face and head it
amounts, on  an average, to ten, twelve,  or fourteen days, less
frequently to  six, but  sometimes  to more, even  two, three, and
four weeks, and even two or three months when it extends over
large portions  of the skin.

   Most of the statements of writers upon the various epidemics  lie within these
limits.   As the average number of days, Velpeau gives twelve, Heyfelder thirteen
and a half, while Billroth considers fourteen days as exceptional even.  The longest
duration is shown when the trunk is attacked primarily or secondarily, the shortest,
in erysipelas of the lower extremities, in which, according to Volkmann, the fever
may disappear after thirty-six hours even.  Ritzmann found the average to be five
days when the erysipelas  was limited to a portion of the head, 7.6 when the whole
head was affected, and  in cases starting upon the head 7.3; in the forms which
extended from the trunk 9.5,  in those starting  from the upper extremities 8.2, and
in those from the lower extremities 8.4 days.  There are but few observations con-
cerning the duration of the period of incubation.

    Convalescence is generally short, and quick,  but it may  be
greatly prolonged by complications 
HABITUAL ERYSIPELAS.
473
                            Relapses.

   Persons who have once had  the disease retain for it, in con-
trast with other infectious diseases, a very great susceptibility.
   In many surgical cases a patient undergoing protracted suppuration may be
attacked with erysipelas two or three times during the process.  Volkmann reports
several instances of this.  Of Ritzmann's 146 cases of erysipelas in the Berlin Mili-
tary Hospital, 13 per cent, relapsed;  of 248 cases in the Zurich surgical clinic 7.6
per cent, relapsed, and there were two cases  in forty-two of Hcyfelder's.   Of  the
former,  fifteen were attacked twice, and two three times with erysipelas duiing
their residence in the hospital.   Heyfelder reports the case of a patient with
gangrene, in whom an erysipelas  relapsed seven times in seven months, extending
each time over the whole body  as far as the fingers and toes.  He became emaciated
to a skeleton, but finally recovered.

   The later attacks generally run  the same course as  the first,
but sometimes the constitutional as well as the cutaneous symp-
toms are milder.   Repeated relapses on the same part may lead
to permanent thickening of the skin.
   Not a  few persons  are subject to a periodically returning
form—the so-called habitual erysipelas, which affects mostly
the face or lower extremities.  The relapses occur once or twice
a  year,  and appear to  start from chronic ulcers of the nasal
mucous membrane, of the tear-passage,  or  of the leg.  If scro-
fulous persons are more frequently attacked than others by it,
it is the more frequent occurrence of ulcers  of the mucous mem-
brane  among them that is  the cause.   The course of the relapse,
the contagiousness of which in certain cases has been established
(see above),  does not vary materially from  the primary process.
Its spread is generally confined,  however, within narrow limits ;
because, as I believe, the  integument, which is thickened at  its
borders in consequence of the repeated inflammations, offers  an
obstacle to the farther advance of the transudation.   Occasion-
ally, too, they appear to give rise to pachyderma.   Schwalbe, of
Costarica, describes an  "hereditary"  erysipelas occurring  in
three generations of a family, which led to elephantiasis.
   The  expression "habitual  erysipelas" has  been often used very loosely in
literature.  Many of the forms described under this name have certainly nothing in 
474
ZUELZER. —ERYSIPELAS.
common with true erysipelas, except some external appearances. With many women,
for instance, erysipelas is supposed to occur regularly in the place of the catamenia,
or simultaneously  with them.  With regard to some of the older descriptions,
indeed, a safe opinion cannot be expressed; but  many of  them relate, as Volkmann
shows, merely to acute oedematous affections of the skin, without, or with but little,
redness, and without a disposition to wander.  Kaposi also makes a definite distinc-
tion between true  habitual erysipelas  which starts in  lupus vulgaris from the
cauterized points, and in lupus erythematosus from the places on the face and ears
where the acute eruption is especially localized, on the one hand, and on the other
hand a streaked or striped lymphangitis and a  peculiar superficial infiltration of
the  cutis, often accompanied by typhous symptoms, in lupus erythematosus.  He
invests the latter with the inappropriate name erysipelas perstans faciei, although it
is quite different from the specific erysipelatous inflammation of the skin.

                            Varieties.

    Erysipelas  neonatorum, which most  commonly occurs  upon
the  navel and  other parts  of the abdomen, was formerly re-
garded as a  special  variety.   It presents, however, no special
and specific exceptional  peculiarities.   Its  cause  is  to be  re-
ferred, according to  Billard, partly to the easy vulnerability of
the hyperemic skin in the first days of life, after  the removal
of the vernix caseosa, and partly to  the navel  remaining open
or  suppurating, its  normal  cicatrization  being, according  to
the  observations of A. Vogel,  especially disturbed  during epi-
demics of puerperal fever.   In children somewhat  older, erysi-
pelas  often  proceeds from vaccine  or impetigo pustules,  from
simple wounds, intertrigo, mastitis, ulcerations  on  the genitals,
and the like.   It occurs most  frequently between the third and
tenth  day after birth, and afterwards in gradually diminishing
frequency.    In  some  foundling and lying-in hospitals  it is
especially common, but less frequent under the more favorable
conditions of private practice.
   In proportion to the deficient development of definite bands
of fibrous tissue in  the  skin,  the attachment of which to  the
substratum is still very loose, erysipelas  in small children shows
a tendency to spread rapidly over the whole trunk, the extremi-
ties, and the face.  It results, also, oftener than in older persons,
in gangrene or prolonged suppurations,  the  prognosis of which
is very unfavorable.   Bouchut,  Moreau, and Trousseau regard 
PUERPERAL  ERYSIPELAS.
475
the affection as always fatal.   Steiner (Compend. 1872) had only
two recoveries among sixty cases ; Billard,  among thirty  cases,
representing the whole early period of life, had sixteen that were
fatal;  while Bednar makes the prognosis better.  It appears to
be  more unfavorable the nearer to its  birth the  child is, and
becomes better with increasing age.   The affection often runs a
fatal course, with severe febrile symptoms, in a few days ; or,
after the erysipelas has wandered for weeks over the skin,  death
occurs from exhaustion; or,  with symptoms of icterus neonat.,
in consequence of umbilical phlebitis.  On dissection, especially
in erysipelas of the abdomen, peritonitis is found ;  and in  other
cases abscesses in the lungs, liver, spleen, and between the mus-
cles, suppuration of the umbilical vessels (Osiander, Martin) and
the like are discovered.
   There is sometimes described as a peculiar variety, moreover,
erysipelas vaccinate, that starts from the cutaneous lesions con-
nected with vaccination, but presents otherwise  no  peculiarities.
With  young  children  it  may easily  become  dangerous, but
with older persons it is not of  serious importance.  During
an epidemic of  erysipelas in Boston, in 1850 (reported in the
American Journal, in October of that year), it  occurred so fre-
quently in vaccinations that  they had to be given up.  Eulen-
berg also reports two cases  of vaccinal erysipelas  in sailors,
which  proved fatal, and advises, therefore, at  times when the
frequent occurrence of erysipelas among the people is observed,
that vaccination shonld be postponed when practicable.
   Erysipelas puerperale,  too, which was formerly described as
an  affection especially to be dreaded,  has  nothing  specific.
Many cases described under  this name,  like those of Osiander
and Ratzius, correspond to the erysipelas malignum  puerperale
int. described by Virchow' as the result of ichorrhemia, which
he himself  considers as a phlegmonous  inflammation, which
extends after the manner of erysipelas.  True erysipelas is not
very common  in childbed,  and in  lying-in women otherwise
healthy it is without serious import.   Its starting-points, accord-
ing to  numerous observations (Hervieux, Doublet, Cornil, and
1 Virchow's Arch. XXIII. 
476
ZUELZER. —ERYSIPELAS.
others) seem to  be  here,  as  in  idiopathic erysipelas,  various
injuries, rents in  the vagina, bruises of the vulva, eczema of the
nose, an angina, and so forth.

                   Mortality and  Prognosis.

   The mortality in  persons  previously healthy is generally
light.   It is difficult, however,  to obtain proper data on which to
determine this point, as so few cases are "pure;"  the majority
of those reported being complicated by  other and often severe
affections.

   Leaving out of the question the element of surgical casuistics, it is not easy to
decide in single cases whether the primary processes or the erysipelas Avere the cause
of death.  Nevertheless it may be allowable to give certain data, which will at least
afford a general idea of the dangerousness of the disease.  In nearly 10,000 cases of
various authors, surgical included, the mortality was on an average eleven per
cent., but varied considerably in the experience of  the various observers.   Wunder-
lich had only three per cent, fatal cases (Blass), Volkmann five per cent, P. Hinckes
Bird seven and a half per cent., Ritzmann in Berlin seven and four-fifths per cent.,
Williams and Heyfelder in Petersburg ten per cent.  In the American war, the mor-
tality of the affected  (in surgical cases) was eleven per  cent.; whilst individual
observers, as Pujos, give thirty per cent, of fatal cases, and Despres even over fifty
per cent.

   The diversity  in the character of the various epidemics  is, in
part  at least, the cause  of these differences, while  it may be
referred also to the  physical condition of those  attacked.   Like
every febrile complication, erysipelas is to be regarded as a seri-
ous  matter  in pre-existing severe  general  affections.  From its
occurrence in exanthematic typhus for  example, Murchison lost
thirty out of  ninety-two  cases, and in typhoid fever it caused
death in six of Louis's nine cases, and four times in the  same
number of Murchison's.   It is also  dangerous in a high degree
in severe  injuries, prolonged  suppuration, carcinoma,  phthisis,
dropsy after nephritis, and the like, especially in the very young
or the very old.   In debility of the heart's action, also, extensive
erysipelas may easily lead to fatal collapse.
   Whether sex has any special  influence over the mortality,
cannot be determined, owing  to insufficient  data.  Very young 
TREATMENT.
477
 children and old persons appear to succumb to the disease more
 readily than strong persons of middle age.  Many external con-
 ditions, too, as  the unwholesomeness of certain hospitals, prob-
 ably have an important influence upon the result.
    The prognosis, then, in uncomplicated erysipelas, especially
 in  sporadic cases, which are not associated  with otlier severer
 affections or injuries, is favorable.  Fever, even accompanied by
 high temperature  and of  long duration,  is not of itself a bad
 sign, except it affect cachectic persons or those with marasmus.
 Much more dangerous, on  the  other  hand, is erysipelas when it
 spreads widely over mucous membranes, especially those of the
 organs of respiration.
    In  hospitals the mortality  may be  increased by the great
 number of cases.   Traumatic erysipelas  especially gives rise to
 pyemic infection in injuries  and in  childbed.  Young children
 and old people yield more readily to  the disease, while  stronger
 persons of mature age resist it better.
    The fatal termination  may be produced  in debilitated  and
 otherwise seriously diseased persons  by  inanition, and perhaps
 also by collapse ;  also in consequence  of pleuritic and peritonitic
 affections, by pneumonia, laryngitis, and oedema  of the glottis.
 In  severe injuries, pyemia as well as gangrene of the skin may
 assist in causing death.

                         TREATMENT.

    Etiological investigations point to the  necessity of adopting
 certain prophylactic measures,  notwithstanding  the relatively
 slight danger  attendant  upon erysipelas, as soon as the disease
 breaks out or individual cases are introduced into hospitals  and
 similar enclosed institutions.  A pedantic cleanliness,  such as
 Billroth observes, immediate and thorough removal of refuse,  and
 especially of soiled bandages, are necessary on other grounds.
 Gosselin and others advise the isolation of patients as far as pos-
 sible ; and this measure, which  is desirable in  medical wards, is
indispensable  in surgical and lying-in establishments.   My col-
league, Herr Oberstabsarzt  Starcke, informs me that erysipelas
in the  surgical wards  of Charite is now confined to the cases 
478
ZUELZER.—ERYSIPELAS.
brought there as such, since they have  followed  the  practice of
isolating them at once.
   In a curative sense the treatment of erysipelas has undergone
great changes.  For a long time is was held that, in addition to
the local, a specific general treatment was necessary,  on the the-
ory that the process was really a general exanthematic affection.
   Venesection figured conspicuously.  "Ubi primum  accedo,"
says Sydenham, "satis largam sanguinis quantitatem e brachio
extrahi  precipio."  The  apparently  favorable results  con-
tributed  to keep  this means in  use  for a long time.  Copland,
Andral, and  others were the first to advise against  it, because
nervous and cerebral  symptoms were easily developed in conse-
quence of it, especially in weak persons.  ("In erysipelas,"  says
Copland, '' there is always a great tendency to asthenic  vascular
action and to exhaustion of the vital powers.")
   After this the  revulsive  method, the administration of eme-
tics and  purgatives, enjoyed great favor up to the most recent
period, and  in course of time the indications were surrounded
with a formal ritualistic observance.  The "bilious and gastric
symptoms" were to be thus lightened; but with signs of  "in-
flammatory hyperemia of the stomach and liver," it was  feared
that emetics would increase the stasis, and with violent cerebral
congestion and meningitic symptoms (not to be confounded with
delirium biliosum!) they could  be employed  after the cerebral
congestion had been controlled by venesection (Canstatt).
   Diaphoretics were  long used (Wilkinson), but, as well as the
administration of oil of turpentine (Cox, Copland, Hinckes Bird,
and others) and of iodide of potassium, again given up.
   Among  other specific remedies colchicum was formerly rec-
ommended by Bullock and Copland, aconite by Ringer (Lancet,
1869.   I. 2), and veratrum viride by Labbe  for its special action
upon the pulse.    Lobel and Billroth have  also  made many
experiments with the tincture of veratrum, but  they proved it
to be useless in spite of the retardation of the pulse.
   The chloride of iron, especially in the form  of the ethereal
tincture1 (Bestuscheff's tincture), has been much praised by Eng-
   1 Chloride of iron in solution, in a mixture of  one part of ether and three parts of
alcohol.  It contains one per cent of iron. — Germ. Ph. 
                         TREATMENT.                     479

lish  physicians ;  it was  introduced into practice by Hamilton
Bell, in 18.H, and has attained since then almost the reputation
of a specific.  According to  Balfour, Campbell, and others, it
shortens the duration of  the disease materially, reducing it  on
the average from eight or ten to  from two to four days, and
lessens the severity of the case,  that is, the typhoid and pyemic
symptoms.  The  remedy is always  given in large doses, from a
drachm and a half of the Bestuscheff's tincture  to two  drachms
a day, and  in the severest forms in from three to four times as
great quantities.
   Of late, quinine has been used  in large  doses, especially in
Germany, in consequence of the well-known  investigations of
Binz.  Liebermeister administers it in  doses up to four and a
half grains every two  hours,  and  commends  its  influence  in
reducing the fever and  shortening the affection.  Russell, and
Blake  also, as well  as Binz,  observed a long apyrexia in some
cases after large doses of quinine.
   Volkmann uses cold baths to reduce  the temperature, which,
repeated according to circumstances  three or four times a day,
lessen  the  fever  materially,  and are willingly taken by the
patient.  They have no influence over the local process.
   Opinions concerning the necessity of  local treatment in erysi-
pelas have differed widely at various  times.   Many of  the older
physicians especially regarded the rash as a noli me tangere, and
were horrified at the use of any remedy by which the process in
the skin could possibly be disturbed and the " recession " of the
rash effect* >d.  Local treatment was often merely expectant, and
partly on this account, partly also on account of the uselessness
of many of the remedies early recommended,  limited  to sprin-
kling the affected parts with rice or bean meal, lycopodium, and
similar  substances, and enveloping them in wadding.  Elevation
of the  parts affected with erysipelas, formerly recommended  as
being as beneficial for the diminution  of  the  blood-flow as  in
phlegmonous inflammations, exerts no influence upon the course
of the process, according  to the  observations of Estlander.
   Attempts at local treatment, however, have been very numer-
ous ; individual views with regard to the nature of the disease
leading  to the trial of various systems. 
480
ZUELZER.—ERYSIPELAS.
   The older physicians placed antiphlogistics in the foreground;
abstraction  of blood holding the first place among the means
recommended for this purpose, as in general treatment.   Lassis,
Dobson, Bright, and others made a number of little punctures
or incisions over the erysipelatous surface (from ten to  a  hun-
dred or more), repeated them often,  and favored the  after-bleed-
ing by a sponge soaked in warm water ;  Hutchinson, McDowel,
and  Lawrence preferred  deep incisions ; while Lisfranc placed
from  twenty to  fifty leeches upon  the inflamed part,  because
smaller numbers did not sufficiently empty the vessels, but acted
rather as an irritant.
   Reuss  and Creutzer  applied cold  evaporating  lotions,  to
which Gouzee added corn-brandy, while Rust gives the prefer-
ence to warm cataplasms.   Martin Solon used merely inunctions
of fat; Dean, Ricord, and others, mercurial ointment instead;
and  Schott, lotions of corrosive sublimate (two  grains  to the
ounce). Griscom employed glycerine, because it abstracts water
from the tissues, and by this depletory action  produces  an  anti-
phlogistic effect upon the inflamed organs.
   As astringents, Velpeau used sulphate of iron in  solution or
in the form of an  ointment; Betz, lime-water with oil;  others,
alum and  tannin.
   The derivation of erysipelatous  cutaneous inflammation by
blisters, has been attempted by Petit, Patissier, and  others.  In
case  it extended, it was pursued with  blisters (Conte, Amiel).
The remedy was employed also in order to reproduce the retro-
gressive exanthem upon the skin.
   Under  the name  of the ectrotic method, Higginbottom intro-
duced the topical use of nitrate of silver.  The portion  of  skin
affected with erysipelas, and a border of normal skin outside of
it, after being freed from fat  by  a  solution of  potash,  were
thoroughly cauterized with the  lunar  caustic in substance  or in
strong solution.   The dermatitis produced  by it, according to
the observations of Wernher and Volkmann, is often followed
without doubt by a fall of temperature, for several hours, and
often, but by no means in all cases,  the farther  spread of the
affection  is  checked.  Thorough painting with the  tincture of
iodine, recommended by Nunnely and Hasse, works in the  same 
TREATMENT.
481
way.  Estlander  praises  the simultaneous use  of  subcutane-
ous  injections  of  morphine and  the painting  with iodine,  and
Schwalbe, local faradization.
   To prevent  the further progress of erysipelas,  Larrey drew a
deeply cauterized line close to its border, with the actual cautery,
while Fenger, Wutzer,  and others, used nitrate of silver in the
same way.   The latter method was in favor  for a  long time.
Velpeau employed  tight  bandaging, especially in erysipelas of
the  extremities, and Spengler painted  the parts with collodium
or a solution of gutta percha.
   Cold, in the form of water or ice applications, is often used
by Hebra and others.
   Specific  remedies to destroy the  infectious matter in situ,
have often  been  sought for: thus  Malgaigne and Jobert intro-
duced the  use of  camphor externally;  James and Kuchen-
meister,  spirituous inunctions; Green, the vapors of sulphur ;
Schedel,  chlorinated lime  in solution;  Kentish  and Meigs,  a
mixture  of basilicon ointment with oil  of turpentine.  Much
more effective  results are  ascribed  to the applications of recti-
fied oil of turpentine, introduced by Copland.  Liicke also  has
recommended  its  application most urgently on account of its
antiparasitic action.   The result in six cases was surprising, and
each time after its use  there was a sensible fall of temperature.
The  patients often  experienced a temporary burning, without
the  appearance of any otlier untoward effect.  The erysipelas
often appeared  to  be  checked,  and  to run its course more
quickly.   Borgien, Bonfigli,  and others,  confirm the  value of
this  method, which has been rapidly introduced into practice.
I have myself seen many good results from it.
   The same idea has lately been  carried farther by Nystrom
and  Westerland, who have introduced the use  of  aseptin (more
accurately : amykosaseptin, Gahn) against erysipelatous inflam-
mation of the skin.

   This remedy is  composed of boracic acid, and of a preparation of cloves, the
former of which exercises a destructive influence upon animal, the latter upon vege-
table parasitic organisms.  It is weaker than carbolic acid, but is to be commended
for its want of  odor and the slight irritation it produces upon wounds.
          VOL.  II.-31 
482
ZUELZER. —ERYSIPELAS.
   Very recently  carbolic acid has  been used.   Kaczorowski
made quite a detailed trial of it.  He mixed carbolic  acid with
oil of turpentine (one to ten),  rubbed it thoroughly into the skin,
and applied over it compresses of lead-water, and in severe cases
ice in bladders  or  compresses also.  Under this treatment  the
cutaneous redness becomes first more intense, and the formation
of blisters more pronounced ; but after from twenty-four to forty-
eight hours he observed the  disappearance of these symptoms,
without recurrence.
   Wilde boasts of good results from the subcutaneous use of
sulpho-carbolate of soda, injecting from fifteen to thirty minims
of a forty-grain solution into the  erysipelatous portion of  the
skin.  After  the first use of it the succeeding evening tem-
perature is reduced; after the second or third  day the  edge of
the inflamed  skin  appears faded ; and after the third or fourth
day the erysipelas  is reduced to a  slight oedema.   The  remedy
itself causes no local disturbances.
   Huter, who  had previously used inunctions  with tar, recom-
mends the subcutaneous  injection  of carbolic  acid.  The local
disturbances occasioned by it are, in fact, very slight;  according
to my own observations, and as Huter states,  the  carbolic acid
seems to exert even a local  anesthetic action.  The results are
much praised.   When the injections are made at some distance
from the affected part, the farther  progress of  the  erysipelas is
said to be arrested. Aufrecht obtained similar  favorable effects
upon four old persons—one  of them eighty-two years old—in
whom five injections of carbolic acid into the healthy subcuta-
neous cellular  tissue in the  neighborhood  of the  erysipelatous
part checked the  progress and effected  the diminution  of tem-
perature, and  a rapid  improvement of  the  general  condition.
(Several trials undertaken lately in the Charite,  however, yielded
no such favorable result.)
   According to these experiences, a specific method of treat-
ment cannot be considered  as  established, although  several of
the remedies mentioned, especially the use of oil of turpentine,
the subcutaneous injections of carbolic acid and its preparations,
and the administration of the  muriated tincture of iron, as by
English physicians,  are worthy of  farther  trial.   What we 
TREATMENT.
483
would at present designate  as rational treatment is the follow-
ing :
   The  expectant treatment  should be preferred.  Mild cases
scarcely demand any treatment besides  rest in bed and keeping
cool.   In cachectic persons,  or in those suffering from otlier
serious  diseases, a  stimulating method from the beginning,  the
administration of a nourishing diet, wine, beer, or other alcoholic
remedies, is not  to be neglected.    Weakness  of  the heart's
action, which is always to be guarded  against in extensive der-
matitis, because it  easily leads  to  collapse,  demands stronger
stimulants.
   In more serious forms,  with high fever, the  mineral acids
may be used, and quinine in large doses (from three  to  five
grains several times daily), according to the method of Binz and
Liebermeister.  As a very valuable means of  reducing the tem-
perature, especially in protracted  cases, with remissions,  cold
baths, repeated several times  daily, are to  be  employed.  They
would be contraindicated  only by great weakness of the heart's
action.  Fear  of  metastasis may be regarded as antiquated.
   When  there are violent cerebral symptoms, prolonged cold
applications to the head, or the  douche, are in most  cases suf-
ficient.  Local  depletions  by leeches,  which  many  physicians
believe  should not be omitted, are of  only temporary  advan-
tage  ; the treatment is  better assisted by active purgatives.
   Severe  gastric  symptoms  are sufficiently  relieved by mild
cathartics (calomel  or  neutral salts).  Rarely is it necessary to
use emetics, according  to the fashion of the older physicians.
   Cases where an affection of the larynx, and especially oedema
of the glottis, are to be feared, demand especial attention.  We
must try to relieve threatening symptoms by the application and
inhalation of astringent remedies, such  as tannin, alum, and the
like; and, when necessary,  proceed  to  tracheotomy,  with sub-
sequent continuation  of this  treatment.  The energetic  use of
cold, by ice bags and  the administration of small pieces of  ice,
wliich the patient may take in the mouth  at  short intervals, is
also  to be strongly recommended.
   Local treatment may be  limited to sprinkling  with pow-
dered starch or similar substances,  covering with wadding,  and 
484
ZUELZER.—ERYSIPELAS.
keeping the affected part still.  A daily painting with collodion,
several times  repeated, to which  glycerine (one part to fifteen)
may be added to give elasticity  and prevent cracking, gives a
good covering, which at the  same time exerts a mild  compres-
sion.  In very violent inflammation the local use of cold (ice-bags
and the like) is indicated.
   Great tension of the skin, of  especial importance in places
threatened with gangrene, is materially relieved by superficial
punctures, and also by warm poultices.  Gangrene  of  the skin,
especially of the eyelids, and abscesses require the proper local
treatment. 
MILIARY  FEVER.
          DER  SCHWEISSFRIESEL.

(FEBRIS MILIARIS, FRIESEL,  SUETTE MILIAIRE.)
 The extensive  older literature  of miliary fever can only be used after  the critical
    winnowing  it has  undergone  in  the  following  works:—Hecker, Der  engl.
    Schweiss.   Berl.,  1834.—Seitz,  Der Friesel.   Erne histor. path. Unters.   Er-
    langen, 1845.—Foucart,  De la suette miliaire.  Paris, 1854.—Hirsch, Virchow's
    Arch. VIII.  u. IX.;—Handb. der histor. geogr.  Pathol.  1860.   I.  256;—From
    Hecker's  grossen  Volkskrankh.  d. Mittelalters.   Berl., 1865.  (A searching
    critique with a comprehensive use of literature.)  Among later works the fol-
    lowing  are  to be mentioned:—Galtier, Rapport sur  l'epid. de suette miliaire
    qui  a  regne" dans  l'arrond.  de Castelnaudary (Aude) pend. l'annee  1864.
    Toulouse,  1866.—Dumas, Hist, d'une 6pid. de  suette miliaire qui a regng pend.
    les mois de Mars, Avril et  Mai,  1860 a  Draguignan (Var.)  Montpell., 1866.—
    Putegnat,  Journ. de mSd.  de Brux.  Janv., 1866.  Ottoni,  Gaz.  med.,  Lom-
    bard.   Nr.  18,  19.  1866.—Bastard, Etude sur le trait, de  suette miliaire.
    Avantage  des bains tiedes.   Paris, 1867.—Gresser,  De  la curability  const, de la
    suette, dite miliaire, ainsi  que des affections qu'elle complique.  Paris, 1867.—
    Coural, Hist, de la suette miliaire qui a r6gng  a St. Chinian 1865-1866.  Mont-
    pell. mSd. 1867 and 1868.—Plouviez, Essai sur la suette  miliaire.  Paris, 1868.
    (Epidemie en  Pernes-en-Artois,  Dpt. Pas-de-Calais.)—Ferber, Arch. d. Heilk.
    1869.  S.  335.  (Description of  a sporadic case.)—Teilhol, Etude sur la suette
    miliaire.   These.  Paris, 1869.—Bernard, Annal. de la Soc. de m6d. d'Anvers.
    Jan. and Fevr. 1869.  (Epidemic in  the Arrond. Beziers.)—Nole, Journ. des con-
    naiss. m6d.-chir.  Nr.  11. 1870.—Santini,  La  migliare esaminata nelle  sue
    pertinenze morb.  Firenze, 1870. — Gresser {Poitiers), Bull, de l'Acad. de M6d.
    XXXV. 569.  1870.  (Recommendation of quinine.)—Liverani, L'Ippocratico
    1871 (in 16 Numbers; Epidemic in Fusignano;  demonstrates, in opposition
    to Hebra,  the independence of  the affection).—Barbieri, L'Ippocr. 1872.  (A
    comparative delineation of typhoid fever and miliary  fever  in  support of  the
    essential nature of the latter.   A disputation upon this subject by the same,
    Gallrtti and Guizzardi, ib.

    In the course  of time,  especially during the  last  century,
diseases of  the most various  kinds, wliich were  accompanied  by 
486
RUELZER.—MILIARY FEVER.
perspiration and showed a tendency to the formation of miliary
vesicles,  came  to  be called miliaria.  A puerperal miliaria,  a
rheumatic miliaria, and the like, were spoken of.  The specific
type of the disease, which was first made known  to us by the
severe  epidemics of the "Sudor anglicus," and from which the
title was derived, retreated so far into the background that not
a few physicians arrived at the theory that there was in reality
no essential disease of this name.  Even in the most recent times
there have been discussions upon this point.   In the meantime,
historical and  critical investigations have succeeded  in again
separating the different diseases improperly called miliaria from
the idiopathic affection.
   By  the name miliaria ("Friesel," or, better, Schweissfriesel,
according to Hirsch), under the revival of the old term,  is meant
a specific disease  which  occurs in the form of circumscribed
local epidemics, and extends less frequently over large  districts,
appearing,  when  it does  so,  nearly simultaneously in various
places.   The epidemics come at indefinite periods, in  times of
moist,  warm weather, and last,  as a rule, only a little while,
generally one or more weeks.
   The disease  is febrile, seldom begins suddenly, but generally
after two or three days of prodromata, and runs its course more
or less regularly  in two nearly typical stages.   The first is
characterized by  a  profuse sweating, which lasts one or two
days,  and  by  a very harassing feeling of compression at  the
epigastrium,  by precordial anguish,  and violent palpitation.
After the sweating  there appears  in  the second  stage a rash
like that of measles, the spots of which  exhibit in  their centres
miliaria  vesicles.   This lasts two or three days, and  ends  in
extensive desquamation.    The remaining symptoms  are less
characteristic, consisting mostly of constipation, loss of  appetite,
headache, more or less uneasiness, and  pains in the limbs.   In
many epidemics, diarrhoea and bronchitis are frequent complica-
tions, in  others they are seldom observed.
   The disease runs its  course, according to time  and circum-
stances,  with varying severity.  In many epidemics  the mor-
tality is very slight, wiiile in others it rises as high as twenty
per cent, or more.   Death  is generally preceded by an  increase 
HISTORY AND EPIDEMIOLOGY.                487
of  the  nervous   symptoms,  and  does  not  reveal  any specific
anatomical  lesions.    Convalescence   is  generally   much  pro-
tracted,  because  the  patients are considerably  emaciated and
debilitated.


                    HISTORY AND  EPIDEMIOLOGY.


    The history of miliaria  extends only as  far back  as the fif-
teenth and   sixteenth centuries.   We  are  acquainted with  a
widely spread epidemic of this period, known by the name  of the
English  sweating-sickness,  which, according  to  the  investiga-
tions of Hecker and Hirsch, is identical with miliaria, or at least
approaches it very nearly.


   The English sweating-sickness is described as an extremely violent fever, which
began after a short chill, with cardialgia, headache, and lethargic stupor, destroyed
the strength at the onset, and ended within twenty-four hours.  According to the
excellent description of Hirsch, in  his edition of Hecker's "Great Epidemics of the
Middle Ages," palpitation and anxiety,  excessive perspiration, and rheumatic pain
in the neck, were its characteristic  symptoms.  In many cases there were extensive
eruptions upon the skin, accompanied often by vesicles or nodules.   The irritability
of the  skin and the tendency to dangerous  metastases' were so  great that the
patients were unable to change their linen during the sweating without fatal conse-
quences.  The mortality of  many epidemics was frightful; eighty  to ninety per
cent., and often  more, of those affected died, while other epidemics ran their course
with remarkable mildness.
   The disease was first disseminated in  England, after the battle at Bosworth, by
the army of the victorious Henry, on the 22d of August, 1486, a year distinguished by
extremely wet weather.  Immediately after  his ceremonious entrance into London,
the disease began to  rage fearfully in the densely inhabited streets.   Two mayors
and six aldermen died within a week,  almost before they had laid aside their festal
garments. ' Many, who were rejoicing at evening, in the morning were no more
among the living.  The pestilence chose most of its  victims  among the strong
men, and  as the heads of the most renowned families and of the great  mercan-
tile houses were  lost,  together with those who were the  support of countless people
of more humble  station, the  gayety of the celebration was turned into the deepest
sorrow.
   Recovery from the disease  gave no  security, as  many of those who had sur-
vived  one  attack were affected with the same severity for the second and third
time, so that even the  small  consolation  of plague and small-pox patients, that of
going through life, after their escape from death, free and unconcerned, was taken 
488
ZUELZER.—MILIARY FEVER.
from them.  Thus the pestilence spread until the end of the year over all England,
and raged in all places with the same violence as in the capital.
   The  physicians,  being  exclusively Galenites, knew  not what  to advise.  The
people, thrown upon their own resources, fell back upon old and well-known Eng-
lish methods of treatment: no powerful drugs, but a moderate temperature; no"
nourishment,  but a little  mild drink, and quietude for twenty-four hours, until
the issue was decided.
   The  next  epidemic in England occurred with much less violence in the rainy
summer of 1507,  and lasted  only  until autumn.   The succeeding one appeared in
July, 1518, lasted six  months,  and showed even greater activity than the first, in
1486.   It ran so rapid a course  that the patients were snatched away in two or three
hours,  and the first chill was regarded as the announcement of  certain  death.
Among the lower ranks the number of  deaths was countless, but the nobility also
were not spared; no precaution  availed to keep death  from their palaces.  Many
persons of the king's household died, and in many places one-third or one-half of
the inhabitants were taken off.
   The disease appeared for the fourth time, and  with equal intensity, in England
in May, 1529, a season of exceptionally abundant rains and  mists.   Historical
writers spoke for a long time of its excessive mortality.   In July  of the same year
it appeared for the first time in Hamburg, introduced, as it was supposed, by a ship-
captain (Hermann Evers) arrived  from England.   Twelve of his crew and passen-
gers died within  tAvo days after their arrival.  The extension of  the pestilence took
place with great  rapidity,  1,100 of the citizens dying within twenty-two days.  A
short time afterwards, or almost  simultaneously,  it showed itself in  neighboring
cities, and also in Zwickau, fifty miles distant, without previously touching Leipzig.
It soon occupied  an immense region, extending on  one side as far as Dantzic, on the
other to Strassbourg, and southwards to Vienna.  It appeared, however, that  " the
flames did not start from  one  focus, but were kindled, as if spontaneously, every-
where, and were met with in all places."  Denmark, Norway,  Sweden, and perhaps
also Poland and  Russia, were  attacked.   It was remarkable that  the Netherlands,
in spite of their close connection with England  by navigation, were visited  four
weeks later than Hamburg, and  that the first cases appeared, as was observed in
England at the time of the epidemics, while a thick mist lay over Amsterdam.
   It was at this period that the custom was introduced  into its treatment of allow-
ing patients to sweat twenty-four hours uninterruptedly, to aid the critical excretions.
They were placed immediately in  bed, and covered with feather-beds and furs ; the
rooms were highly heated and the  doors and windows carefully closed.  A single
physician in Zwickau only, whose name is not preserved, vigorously opposed "this
fatal error."  He went from house to house, and wherever he found a patient buried
in hot beds, he tore them off with his own hand, and forbade them from murdering
the patients by heat.  By his determined bearing he rescued many who must other-
wise have been smothered.
   The last outbreak of the  disease in England was in 1551, and was unchanged in
violence.  It appeared again in spring, also at the  time of an intense fog. 
HISTORY  AND  EPIDEMIOLOGY.
489
   After this the  disease was no longer observed in this wide-spread distribution
and  intensity; a circumscribed  outbreak  only, the  sweating-fever  of Rottingen
(Sinner), which occurred nearly  250 years  later,  in  Nov.  1802, during rainy and
misty weather, recalls those descriptions.  The epidemic was  limited to this town,
and ran its course in ten days, but caused frightful mortality.  It was characterized
by a-pouring sweat, tearing pains in the neck, and palpitation, and led to death or
recovery within twenty-four hours.
   If we  review the epidemics thus found recorded in history, their resemblance to
miliaria in etiological and symptomatic  relations leads to the theory, according to
Hirsch,  that they represent a morbid process, if not identical with it,  at least differ-
ing from it only by gradual modifications.   The  sudden occurrence and the exces-
sively short duration of the epidemics, oftentimes, their dependence upon certain sea-
sons and conditions of the weather, the peculiarity of  running a highly fatal course
at one time, and a  mild one at another, are common to both.   In both the outbreak
occurs at  night, with chills, prostration, pains in the limbs and back, anxiety and
palpitation,  profuse sweating, and a rash, which latter, however,  is not constant.
Moreover, the same course,  and like disturbances  of  convalescence are common to
both.  Finally, the history of the Rottingen epidemic  establishes the connection of
both diseases in so striking a manner, that it can be correctly ranked with the latest
malignant epidemics of miliaria as well as with the mediaeval form of the disease.
   In the further  history of miliaria  there have accumulated so many errors and
misinterpretations,  that only the  most persevering critic, as Hirsch has shown him-
self to be, could succeed in following the historical record of the disease in its epi-
demic outbreaks.
   Men had gradually begun to disbelieve in the essential nature of the disease, and
to attach undue importance to certain symptoms;  at one time to lay special weight
upon the red papular rash (" purpura "), at another upon the occurrence of sweating
accompanied by vesicles  (" miliaria ").  Thus it came to pass that, by degrees, the
most different forms of disease, in the course of which " purpura" or  "miliary vesi-
cles " appeared, were called  " miliary fever." The peculiarity of the affection was
in this way so hidden, that not  a few physicians, and especially  dermatologists
like Hebra and his school,  came to deny the existence of  a miliary fever, and to
refer  the belief concerning it to a vesicular eruption which occurs as an accidental
complication due  to excessive sweating in the  most  various febrile  affections or
artificially  produced.  Historical investigations have furnished, however,  in  con-
tradiction of these  negative views, proof of the existence of the contested specific
affection.

    After the epidemics  of the sudor  anglicus the disease  disap-
pears  completely for  more than 160  years.  We meet it  again,
according to  the historical evidence, which  has lately been care-
fully sifted, only since the beginning of the last century, and es-
pecially in France and Italy, and likewise also  in Germany, Aus- 
490
ZUELZER.—MILIARY FEVER.
tria,  and Belgium.  The first epidemic, best known  under the
name of " the sweating sickness of Picardy,"  appeared in the
year 1718 (perhaps even somewhat earlier) in different districts of
Picardy and the neighboring provinces.  After this (compare the
tables of Hirsch) followed 174 epidemics up to the year 1861, and
since then  an  additional  and  not  inconsiderable number  on
French territory, which are described by Dumas, Galtier, Coural,
Plonviez,  JSTole, and others.  They occurred at varying intervals
and in very various localities, always confined, however, in point
of time and space, within narrow limits.  The area most particu-
larly affected has been a portion of territory in the  north-east
of France, which includes Normandy, Isle de France, Picardy,
Flanders,  the northern  portion  of Champagne, and  Franche-
Comte,  and comprises  also a  part of Elsass-Lothringen.   Other
districts, especially to  the  southward, have been less frequently
visited.
   Italy, too, has been attacked with quite a long succession of
epidemics.

   After the disease had prevailed in and around Turin from 1715 to 1720, there
appeared  the following outbreaks in other districts of Piedmont: in Modena in
1775; in the Venetian  provinces in 1790 (at Modena, and later in other places) ; on
the plains of Lombardy at the beginning of this century ; at Milan 1844, 1846 to
1848, and at other times; in Tuscany (Florence) in 1836 and 1837. Since then, both
there as well as in other regions of upper and middle Italy, several epidemics have
been observed.  The most recent of these have been described by Ottoni, Santini,
and in a particularly thorough and critical manner by Liverani.

   While middle  and north Germany, contrary to former views,
show in  all,  since  1801,  only  four small  isolated  epidemics
(Wittenberg,   1801,  district Kalau  in  the autumn  of  1838,
Frauenstein in Saxony in the winter of 1839, Wegeleben in the
winter of 1849), there have been observed several larger  ones
especially in  the  south-western parts, in Wurtemberg, Bavaria,
and  Baden.   Single epidemics have appeared also in several of
the mountainous districts of upper Austria, Styria, and Galicia ;
also in Belgium, in 1849 (together with the cholera), at Luttich,
Namur, and in the vicinity of  Mons, and in 1850 in Luxembourg
(Hotton). 
ETIOLOGY.
491
   Ferber describes an affection observed in a patient from Caracas, which he con-
sidered  " idiopathic miliary fever."  It is doubtful, however, if sporadic cases
occur in this way independently of epidemics.  The example is not free from objec-
tion.  Nine single cases of remitting fever, with the formation of phlyctenae, also
observed by Wunderlich,1 do not belong here.

   Historical research shows that miliary fever has been confined
in its  geographical distribution within more narrow limits than
almost any  other infectious disease.   Its  epidemics are  often
limited to single  places, or spread only over definite districts.
Only exceptionally does the disease show a wider spread over an
extensive country, and then it  is often found that the fever has
arisen  at the same time in different places.   It seldom spreads by
gradual progression, but more often by leaps over broader dis-
tricts.
   The period  of duration of the epidemics is also limited.  They
last on the average only from seven to fourteen days, seldom two
or three months ; and then generally run their course in such a
way that the majority of the cases are confined to the first two,
three,  or four weeks, and the further prolongation of the epi-
demic  is shown only by single  cases.
   On the other hand, the epidemics often attain in some places
that are affected  a very wide prevalence.   In one which spread
over a portion of Languedoc  in 1782 (Pujol), more than 30,000
persons were  affected;  and in the epidemic of  Forcalquier,  in
1772, out of  2,000 inhabitants 1,400 were attacked.  On the aver-
age, according to Hirsch,  from ten to  twenty per cent,  of the
inhabitants are affected ; it rises even to thirty per cent, or more ;
epidemics are  not rare, however, in which  the  number is  much
smaller.

                           ETIOLOGY.

   The epidemics of miliary fever show, on  the whole, a very
decided dependence upon the  seasons  of the year.  Of the 174
mentioned by Hirsch, fifty-nine began in spring, seventy-eight in
summer, but only eight in autumn, and twenty-eight in winter.
Five-sixths of  all  the epidemics prevailed in spring and summer,
1 Arch. d. Heilk. VIII. 174. 
492
ZUELZER.—MILIARY FEVER.
while the disease  was  extremely rare in autumn, and  although
somewhat more  frequent  in  winter, yet it occurred only in very
limited outbreaks.  (The epidemics of the English sweating-sick-
ness also began in  spring and summer.)
   In view of such a decidedly expressed preference  for particu-
lar seasons,  we are authorized in seeking  the cause of the disease
in the atmospheric  conditions  peculiar  to  these  seasons.   The
great majority of cases  shows, in fact, that the disease has devel-
oped with predominant frequency in warm and moist or very
changeable weather, or directly after it.   At the  time of most of
the winter epidemics, too, which have been of two or three weeks'
duration only, a  "moist,  dull" weather was observed.  More-
over, in the  history of  the English affection, the coincidence of
its occurrence with the appearance of misty and damp weather
was so pronounced that Hecker was inclined to recognize in it a
relationship  of cause and effect.
   On the other hand, it  cannot be demonstrated, according to
Hirsch, that the  occurrence of the disease is  dependent upon  the
condition of the  soil.

   From the observations  concerning its prevalence during damp  weather, many
physicians were inclined to connect its appearance with  the boggy  and moist con-
dition of the ground.  It had been noticed that the first epidemic in Picardy spread
along a moist valley in a  peat district, but that it  spared a chalk  district of the
neighboring plain.   Other epidemics led to  the same observation;  in those of
1772-73 in Provence, of 1812 in Elsass, and of 1820 and 1824 in Bavaria, the dis-
ease was confined to  deep, moist valleys; and that of 1829, in Ensingen, was pre-
ceded by an overflow.   Barthez  mentions that the  epidemic of 1839, in Canton
Rebais, affected only  the valleys which were exposed  to frequent inundations;  and
Martin  Solon and others state that that of 1841, in Charente, was  confined to the
swampy shore of the Lione, and extended farther into the country with diminishing
intensity.   In  opposition to  these and numerous other observations, it has been
shown that not a few epidemics have developed upon dry, airy, and elevated plains,
avoiding swampy and  low valleys, as, for instance, in the years 1810, 1821, and
1832, in the Department of the Oise, in 1820 in Giengen, in 1830 in Mettingen and
Gmiind, and in numerous other cases.  In the epidemic of 1866, in Pemes-en-Artois,
three airy and  elevated places, and three lying in the valley, were  alike affected.
Similar relations are stated in the descriptions of several of  the latest  epidemics
(Teilhol, Liverani, and others).
   Finally, we have,  in opposition to the  theory that the poison is really promoted
by a swampy region, the  evidence that the extensive swamps of  Gascogne were 
ETIOLOGY.
493
only attacked by the epidemics after 1840, and only slightly at that; while in
upper Italy the first epidemics were confined for a long time to elevated places.

   Nevertheless many epidemics do show a connection with cer-
tain contaminations of the soil.  In that of  St. Chinian, in 1864-
67, Coural, for instance, made the observation that the neglected
condition of the drains, and the collections of refuse in gardens,
and the like, if  they did not create, at least contributed to  the
further spread and severer form of the disease.   It seems to him
especially deserving  notice, that  when a canal situated at  one
end of the city was cleaned in April, 1866, and the mud from it
was allowed  to  lie upon the shore, all the houses in the neigh-
borhood were visited  within five weeks by the disease, and  in its
severest forms,  while in all other parts of  the town  only mild
cases occurred.    Similar observations were made in the epi-
demic of Noyons in  1849, and in Languedoc on the  Canal du
Midi.
   As regards individual predisposition, it appears that  the dis-
ease  affects on  the average more women than men,  and espe-
cially the vigorous age between  twenty  and fifty years.   The
reverse relation is relatively infrequent.
   In the epidemic  of 1821, in the Department of the  Oise, there were 803 male
and 1,177 female patients ; 1,461 were between the ages of sixteen and fifty, while
156 were  below, and 284 were above those limits.   In the epidemic of 1851 in
Carentan, 97 men and 181 women were attacked; among them were  19 children.
In that of  1854 only women were affected.  The epidemic of 1844, in Bavaria,
attacked 2,109 women and only 1,535 men.  In single epidemics, on the other hand,
that for instance of  1845, in Poitiers, and of  1855 in Hastinguer, the numbers in
both sexes were nearly alike, and occasionally the male sex was in excess, as in 1849
in Niort and Dole, in 1854 in Marvejols, 1865-66 in St. Chinian (among 107  only
25 women), 1866 in Pernes-en-Artois (40 per cent, women), and in Davayat (Puy-de-
Dome).
   The disease appears  especially to attack healthy and strong
persons.  The puerperal condition, typhus, and other diseases in
no way produce a special predisposition to  it, as was formerly
believed.
   From the  first appearance of the English sweating-sickness, it
has been shown that the disease affects all classes of the people
alike, and is in no way confined to the poorer.   This peculiarity 
494
ZUELZER.--MILIARY FEVER.
has been confirmed by later observations.  It has  been further
noticed, moreover, in this connection, that the spread of the dis-
ease is not promoted even  by the collection of great numbers of
persons in institutions of various kinds, as prisons, barracks, and
the like ; sometimes such establishments are even wholly spared.

   " Observation has shown," writes Parrot, whom I quote as an example (Epidemic
of 1841 in the Dordogne), " that the  cases diminished in numbers and severity
the greater the aggregation of individuals;  ....  in Pgrigeux all the estab-
lishments in which great numbers of people dwelt together were spared.  In the
barracks, where two battalions were generally quartered, as in the  college, where
there was no vacation during the first days of the epidemic, not  a  case occurred,
and in the prisons, containing from 100 to 120 inmates, only three were slightly
affected."

   Concerning the exciting causes  of  the disease we know very
little.   In the earlier epidemics (Loreau in Poitou,  1845 ; Rayer,
1821, in the Department of the Oise, and others) it was believed
to have been noticed that the disease could  be communicated
by intercourse.   Fourcart, however,  in his observations of the
epidemic  in the Department of Somme,  1849, came  to no defi-
nite conclusion concerning this, but considers a "transmission
infectieuse," in the same manner  as it is accepted  in the acute
exanthems, as probable.  At all events, miliary fever is not con-
tagious in the sense that the disease may be conveyed directly
from the sick to the well.  The  limitation of many epidemics
exclusively to a single place  is opposed  to such a theory, and,
moreover, they do not spread in establishments where great num-
bers of people  live together.   Finally, the disease  may attack
certain individuals among the families and inmates  of a house,
while it spares the others.
   Attempts  at inoculation with  contents of the  vesicles have
been  without result, although  Seitz  regards  the fluid as  the
vehicle of the contagium.

   The occurrence of miliary fever simultaneously with epidemics of scarlet fever,
and with those of measles, has been observed (1820 inGiengen, 1830 in Gmund, 1831
in Esslingen, 1855 in the  Department of Jura).  The cases are, however, so  infre-
quent that they do not support the repeatedly expressed suspicion of a relationship
between the poisons. 
ANATOMICAL  CHANGES.
495
   With regard to cholera, a certain relation between it and miliary fever has been
accepted by some writers.  In the earliest cholera epidemics, Hufeland called atten-
tion to their resemblance to the Sudor britannicus.  It is peculiar that subsequently
several cholera-epidemics were accompanied by or followed  miliary fever (1832 in
the Department of the Oise, 1849 in the same  and neighboring departments, 1854-
55 in several of the middle and southern regions of France, and elsewhere).   Some-
times, also, the disease has appeared in the wake of  cholera (1849  in Tournay and
elsewhere). Very remarkable individual observations have been made, showing that
miliary fever  and cholera may spread in neighboring  districts, and appear to
exclude each other; in La Marche,  for example, with 2,000 inhabitants, there were,
in 1854, ninety-seven cases of miliary fever and only forty-three of cholera, while in
Flameraus, near by, the reverse proportion obtained.
   Finally, cases  are described  in which, with various modifications, one and the
same person is attacked by both affections  simultaneously, or  one  after the  other.
An accession of  miliary fever is supposed  to exercise a favorable influence on the
course of cholera (Verneuil) ; the reversed relation, however, is thought to hasten the
unfavorable result.
   It is difficult  to form a definite judgment as to these relations.   Although not
very numerous,  the  observations appear to be satisfactorily founded.  Hirsch is
inclined not to regard the coincidence of the two diseases as accidental, and reminds
us that the affection described by Murray under the name "sweating-sickness,"
during the Indian epidemic  of 1839^40, appeared  to afford a  certain protection
against the cholera.
   A  peculiar sweating disease was also observed by the naval  surgeon Roux,'
which occurred at Toulon in the cholera years 1849,1854, and 1855, and was essenti-
ally characterized by profuse intermittent sweats, with great weakness, but ending
favorably.  A similar affection, with a very malignant course, and  with symptoms
of asphyxial cholera, occurred in the French fleet in the Mediterranean during the
Crimean war, and  also (according to the statements of Houle and Bourgogne) in
some of the French Departments during the cholera epidemic of  1854 ;  in place of
the intestinal discharges, however, there was excessive perspiration.
   A relationship of the two processes cannot of course be deduced from this evi-
dence,  and least of all are we warranted in regarding cholera, as Dubun does, a sort
of "internal miliary fever" (Suette  interne), or  the latter as a kind of "skin-cho-
lera."   The facts "hitherto  noticed, however,  demand that this relationship should
be more thoroughly observed in future.


                         Anatomical Changes.

    Reports of dissections in miliary fever are not very numerous,
and reveal no characteristic  changes,  at least not such as suffice
to explain the violent symptoms during life.
              1 Union Med. 1855, Nr. 27 et seq.   1857, Nr. 131 et seq. 
496
ZUELZER.—MILIARY FEVER.
   The most striking  is the rapid occurrence of decomposition,
which, as Galy1 says,  "begins almost during life.  A few hours
after death  the  skin is everywhere  oedematous, frothy  blood
flows from the nose and mouth, and  the  odor of decomposition
quickly prevails."
   The internal organs  show nothing positive except great hy-
peraemia.    The  lungs are  much congested,  and the  mucous
membrane of the  bronchi and  trachea is found  reddened  and
often covered with reddish mucus.  The heart is soft (Galy and
others), and  the pericardium occasionally ecchymosed (Primbs,
Borchard).  The  mucous membrane of the stomach and  intes-
tines appears generally reddened (Rayer, Dubun), occasionally
studded with red spots (Primbs), and, in the small intestine,
with  "vesicles," which some (Barthez, Landouzy,  and others)
regard as  swollen solitary follicles; others, as Bourgeois, as  dis-
tinct miliaria vesicles formed of epithelium and filled with fluid,
wliich occur here as the analogues of the cutaneous eruption.3
Immediately over  the  valves superficial  follicular  ulcers  are
sometimes found (Beck).  The liver is full of  blood, and  some-
what soft, and the spleen is always enlarged,  softened, and often
friable (Borchard  and others).3  Galy found the kidneys  gener-
ally  hyperaemic, Primbs describes them as normal.
   In the  central organs of the nervous system nothing abnormal
is  found except occasional hyperaemia and a more or less con-
siderable oedema of  the meninges (Liverani).  Theden4 alone has
several times seen the  sheaths of some of the cervical nerves (the
fifth and  seventh pairs), as well  as the ganglia of the  cervical
sympathetic, filled "with yellow serum."
   The blood in  the dead body is uniformly described as thin
and dark-colored, while  that drawn during life by venesection is
bright red, thin, and coagulates imperfectly.
   The contents of the miliaria vesicles have been examined by Seitz and Beroaldi.
   1 Canstatt's Jahresber. II. 14.
   2 Eller describes similar vesicles upon the liver, Seitz  also upon the pericardium and
on other parts.
   ;i Hirsch calls attention to the fact that this is found mostly in, persons who have
lived in malarial regions.
   4 Compare Canstatt's Handb. 1874, p. 213. 
SYMPTOMS.
4P7
It is clear in the beginning,, and contains, besides many smaller nuclei, cells which
are smaller than pus-corpuscles (!), with three or more nuclei, which remain visible
after the disappearance of the cell membrane by the addition of acetic acid.  Seitz
seeks in these nuclei and cells, which he observed also in the lymph of varicella and
cow-pox (without doubt only pus-corpuscles), the real virus of the disease.  In the
later stages of the vesicles, these cells appear in greater quantity,  until they finally
form nearly the whole contents of the oldest and dried-up vesicles.

                        Symptomatology.

    A prodromal stage of two or three days' duration precedes the
outbreak  of the  disease in  cases  of moderate severity.  The
patients complain of  great irritation of the  skin, dryness of the
mouth, increased  thirst,  weakness,  headache, and  feebleness  of
the limbs.  There is often a peculiar painful sense of oppression
in the region of the stomach, which not unfrequently increases to
an intense feeling of suffocation peculiar to the disease (Nole and
others).   There are occasionally also ringing in the ears and diz-
ziness.  In milder cases these precursors are wanting (Coural).
    The beginning of the disease generally  occurs, according  to
Plouviez and others,  as well as the older observers, in the night,
or late in the afternoon or evening, and,  as a rule, it is indicated
only by a slight chilliness, seldom by a pronounced chill,  and is
characterized by a profuse and persistent  sweating.  Its onset is
accompanied by a feeling of prickling and  stinging in the skin,
either first upon the head and breast, gradually descending,  or
simultaneously over  the whole body,  and is so abundant  that it
quickly penetrates bedding, mattresses,  straw-beds, and  every-
thing, and often macerates the skin, as it were.   The sweat is of
acid reaction,1  according to  Seitz, and diffuses  an  unpleasant
odor, which has recently been noticed  by Plouviez also, but
which was referred by earlier observers (Foucart and others) to
rapid decomposition promoted by  uncleanliness.
    At the same time  a more or less severe fever sets in, the pulse
is quickened to over 130 in the minute,  and the skin is  burning
hot.  The headache increases, and in many  cases (in one-quarter
of  the patients, according to  Plouviez)  the patients experience,
   1 Stahl did not find it always acid, and Barthez, who examined only that of the face,
found it neutral.
           VOL. II.—32 
498
ZUELZER.—MILIARY FEVER.
together with a violent and tumultuous palpitation and abdomi-
nal pulsation, a feeling of constriction in the chest and the epi-
gastrium (barre epigastrique), and precordial pain.   These symp-
toms increase  not infrequently to a  frightful  degree, although
neither in the heart nor in the lungs is any anatomical lesion to
be discovered.   The respiration becomes at times irregular and
interrupted.  The epigastrium is extremely  sensitive and pain-
ful on pressure.                                              »
   This condition remains unchanged until the outbreak of  the
rash,  or it undergoes exacerbations, occurring irregularly or
sometimes in such regular intermissions that the  suspicion has
suggested itself to many observers that they were dealing with
intermittent fever.
   The rash appears on the third  or  fourth  day of the disease,
seldom earlier ; but in other cases not until from the seventh to
the tenth, or even until the  fifteenth  day (Coural), and is often
attended with  a marked increase of all the symptoms, and a
stinging, pricking feeling in  the skin.  The other symptoms, as
a rule, disappear either suddenly or gradually after its outbreak.
In the milder cases, the efflorescence is often wanting (in ten  per
cent, of Plouviez' cases, and in one-third of VerneuiT s).
   The exanthem consists, as a rule,  of small, round, or irregu-
larly shaped spots, of from  two to five mm. in diameter.   They
are sometimes  so closely aggregated  that the skin  appears uni-
formly reddened (Coural), or they become confluent and look like
the eruption of  scarlet fever.  In  their centre  there  arise, after
some hours, according to the statements of Coural and many of
the older writers, vesicles, which in the beginning  are  so small
that  they are to be discovered only by passing the finger over
them, or by the magnifying-glass.   They soon become  larger,
however, and attain the size of a millet seed  (hence the name
miliaria), or sometimes even that of a  pea.  They contain a clear
fluid,  which gradually becomes milky and yellowish from pus
(miliaria alba).  Finally, after two or three days they burst, or
dry up and form crusts, which are cast off in the form of  scales.
In milder cases the vesicles appear  also without  the red spots
(miliaria crystallina).
   The  rash spreads  by distinct advances, one  after the other, 
                          symptoms.                      499

 sometimes with fever, and first appears upon the neck and breast,
 then  upon the back and extremities, less frequently  upon the
 abdomen and scalp (Coural).  Sometimes it occurs also upon the
 mucous  membrane of the mouth and nose,  and upon the con-
 junctiva.  Foucart and others noticed it  more frequently upon
 the mucous membrane of the mouth,  where it easily led to exco-
 riations.
   These symptoms were observed in all the epidemics,  according
 to the descriptions, and are therefore characteristic,   The remain-
 ing symptoms are developed with varying frequency at different
 times; headache,  dizziness, and  sleeplessness  accompany  the
 affection quite  often.  There are generally also loss  of appetite,
 unnatural taste, moderate thirst, and  nausea, but seldom vomit-
 ing.   Persistent constipation is the most uniform of all.
   The urine is turbid, high-colored, and scanty ; sometimes com-
 plete  suppression has been observed (Foucart and others), so that
 possibly  a certain portion of the particularly violent symptoms
 may be referred to uraemia.  In some cases strangury and pains
 in the region of the bladder  and elsewhere  have been noticed.
 Sedoni considers the profuse secretion of urine, which sometimes
 occurs during or after the sweating stage, a favorable sign.
   The disease ends with more or less extensive desquamation ;
 convalescence, however, in consequence of the great debility and
 emaciation, is often protracted much longer than the severity of
 the disease would lead us to expect, and is sometimes delayed by
 irregular sweats, furuncles, and the like.
   This nearly typical course is not infrequently modified in vari-
 ous ways.
   In the severest forms (Coural and others) all the symptoms,
and especially the heat, reach a very high  degree  at  the  time of
an exacerbation, and the feeling of constriction and the  precor-
dial pain are  so great that the patient believes he must suffocate.
Sometimes  they increase to  a  sensation of being  laced together
(barre tracheobronchique), extending  upwards from the  epigas-
trium to  the larynx, and of apnoea (Bazin, Verneuil), so that true
cases  of  suffocation occur without perceptible changes  in  the
heart  or  lungs.   The patients  have no rest for a moment, and
throw themselves about in bed, or fall into raging delirium.  The 
500
ZUELZER.—MILIARY FEVER.
sweating and rash are often absent, and the patients die  with
muscular cramps or convulsions.
   Occasionally the course in the  sweating  stage is fulminant;
the patient, up to this time comparatively easy, utters a few dis-
connected words, the face becomes  cyanotic, the carotids and the
abdominal aorta pulsate violently, and a fatal collapse  quickly
follows.
   These cases call to mind the mojt violent forms of the English
sweating-sickness ; but they appear to have becc   e less common
in the most  recent  epidemics.   Of  seven cases of this sort
recorded by Coural, five died between the second and fourth
days, two in rapid collapse, three in an accession of delirium and
convulsions.
   There is sometimes  developed in the  sweating period a grave
typhoidal condition, as among others Nole describes it, which
leads to death, preceded by somnolence or coma, syncope, a soot-
like coating upon the teeth and tongue, and profuse bleeding
from the nose and uterus, and in which no considerable anatomi-
cal changes are to be discovered.
   In mild cases, on the other hand (abortive cases, according to
Nole,), the whole process  is often ended in from three to five
days.  They  run their course without prodromata,  and often
without the rash (suette sans eruption), and only with repeated
sweatings, sometimes so slight that the patients  do not need to
give up their business.
   Complications are not common.  Sometimes an angina accom-
panies the affection.  A more or less intense bronchitis is espe-
cially mentioned.  Pneumonia was seen only once  by Coural,
and Robert believes that pneumonia is sometimes thought to be
present when auscultation  shows  nothing abnormal.   In  some
epidemics, especially perhaps in the winter season, bronchitic
affections appear to be more common, in others (at cholera sea-
sons ?) diarrhoeas.

                         Diagnosis.

   The diagnosis offers no difficulties during the epidemic occur-
rence of the disease.   The profuse sweatings, with prickling of
the skin, the oppression and precordial pain, and the subsequent 
MORTALITY  AXD  PROGNOSIS.
501
outbreak of the rash assure against any possibility of  confound-
ing this disease with measles.  When  a  decidedly intermittent
type  prevails, the  occurrence  of the exanthem is generally
enough to distinguish it from  intermittent fever.  From  typhoid
fever in its early stages, the disease is distinguished by the short
course, the low degree of fever, the initial  sweating, and  the con-
stipation.
   The duration of the affection amounts on  the average to six
or eight days, of which one, two, or three belong to the sweating
stage, and three  or four to  that  of the  exanthem.  A longer
duration of the fever has, however, been  occasionally observed,
when the rash does not appear until later, or in successive out-
breaks.  A shorter  course, like that of the  English epidemics,
appears  to belong only to the fulminant  and to the  very mild
cases.
   Relapses are mentioned by most observers.   They run their
course without severe symptoms, only with repeated  sweatings,
and mostly favorably.  In other cases they seem to be produced
by errors in diet, and  then not unfrequently assume a  severe
form.
                  Mortality and Prognosis.

   The mortality differs  greatly in various epidemics.    Some-
times fatal cases are a great rarity, whilst the mortality,  in some
of the recent epidemics even, rose to twenty or  thirty,  or even
fifty per cent. (Wurzburg epidemic of 1825  and others).  On
an average  among 16,000  cases,  which  have  been collected
partly by Hirsch, and partly from the accounts of the later epi-
demics, a mortality of from  eight to nine per cent, occurs.

   In the epidemics of 1849 (Department of the Oise), 1851 pepartment of He-
rault),  1855 (Cognac), and among 130 cases of Gresser, not a patient died.  In 1842
(Department of the Lot-et-Garonne and Dordogne)  and in 1851 (Carentan)  the
mortality was very slight.  On the other hand, it rose in some epidemics (1841 in
Dordogne, and 1849 in Niort) much  higher.  In 1866 (Pernes-en-Artois)  ten  per
cent., eight of Liverani's sixty-eight patients, thirty of Coural's 117, and eleven of
Teilhol's forty died.

   The prognosis depends  therefore essentially upon the char- 
502
ZUELZER.—MILIARY FEVER.
acter of  the epidemic.  Coural is of  the opinion that it would
be well  to pronounce it dubious  in all severe forms.  With
the regular course of  the disease, and with moderate severity of
the symptoms, the result is favorable, while high  fever, exces-
sively profuse sweating, and a considerable  increase in the feel-
ing  of constriction appear to be  dangerous  to life.   Profuse
hemorrhages, somnolence, and coma,  convulsions, rapid sinking
of the strength,  with small pulse, violent  delirium, and great
dyspnoea, belong to the gravest symptoms,  wliich generally end
in death.
   The fatal result is  seldom observed after the eruption of the
rash, and during the  period of  desquamation.  It occurs most
generally in the  sweating stage, before  the appearance of the
rash, at the time of the  exacerbation, which precedes this, and
with a sudden increase of the nervous symptoms.

                         TREATMENT.

   After the experiences of the early epidemics of the  English
sweating-sickness had led to  the expectant treatment  (the so-
called old English method), the  theory was again adopted, dur-
ing the great epidemic in the Netherlands, that the eruption and
the sweating were critical manifestations, in which  the patient
must be  aided by diaphoretics of all  kinds, and by the warm-
est  and most  careful  covering.  This  view  was maintained for
a long time.  Foucart even was enabled, as he communicates
in a graphic description of his experiences in the epidemic  of
1849, to observe its practical  workings in the extremely ener-
getic use of  all sorts  of  diaphoretic agents.  This  consisted  in
the excessive employment of materials for producing heat—beds,
furs, clothing, exclusion of air, bottles of warm water, and the
like—although the epidemic occurred towards the end  of May
and the beginning of June !
   Blood-letting,  which the physicians of the last  century con-
sidered to be indicated, especially where there was a feeling  of
suffocation and apnoea, was soon shown to be injurious, and
Foucart states expressly that  it generally led to an aggravation
of the patient's condition,  and  not infrequently to a fatal result. 
TREATMENT.
503
   Among special remedies anti-spasmodics and nervines, vale-
rian,  camphor,  and,  under some  circumstances,  opium, were
often used.  The intermittent character of many cases led Pigne,
Parrot, Galy,  and others to the use  of  quinine, wliich  is more
recently again recommended in large doses by Gresser,  Coural,
and others.  It diminishes the fever, but it is uncertain whether
or not it shortens it, although it is certainly effective against vio-
lent nervous symptoms.
   To incite diuresis, Schonlein gave seltzer-water,  and Sedoni
cold water in  great quantities, to which,  in persistent delirium,
Gresser added from forty to fifty drops of solution of chloride of
iron daily.  Chlorine water  (Herzog),  corrosive sublimate (Eisen-
mann), and similar drugs have been tried in the epidemics of  the
last thirty years.  In several of the later epidemics ipecacuanha
was  used  in  the  beginning  of the  disease, according to  the
example of Foucart,  as an emetic (from thirty to forty grains,
in three doses, at intervals of  fifteen  minutes); its boasted effi-
cacy, however, has not been confirmed.
   Opinions concerning the use of cutaneous irritants (sinapisms,
blisters, etc.) in nervous symptoms  are more unanimous, especi-
ally in the sensation of  constriction. Lately, subcutaneous injec-
tions of morphine have also been used with advantage.
   Schonlein,  in the Wurzburg, epidemic attempted to neutralize
the acid secretions by washing the skin  repeatedly with a solu-
tion of caustic potash (twent3^-five to fifty grains to the ounce).
Rayer used cold applications  to relieve  the  pain at the epigas-
trium, and Fodere applied ice-cold compresses  during collapse.
More general warm baths were employed by Bastard.
   Warning is given against the use of purgatives in large doses ;
and bleedings, even locally by leeches and otlier means,  are espe-
cially to be avoided.
   In general, a return has been made to the expectant treatment.
Most physicians limit their efforts to the  use of mineral acids
and lemonade, or light aromatic drinks, as mint teas, etc.
   Warm baths, where possible, or washing  the skin with wann
water, to which vinegar or  alum has been  added, appear  to  do
good.  Stimulating treatment—such as alcoholic stimulants, cam-
phor, and the like—seems  to be indicated only in  the  severest 
504              ZUELZER.—MILIARY FEVER.

cases.  Most observers are unanimous in recommending quinine ;
while in persistent sleeplessness  opium, either alone or with
ether, is also advised.
   Attention to good hygienic conditions remains the chief point
in treatment.  The  patient must be kept cool and lightly cov-
ered, although protected against draught, especially during  the
frequent changes of the clothing wet with perspiration, and dur-
ing the washings and baths.
   The diet should be moderately nutritious, and during con-
valescence the prolonged use of tonics is indicated.
   From a prophylactic  point of  view  nothing but leaving  the
infected region seems to be of any avail. 
    DENGUE,  OR   DANDY  FEVER.
                               (DENGUIS.)
The Spanish word Dengue is derived from the English Dandy, and corresponds
                                    to it.
Rush, Med. Inq. and Obs.  Phila., 1789—Pezet, Med. Repos.,  N. Y., New Ser., VoLV.
    No. II.  1819.—Kennedy, Calcutt. Med. Trans., I. 371. 1824.—Mellis, ibid., 310.—
    Twining, ibid., II. 32.  1825.—Mouat, ib., II.  41.— Waring, North Amer. Med.
    and Surg. J., Apr., 1830. V. IX. 374.—Stedmann,  Edin. Med. and Surg. J., 1828,
    Vol. XXX. 227.—Luders, Hufel. J. LXVIII.  Hft.  4. 33.  1827.— Ruan,  Edin.
    Med. Chir. Trans., III., part II. 1827.—Squaer, Lon. Med. and Phys. J., 60, 21.
    1828.— Waterson, Med. and Surg. J., IV. 303. 1827.—Nicholson, Edin. Med. and
    Surg. J., XXXI. 115.  1829.—Furlonge, ib.,  XXXIII. 50.  1830.—Moreau, Rev.
    Med.  1828. III. 475.—Maxwell Edin. Med. and Surg. J., LII.  151  and 154.
    1839.—Lehmann, Am.  J. Med. Sci., Aug., 1828.  477.—Hays, ibid., Nov., 1828.
    23'S.—Tuite, N. Y. Med.  and Phys. J., VII. 375. 1828.— Osgood, Boston Med.
    and Surg. J.,  I. No.  36, 361.  1828.—Lawson,  in  Forry, The Climate of the
    U.  S., etc. N. Y.,  1842.—Dickson, Am. J. Med. Sci., III. 3.  1828, and IV 62.
    1829.—Dumaresa,  Boston Med. and  Surg. J., I. 32.  1829.— Daniell,  Am.  J.
    Med. Sci., Aug., 1829.  291.—Raleigh, Ind. J. of Med. Sci., New Ser.. I. 452. 1830.
    —Pruner, Ib.  311. 1845.—Lallemant,  Das  gelbe Fieber etc.  91.  1846.—Hes-
    ter, Transact. Am. Med. Assoc, II. 161. 1848.—Fenner, Southern Med. Reports,
    N.  Orleans and N.  Y., 1851.  II.  93. — Holt, ibid., 437.— Arnold, Charleston
    Med. J., July,  1849.—Dickson, ibid.,  Nov., 1850.—Campbell, South. Med. J.,
    Nov.,  1850.—McCraven, Transact. Am. Med. Assoc, V  676. 1852.— Hearde,
    ibid., 683.— Wragg  and  others, ibid., IV. 71, 173, and 211.  1851.—Anderson,
    Proceed.  Med.  Assoc,  of  Alabama, 1851.—Smith,  Edin.  Med.  and Surg.  J.,
    LXXXn. 166.   1855.—Hirsch, Dtsch.  Kl. 1852.  48, 49.—Jarvis, in Coolidge's
    U.  S. Army Statist.  Report, from 1839 to  1855.  Washington,  1856.   365.—
    Gaol, Zeitschr.  d. Wien. Aertze.  1858. No.  8.—Compare also Hirsch,  Handb.
    der histor. geogr. Pathol.  1860. I. 272 et seq.—Taly, Arch, de Med. nav.  1866.
    p.  37 (Epid.  in Goree).—Ballot, ibid., 1870. p. 470 (Epid.  in Martinique).—
    R.  II.  Poggio (La Calentura roja observada en  sus apariciones de los anos
    1865, 1867).  Madrid (Epid. in Andalusia, etc.).—Read, Proceed, of the Sanit.
    Commiss.  of  Madras.  1871 (Epid. of Aden,  Zanzibar,  etc.).—Chipperfield, 
506
ZUELZER.—DEXOUE FEVER.
    Madras Monthly J. of Med. Sci., 1872. No. 28.—Christie, Brit. Med. J., 1872.
    I. 577 (Epid. in Zanzibar).— Vauvray, Archiv.  de Med. nav. 1872.  p. 74.—
    Dunkley, Brit. Med. J., 1872. II. 378.— G Conn ell, Raye. Ind. Annals of Med.
    Sci., 1872.  137.—Davson,  Lancet,  1872.   II.  542.—Mood em  Sheriff, Med.
    Times and  Gaz., Nov. 15, 1873, p. 543 (Epid. in  Madras, 1872).— Unknown
    Author, Union MMicale. 104.  1873 (Epid. in India).—J. J. de Wilde (Niedrl,
    Tijdschr.  1873).  Dengue in Fort Willem I. in Java).—Midler and Manson,
    Brit. Med. J., 1873. II. 294. — Charles, Clinic. Lectures on Dengue. Calcutta.—
    Cock, Edin.  Med. and Surg. J., XXXIII. 43. 1830.—Aitken, W., in System of
    Med.  Edited by J. Russell Reynolds.  London, 1866.  I.  258.—Rey, Archiv.
    de Med. nav. IX. pp.  278 and 382.  1868.—Pochard, J, Article in Nouv. Diet.
    de Med. et de Chirurg. Prat.  Paris, 1869.   XI. 130.—Faget, New Orleans Med.
    and Surg. J, New Ser., Jan., 1874.  603.—d'Aquin, ibid., July, 1874.  37.—
    Hoover, Am. J. Med. Sci., Apr., 1874. p. 379.

    The  name Dengue1 is applied  to an acute disease, which
mostly occurs as  an epidemic in hot  climates,  seldom sporadi-
cally, and  the course of which,  after a sudden onset or after
slight prodromata lasting several days,  consists  of two parox-
ysms  accompanied by fever,  either  following immediately one
upon  the  otlier, or after an  intermission of one, two, or  three
days.   But the two paroxysms are essentially different one from
the other;  the first  is characterized by continuous  high fever,
and numerous exceedingly painful swellings of the joints, which
interfere with motion, also more rarely by an exanthem.   These
symptoms subside after  two or three days, simultaneously with
the sudden  outbreak of a sweat, an  epistaxis,  or a diarrhoea,
which is often critical.
    The second febrile stage, which lasts  from two to three days,
is marked by a remitting fever  and  a  more or  less  extensive
blotch}^ or uniform,  non-elevated, rose-red eruption,  and  great
itching of the skin, also less frequently by swelling of the joints.
    The subsequent  recovery  is gradual,  and  accompanied by
decided  desquamation.   Its course is generally accompanied by
great loss of  appetite, restlessness and sleeplessness.   More seri-
ous brain symptoms  are absent.

   1 In  accordance with The Nomenclature of Diseases, drawn up by a joint committee
appointed by the Royal College of Physicians  of London, 1869, p. 5, the name is
now generally accepted. 
HISTORY  AND ETIOLOGY.
507
   The disease attacks all ages and both  sexes; with adults it
terminates favorably  in recovery, and is only occasional^ dan-
gerous in children.  It sometimes leaves behind long-continued
and painful swellings of the joints,  diarrhoeas,  emaciation, and
great debility.   Relapses also occur.
   It is not yet determined whether  the disease is contagious or
occasioned by minsmatic influences.

                     HISTORY  AND ETIOLOGY.

   Our knowledge of the history and etiology of dengue is still
but  little developed,  because general attention has only  been
directed towards it in the most recent  times,  on account of the
greater notoriety and wide  diffusion of the epidemics.  The dis-
ease by preference seeks  hot regions near  the  tropics ;  still, iso-
lated cases also occur in places  far  removed from there (New
York and others).
   The reports refer  chiefly to outbreaks  of  the disease lying
far apart from one another  in  point  of time.  It is still impos-
sible to decide whether in  the intervals it is  completely extin-
guished,  and constantly springs up again indigenously at certain
times (date-harvest), or whether  a connection  is established by
means  of sporadic  cases, which  may accidentally  develop  into
greater epidemics.

   Our first information about the  disease, according to de Wilde, dates from the
year 1779.  The  chief physician of Java at that time, David Brylon, informs us
briefly of an epidemic disease under the  name of knockelkoorts (bone fever), which
attacked many of  the natives and colonists in  Batavia. In  the  next year (1780)
Rush describes a  dengue  epidemic in Philadelphia,  and  at the same time the
missionary  (Wise according to an  anonymous French writer) observed the same
disease on the coasts of Coromandel, Africa, Arabia, Persia, and  Thibet.  After a
long interval it is reported (Pezet) that it occurred in Lima in 1818.  Eight years
later it appeared in Savannah.
   According to  Hirsch the almost epidemic spread of the disease beginning in
America in 1827, and which was then described under the name of break-bone fever,
excited greater attention.  It showed itself first in September upon the island of
St. Thomas, the next month in St. Croix, went thence in one direction over the
Antilles towards the mainland of North America, in the other over the Caribbean
islands towards Columbia, and lasted until September, 1828, at which time it had 
508
ZUELZER.—DENGUE  FEVER.
extended to Savannah.  Sporadic cases also occurred in many of the large cities of
North America, such as Boston. New York, etc.
    After some outbreaks which remained  isolated (1831  in Louisiana, 1844 in
Mobile, etc.), the fever extended in  the summer  of 1848 simultaneously with  the
yellow fever in New Orleans, Mobile, and the  neighboring  regions.   It was popu-
larly called Dandy-fever (Spanish, Dengue) from the stiff, affected gait  the patients
were forced to adopt.  Some isolated cases followed in the next two years.
    A new  epidemic attacked the Southern States of North  America in 1850, and
again established itself especially in Savannah, Mobile, and New Orleans,  extend-
ing further, however, into Texas.  The last epidemics  known to have occurred in
this country were in the years 1861 and 1866.
    A considerable epidemic  of dengue prevailed in Brazil in  the summer of  1846,
and to a less extent in each of the following three years, likewise at the same sea-
son.  It also appeared in Peru in 1852—here, too,  as a precursor of yellow fever.
    The disease found another  remote field in Lower  Egypt  and on the coasts of
Arabia, where, subsequently to the epidemic of 1779 which we  have mentioned, it
was first observed  at  Cairo, in 1799,  by Gaberts, and  then  occurred again,  after
a long interval, in 1835 and  1845, under the name of " knee-evil" (Pruner).
    Next to these we see India most frequently visited by epidemic dengue ; first, in
the year 1824, it appeared during the hot season in the southern  parts; in the  rainy
season in Calcutta, and spread thence along the Ganges, over the largest portion of
the Bengal and Madras Presidencies.  In the succeeding year, and again in 1836, the
dengue returned to Calcutta during  the rainy season, and again spread  as an epi-
demic in the  same locality  and  in the Bengal Presidency.   Epidemics were next
recognized in  the years 1853 and 1854.
    In 1860 the dengue appeared at  Martinique, first  among the ships  which had
recently arrived  and in the garrison.   According toBallott, one hundred and twelve
cases of the disease occurred among the four hundred men constituting the garrison.
The disease did not extend into the city until later.
    In Spain, too, the disease was recognized in the years 1864-1868 under the  name
of  La piadosa (the exciter of compassion) or La pantomima.   It appeared first at
Teneriffe, at Cadiz, and  at  Seville, and  in the following  years in Andalusia and
some other provinces of Spain.
    The last outbreak of dengue  occurred very recently,  in the years 1871  and  1872.
The epidemic first appeared  in Arabia, where  it was called Aburuka-Bah  (Father
of  the knee), and was observed  in 1871 by Read,  especially in Mecca, Medina, and
Aden.  In Aden it prevailed epidemically for over seven months ;  of the garrison
of  nine hundred men, seven  hundred had the disease.   Sporadic cases showed  them-
selves for a still longer time.  As a result of the constant communication with ports
in  the southern seas, the disease  was  carried in 1871 to Zanzibar and other points on
the African coast (Read, Christie, and others).  Vauvray communicates  the intelli-
gence that it prevailed at the same  time at Port  Said, where, however,  it icas  epi-
demic every year at the season of the date-harvest, and thus acquired the name of date 
                            ETIOLOGY.                          509
fever.   In November,  1861,  it reached Java, and became localized for several
months, especially in Fort Willem I. and its vicinity.
   Furthermore, it was  imported directly into Bombay and Cananore  by two troop-
ships pi. Sheriff). Thence the  epidemic extended in 1872 through all India, thouo-h
confined at first to the Madras  and Bombay Presidencies, especially along the course
of the railroads.  Even in other English stations in  Burma, China, and Nepaul
cases of this highly remarkable epidemic were found.  In its diffusion the disease
was as wide-spread as it was  intense.  In some of the cities attacked, scarcely an
inhabitant remained exempt.  It prevailed most violently and most extensively in
Madras, where not a house escaped, and it attacked equally both sexes and all ages (the
oldest  patient was eighty years, the youngest two months old), and persons of every
condition, even up to the highest classes. The fever attained its greatest  extent in
Madras in September and October.   According to Mooden  Sheriff there came into
the public dispensaries for treatment in July, twenty-five cases; in August fifty-two ;
in September, one hundred and seventy; in October, one hundred and fifty-seven.
After a heavy fall of rain, between the 13th and 14th  of October, the disease sud-
denly abated to such a degree  that only slight sporadic cases occurred up to the end
of the year ; only four in November and December.

    The  etiology, in regard to the  exciting causes, appears com-
pletely obscure.  The question whether the dengue is contagious in
the ordinary sense still eludes decision, although the disease is
capable of being  conveyed  to  a distance  by  articles  which are
constantly passing from hand to hand,  as  was made evident by
the mode of diffusion of the last epidemic especially.  Certain
observers, as M. Sheriff, favor the assumption  of its contagious-
ness,  without, however, being  able to  adduce positive proofs ;
others, as Thaly, deny  it decidedly.  Most physicians who have
had an opportunity of observing the disease refrain from express-
ing an opinion about it.
    In certain cases the affection appears  as  the precursor  or
companion of yellow-fever  epidemics in the  maritime countries
attacked by this disease (Ave-Lallemand), but it has also occurred,
independently  of  the  latter, there, as well as in mountainous
regions  otherwise healthy.   Moreover,  no uniformity  can be
assigned in regard to the seasons of the year  especially favored
by dengue, only it appears hitherto to have been essentially lim-
ited to tropical regions  or those lying near the tropics.  Finally,
all races and nationalities, with the exception of  the  negro  (de
Wilde),  appear to be equally subject to the affection (M.  Sheriff
counted among the patients  in the public dispensaries fifty-seven 
510
ZUELZER.—DENGUE FEVER.
Europeans, two hundred and thirty-five Mohammedans, and one
hundred and  twenty Hindoos).  In the  last epidemic persons
recently arrived appeared to be somewhat  more lightly attacked
by the disease than residents already acclimated.

                      Symptomatology.
  The features of the disease as given by the first observers have been modified
and enlarged by more recent observations, but still exhibit many defects.

   The disease begins after a stage of incubation of three to five
days (M. Sheriff), while, as estimated, in about half the cases it
begins suddenly.  In the  same way it often has a prodromal
stage of one to three days' duration, with  slight chills,  headache,
pains in the back and along the spine, and a burning sensation
in the stomach.
   With the beginning of the fever  there  follow the painful
swellings of the joints peculiar to the disease, together with tur-
gescence of  the skin, the face, and  the neck; less frequently an
exanthem now shows  itself, the temperature advances quickly
and significantly, and reaches its height within the first twelve to
twenty-four hours.  A bodily heat of 106.7° F.  and 107.6° F.
is not seldom observed in the axilla  (Muller and Manson and
others); once even,  according to an anonymous  French  naval
surgeon, a heat  of 108.8° F.   The  fever is now continuous, the
pulse  exceedingly  frequent (120 to 140) and  very strong, the
breathing quickened (28 to 30), and the skin  dry and of a  burn-
ing heat.
   After two  to  three  days,  sometimes in less time, but  some-
times  only after  five to seven days,  the fever  generally abates
suddenly, often with the occurrence of critical symptoms, as  in
the case of  relapsing fever, such as profuse sweats, or diarrhoea,
or epistaxis (Muller and Manson and others).  The temperature
sinks, but  still remains somewhat  above the normal, while the
skin becomes  moist, and the  other symptoms  of  the disease so
far subside that the patients do not  hesitate to leave the bed, and
even the chamber.
   This favorable state, which seems to be analogous to the stage
of intermission in relapsing fever, is sometimes wanting (Ballot). 
SYMPTOMS.
511
According to de Wilde, it generally lasts one or two days.   Now
the second paroxysm follows, with a new and rather moderate
elevation of temperature of a remitting character, and simulta-
neously with it an exanthem shows itself  upon the skin.   Less
frequently there is a relapse of  the joint-affection.  The symp-
toms last for some two  or three  days.  The disease, as a rule,
comes to an end with a gradual subsidence  of the symptoms, the
second paroxysm seldom extending over a longer time.
   In exceptional cases the first  paroxysm  is accompanied by a
peculiar  affection of  the joints  and, limbs.  In  severe cases it
involves  all the joints ;  often, the pains in the bones and  mus-
cles are described as " boring " and "breaking " with more or less
stiffness of the affected limbs and swelling of certain tendons.
   The affection attacks  large and small joints without distinc-
tion, seldom  fewer than six to eight at the same time.  In suc-
cession the joints of the hand, foot, and knee are first attacked,
the spine and fingers, then the toes and the joints of the  elbow
and shoulder.  It happens most  frequently  that the hand cannot
be closed, and it  is particularly difficult to bend  the fingers in
the morning.  The joints affected are much  swollen, red, immov-
able, painful, and highly sensitive on pressure.
   Most authors characterize the pains  as diffuse, rheumatic, or
rheumatoid ; still de  Wilde several times  observed the occur-
rence of single painful points, or where  nervous trunks;, as, e.g.,
the ulnar, were specially affected ; and Thaly also regards them
as gouty.  It is very noticeable with what  celerity  the  pains
change and diffuse themselves.   According to Dunkley,  while
the patient in the morning complains  only of severe headache
and pains in the hands, by evening the joints  of the foot or the
knee are chiefly affected.   According to Hirsch, in three autop-
sies serous infiltration of the connective tissue  in  the  neighbor-
hood of certain joints was twice found, and  redness of the crucial
ligaments of the knee  once.
   This affection diminishes with  the subsidence of  the fever;
sometimes, however, it is persistent, and yields only after weeks,
or even months.
   In many cases, conformably  to the two distinct paroxysms,
a primary and a secondary exanthem  are to be distinguished, 
512
ZUELZER.—DEXOUE FEVER.
according to the time of their occurrence (de Wilde and others).
The primary, less often observed, appears and disappears  simul-
taneously with the  fever ; but the eruption on the  skin quite
regularly accompanies the second paroxysm.  It is acconqianied
by decided itching of the skin, and is variable  in form;  some-
times maculated, like roseola; sometimes elevated, like  lichen
tropicus ; evenly distributed,  resembling measles or  scarlatina,
or in blotches, reminding one of urticaria.  The  bright red color
of the affected parts  often passes into crimson on the palm of the
hand and sole of the foot (M. Sheriff, de  Wilde,  and others).
   The  affection of the skin is of variable extent, limiting itself
sometimes  to single  spots, or again extending  over the greater
portion of the  body.  Most frequently it is localized upon the
face (where in the neighborhood of  the eyes it induces marked
conjunctivitis and lachrymation), upon the neck, chest, and arms ;
also upon the feet and hands.  It lasts only a few hours, or two
to three days,  and generally leaves behind a furfuraceous des-
quamation, which may continue for a  long time on the tips of
the fingers in certain patients (de Wilde).
   According to Christie's description, in  severe cases  we also
frequently find the mucous membrane of the nose, mouth, and
throat inflamed ; and the lymphatic glands in the neighborhood
of these, and of the skin affection, are often the seat of transient
swelling.
   Of the remaining symptoms of the disease, the loss of appetite
which accompanies the whole course of  it, and the great  increase
of thirst, assume prominence.   The patients complain of  a dis-
ordered taste and of nausea; it seldom amounts to vomiting.
The tongue is coated white or of a greenish yellow (according to
Dunkley silver-white).  Constipation appears generally to last
through the first part of the fever, but to subside after the crisis,
wliich is sometimes marked by diarrhoea.
   During  the  fever the urine shows a high specific gravity, a
dark color,  but no  albumen; from being  previously scanty it
often increases  materially in quantity at the time of the crisis
(Muller and Manson).
   During the fever  the patients are restless and sleepless, and
complain of pains in  the head, which,  according to the descrip- 
RELAPSES.
513
tions, especially involve the forehead.  Certain ones are delirious
at night.  Severe cerebral symptoms are not observed.

   A case of M. Sheriff's, ending in recovery, is worthy of mention, as it was marked
by spasms of the respiratory muscles; they recurred at intervals of two or three
minutes, and lasted for a time, whereby the patient was highly distressed.

   Next to the emaciation which quickly appears, the patients
experience a marked sense of loss of strengtlt, especially in the
legs, which is often perceived early, and is even long  complained
of in convalescence.
   Not seldom there remains after  the fever an affection  of the
lieart,  which has  been repeatedly considered to  be pericarditis,
even by M. Sheriff and Dunkley, but it never leads to a fatal.
issue, and subsequently disappears.
   Beyond two or three cases of pleurisy observed by Dunkley,
the respiratory organs have been found  completely intact.
   Certain cases of pregnancy at various stages resulted in abor-
tion.
   In  children the  features of the disease are often somewhat
modified by the shorter duration of the fever, but  especially by
repeated  or  persistent  convulsions,  wliich  may  even  lead to
death.
   In adults the prognosis is very favorable; fatal  cases seem to
have been observed oii\y very exceptionally.  Out of 105 patients
of de Wilde's none died, while among the children affected, some
cases ended fatally from convulsions (de Wilde,  M. Sheriff, and
ethers).
   The course of the disease may be generally divided, according
to the  more  recent  communications, into periods of the  first
febrile access (two to three days), the intermission (one, two, or
three days),  which,  however, is  not seldom wanting, and the
second febrile stage (two to three days), whereupon convalescence;
begins.   This latter, however, is now and  then disturbed for a
long time by great weakness, emaciation, and persistent  affec-
tions of the joints.
   Veritable relapses, after an interval  of two or three weeks,
were repeatedly seen to occur by Sheriff;  they seem to  run a
milder course than the primary affection.
          VOL. II.-33 
514
ZUELZER.—DENGUE FEVER.
   In the first paroxysm the disease sometimes appears to offer
certain resemblances to articular rheumatism ;  in the second, to
scarlatina.   Still, the diagnosis can scarcely be difficult.
   Scarcely any conjectures have been raised as to the nature of
this  obscure affection.   Only there remains, when it  follows a
typical course, a certain striking likeness to relapsing fever, and
this  certainly calls for an examination of the blood.

                        TREATMENT.

   Among  therapeutic procedures it is worth noting that, accord-
ing to M. Sheriff,  quinine  (gr. iij.-v. every three  or four hours)
seems to have some influence in shortening the disease ; taken as
a prophylactic it is said to furnish great protection against it.
   The treatment is generally begun, according to the practice in
the tropics, with an emetic  or purgative ; then quinine, diapho-
retics, and  warm baths are employed (M. Sheriff),  or laxatives
—rhubarb,  aloes, sulphate of magnesia, and the like—(de Wilde);
while the French naval surgeon already mentioned, Christie, and
others recommend belladonna in large doses as very efficacious
against the pains in the joints ; also strychnine, phosphoric acid,
and  colchicum.  Cold baths  also are  in  repute.   After the
disappearance of the  fever, Christie and others give  iodide of
potassium.   For the relief  of the  pains in  the  limbs, friction
with  spirituous and  stimulating  liniments  is employed, and
chloroform, electricity, tonics,  etc., to do away with the great
weakness which often lasts for a long time.
   To prevent the spread of the disease, M. Sheriff advises isola-
tion of the  patients and quarantine  of the districts affected. 
INFLUENZA.
        EPIDEMIC CATARRHAL  FEVER, LA  GRIPPE,  GRIPPE.

The literature of influenza, wliich formerly excited a high  degree of general inter-
    est, has reached such an extent that we must renounce the idea of presenting it
    in detail in this place.   It  is principally comprised  in  the following mono-
    graphs : Saillant, Tableau historique et raisonne des gpidemies catarrhales, vul-
    gairement grippe, depuis 1510 jusque et y comprise celle de 1780.  (Detailed reci-
    tal of the older literature.)—Zeviani, Opusculo sul catarrho epidemico. (Memor.
    di Mathem. e di Fisica della Soc. Ital. dclle Scienz.  T. XL  Modena, 1804.—H.
    Schweich, Die Influenza.  Berlin, 1836.—G. Gluge, Die Influenza oder Grippe, nach
    den Quellen histor.-pathol.  dargestellt.  Minden, 1837.   (Good critical review.)
    —A. Hirsch, Handb. der histor.-geograph. Pathologic I. 277-300.   Erlangen,
    1860.   (Especially treating of the epidemic relations.)—J. Fuster, Monographic
    clinique de Taffection catarrhale.  Montpell., 1861.—Next to these, prominence is
    to be given to the following works :  Cullen, Synopsis Nosologise Method. Ed.
    quinta, 8vo.  Edin.,  1792.—Ph. L.  Wittwer, Ueber den jiingstcn epid. Catarrh.
    Niirnberg, 1782.—N. Webster, Hist, of Epid. and Pestilential Diseases.  Hartford,
    1799.  Vol. II.—Adams, An Inquiry into the Laws of Epidemics. Lond., 1809.—
    Petit,ln Diction, des Scienc. MSd.  T. XIX. p. 351. Par., 1817.—Most, Influenza
    Europsea oder die grosste Krankheitsepidemie der noueren Zeit.  Hamb., 1820.
    —Fodere,  Lecons  sur les  epidSmies et Phygiene  publique.   Par.,  1822.—
    Schnurrer, Chronik der Seuchen.  Tubingen, 1823.—J. Frank, Prax. Med. uni-
    vers. praecept. Vol. L  Sect. II. p. 50 et seq. Lips., 1826.—Sprengel,V ex-such, einer
    pragmat. Geschichte d. Arzneik. T. V.  3  Aufl.   Halle, 1828.— Naumann, Handb.
    d.med. Klinik. I. Bd. p. 424 et seq.  Reutlingen, 1832.—Zlatorovich,  Geschichte
    des epid. Catarrhs (Influenza),  welchcr im Friihjahr 1833 in Wien grassirte, und
    fiber sein Verhaltniss zum stationaren Genius der Krankheiten.  Wien,  1834.—
    Ozanam, Hist. M6d., etc.  2ded. T.I.p. 29-218.  Par., 1835.— Richelot, Recherch.
    sur les epidSm. de grippe, etc. Arch. gSn. T. 37 and 38.  1835.—Dunglison, Med.
    Review. T. XX.   1 Ser. p.  444.—Bouvier, Annal. d'hygiene  publ.,  Avril 1837.
    T. XLIII.—Nonat, Recherch. sur la grippe et sur les pneumonies  observers pen-
    dant le mois FeVrier 1837.  Par., 1837-8.—Lereboullet, Rapport sur I'epidem. de
    grippe, qui a regng si Strassb. pendant les mois de  Janv., Fevr. et  Mars 1837.
    Paris et Strassb., 1838.—Copland, Diet, of Pract. Mod.  New York,  1846.  Vol.
    IL—Graves, Clin. Lect. on Pract. of Med.  2d cd. Vol. I.  Dublin, 1848.— Can-
    statt, Handb. d. med. Klin.  II. Bd,  2. Abtheil.  Erlangen, 1847.— Toulmouche, 
516
ZUELZER. —INFLUENZA.
   Do la grippe epidemique, qui a regne en 1837, etc. Gaz. mSd. de Par., 1847, p.
   858.—Theoph. Thompson, Annals of Influenza;  prepared for the  Sydenham
   Soc.  Lond., 1852.—Forget, Gaz. med. de Strassbourg.  1858.—H. Hdser, His-
   torisch-patholog. Untersuch.  I. §8.—Legrand, Sur la grippe; constitution med.
   etc.  Par., 1860.—H. van  Holsbeck, La grippe et  son traitement.  Annal. de
   la Soc. de Med. d'Anvers.  Janv.  1861.— Biermer, In Virchow's Handb. der
   spec. Path. u. Ther.  Erlangen, 1865.  V  1st  Part, 592.  (Very comprehensive
   statement.)—Corradi, L'Influenza ovvero Febr. cat. epidem. d'ell' an. 1580 in
   Italia, con nuovo docum. illustr. Milano, 1866.—Hjaltelin, Edin. Med. J., May,
   1866.—Hall, Lond. Epidemiol. Transact., II., Part I., p. 69.  1866.—Gerard, De
   la Contag. de l'influenze. Ann. 575.  1866.— Tigri, Annal. Univ. Vol. CCII. p.
   677.  1867.—Moutard-Martin, Gaz. d. hop. No. 26, p. 101; No. 29, p. 113. 1867.
   —Petit, Quelques mots sur la grippe. Ibid., No. 37, p. 147.— Vincent, De differ.
   formes de la grippe, 34, p. 4.  Paris, 1868.—Lydtin, Infl. der Pferde.  Fuchs.
   M. S. 179. 1869.— Richardson, St. Andrew's Med. Grad. Assoc. Trans., II., 1869,
   p. 234.—C. Handfield Jones, Brit. Med.  J., July 23, p. 81. 1870.—J". 0. Webster,
   Report of an Epid. of Infl.  Bost. Med. and Surg. J., June 8, p. 377. 1871.—II.
   Gintrac, In Nouv. diet, de Med. et de Chir. pratiques.  T. XVI. p. 728.  Par.,
   1872.


   Influenza is an epidemic disease which is essentially charac-
terized  by catarrh of  the  respiratory,  and  generally also of the
digestive  organs, by great  and rapidly  developed  weakness,
pains in the limbs, severe headache, as well as by  serious ner-
vous symptoms, and fever of greater or less intensity.
   The disease is principally distinguished from simple epidemic
catarrh by its  universal diffusion: it  spreads  with  the greatest
rapidity over extensive districts of country, and even over whole
quarters of the  earth, and in  those regions in which it occurs
it spares only a small fraction of the population.   It appears
unconnected with atmospheric  influences, especially with  those
which otherwise are  wont to occasion catarrhs.   Moreover, the
course of the disease is marked by important lesions of function,
which  would not  correspond  to a  simple respiratory catarrh.
The affection, therefore,  in spite of this special localization, has
been regarded by numerous authors as a general  febrile disease,
which is dependent on miasmatic influences as yet  unknown to
us.

   Its names, which have a pre-eminently popular origin, are very numerous; Gluge
and  Schweich especially give  a  comprehensive collection of them.  Many of the 
HISTORY.
517
older appellations are significant; such as Modefieber (fashionable fever), Schafs-
husten  (sheep-cough), Huhnerziep (crowing), Blitzkatarrh (lightning catarrh), or
Barraquettc, Petit-Courrier (the little courier), la Follette (the frolicksome), la Gene-
rale.  (Coqueluche is used ambiguously.)  Other names signify the region where
the disease was thought to originate: Spanish catarrh, Russian catarrh, etc.
   The name now in common use in Europe, "La Grippe," comes, according to
Biermer, from agripper (to seize), according to Joseph Frank, from the Polish word
chrypka (raucedo).  The word "Influenza" is of Italian origin; perhaps it refers to
the assumed influence of the climate or atmosphere, or from the further signification
of the word (something fluid, transient, or fashionable), to the name commonly used
in the epidemic of 1709.1  According to Biermer, Pringle 2 first designated the dis-
ease by this name.

                             HISTORY.

   The  history of influenza can be traced back with  certainty
only to the beginning of the sixteenth century.  Since that time
only have the records been particular and distinctive enough to
enable us to infer its existence unequivocally from them.  Yet it
deserves to be brought into prominence, that even as early as the
ninth  century not a few epidemics of catarrhal fever, Italian
fever,  and the like are cited,  which possibly refer  to the  same
disease.  In the writings of classical antiquity no statements can
be established as referring to it.
   AVith the year 1510 begins a series  of epidemics, the wide dis-
tribution of which has been reached by no other acute infectious
disease.  In  this respect it forms a diametrical contrast to the
summer-rash which has been spoken of before.  Up to the year
1870 more than ninety epidemics, connected to a greater or less
extent,  have  been described,  which generally extended  over
whole countries, frequently over several  quarters of the earth.
They returned at indefinite periods, and affected every season
and latitude, although  the colder climates somewhat more fre-
quently.   As a rule,  they advance in  a great wave,  in our hemi-
sphere  passing from  the east and north-east towards the west.
More rarely  they  seem to have taken another direction  or to
   1 Slevogt,  Prolusio, qua die  Galantriekrankheit oder das Modefieber delineatur.
Jen. 1712.
   2 Observ. on Diseases of the Army.  Lond., 1752. 
518
ZUELZER. —INFLUENZ A.
have  radiated  from particular centres.   Sometimes they  occur
simultaneously at several points of the earth.
   In rare instances the epidemics are preceded by the appear-
ance of sporadic cases.  Much more  commonly they simultane-
ously attack with great  rapidity a large number  of the inhabi-
tants of the affected districts, so that in  populous  cities business
is often  suddenly destroyed as by a shock, and the number of
the sick is soon counted  by thousands.  They  are only  very
exceptionally limited, as in the epidemic of 1836-37 in St. Peters-
burg  and Paris, to the environs of certain cities, or,  as in certain
smaller epidemics, to particular classes in the population (e. g., in
the epidemic of July, 1833, in Novara, according  to  Galli,1 it
spread from among the population to the garrison,  and in 1803
was confined to the civil inhabitants, while it rather avoided the
military).
   This peculiarity of influenza is so striking that  many authors
have  been  led to the  opinion that  the numerous epidemics,
limited to more narrow precincts, of wliich Hirsch  (loc. cit., p.
286) enumerates nearty eighty, were not at all to be regarded as
of this disease, although when looked at apart from its  universal
spread they actually differed from it in no respect.
   The epidemics lasted, as a rule, four to six weeks ; less often
they  ran their course in a shorter time, and only  exceptionally,
as in Paris, in 1831, did they last, according to Fuster, for nine
to ten months.  They rapidly reached  their height, and  their
ending was  almost  equally as sudden as their beginning ; yet
sometimes they returned to a district which  had already been
once attacked.
   Among the most important epidemics which have been care-
fully described are the following:

   The epidemic of the year 1510 spread from Malta in a direction from south-east to
north-west over the whole of Europe, and attacked everybody. Yet, with the excep-
tion of children, very few died; among them Anna, consort of Philip I. The life
of Pope Gregory  XIII. was also  endangered.  The disease was accompanied by
severe pains in the supraorbital region, by delirium, gastrodynia, syncope, subsultus
tendinum,  and a black coat on  the tongue (on the  seventh to eleventh day).  On
the abatement of the disease diarrhoea and sweats  usually set  in.  Bleeding and
1 Schmidt's Jahrb. VI. 
HISTORY.
519
purgatives  proved injurious, therefore blisters were generally used.  Two each to
the arms and legs, and one to the occiput.1
   The epidemic of the year 1557 spread  from Asia across Europe, and  across the
ocean even to  America.  It broke out late in the  autumn, and lasted  during the
winter, spring, and summer.   Almost everybody was  attacked (in Nismes) on the
same  day.2  Its  symptoms were more or less severe fever,  headache, catarrh, sore
throat, cough,  and great weakness.   If, after bloodletting  and the use of expec-
torants, an offensive sweat occurred, the patient recovered; but if the fever continued
with great  exhaustion, he succumbed to the disease.3  The disease was often ter-
minated by a diarrhoea.4  The affection was most destructive in Sicily.
   The epidemic  of the year 1580 spread from south-east to  north-west over Asia,
Africa, and Europe.  The  disease came  from Constantinople and Venice to Hun-
gary and Germany, thence to Norway, Sweden, Denmark, and Russia.   In Spain it
prevailed during the whole summer;  in Italy from August to the end of September.
The  issue was almost always favorable,  and was  marked  by copious  sweats.   In
many places, on  the contrary, the disease ran a very severe course; in Rome, e.g.,
it claimed  about 9,000 victims, and  Madrid must have been almost depopulated
by it.  Wier5  ascribes the  great mortality in Rome to the venesections;  "the best
mode of treatment consisted in trusting entirely to nature."  The number of patients
was very great; in many regions, as in Saxony, nearly four-fifths of the population
were attacked.6
   In the year 1591  the influenza appeared anew in Germany ; in 1593 in Holland,
France, and Italj ; in 1626-27  in Italy and Fiance; in  1642-3 in Holland;  in
1647 in Spain  and North and South America ; in 1655 again in North America; in
1658  and  1675 in Germany,  Austria, England, etc.; in 1088  in Great Britain;  in
1693 in Great  Britain, France, and Holland; in  1709 in the countries of Central
Europe;  in 1712 it was very prevalent in  Denmark, Germany,  and Italy.
    The epidemic of the  years  1729-30 was one  of the  most  wide-spread  in
Europe;  in five  months  it overran Russia, Poland, Hungary, Germany (in Vienna
more  than 60,000 persons were attacked by it),  Sweden, and  Denmark; in the
autumn it reached England,  France, and Switzerland, and  from there  Northern
Italy ;  it visited  Rome and Naples in February, and  is said to have made its way
through Spain even to Mexico.  Its essential manifestations were, pains in the limbs,
catarrh, oppression of the chest, hoarseness, and cough ; sometimes there also occurred
cerebral symptoms, delirium, somnolence,  attacks of faintness, etc.   In some cases a
petechial eruption was observed about the fourth to  the  seventh day (was spotted
   1 Senneret, De abd. rer. caus., conf.  Ozanam and others.
   a Mercatus, De Corp. hum. Affect. II. 1.  Op. Venet., 1611.
   3 Riverius.  Op.  Ludg.  Batav. 1663.   Appendix.
   4 Valleriola, Loc. Med.  Com.  App. II.
   5 Observationes.  Amstelod., 1660.
   6 Reports on the subject in Salius Diversus, Opusc. Med., Riverius and others;  conf.
Gluge. 
520
ZUELZER. —INFLUENZA.
fever prevailing at the same time ?).  The disease was often characterized by turbid
urine, copious sweats,  bilious  stools, hemorrhages from the nose, etc.   In Switzer-
land children and aged persons were almost the only ones that died.]
   The epidemic of the  years  1732-33 spread from Saxony and  Poland, in  the
middle of November,  over Germany, Switzerland, and Holland, and reached Great
Britain in  December.  Towards the end of January it advanced  in  one direction
south-easterly (to Paris, Italy, Naples, Madrid), and in the other across the ocean to
North  America;  then extended southwards to Jamaica, Barbadoes, Mexico, and
Peru.   The epidemic also  continued during the years 1834-37, overrunning north-
eastern Europe and spreading towards  the south-east.   In Italy  the brain symp-
temis predominated—headache, mental disturbances,  perversions of  the senses of
smell and taste, aphonia, etc.  Its  course was generally favorable;  the disease came
to an end on the third to the fourteenth day, with sweating, epistaxis, abundant expec-
toration, or  defluxion from the nose.   The aged, however, the asthmatic, and  the
phthisical succumbed almost everywhere.  In Scotlanel the " three forms of  the dis-
ease" (encephalica,  thoracica, and  abdominalis) were observed; in England more
frequently the encephalic form, with catarrh, sneezing, sleeplessness, dizziness, head-
ache, slight delirium, ringing in the ears.  Almost all e>bservers ascribe the epidemic
of 1732-37 to the continual changes in the temperature.2
   In the years 1737-8 the influenza again  prevailed in England, Ne)rth America,
the West Indies, and France;  in 1742 in Germany;  in 1742-3 in Switzerland, Italy,
France, Holland, and England.  In 1757 it showed  itself generally in North Amer-
ica, and appeared in the West Indies, France, etc.   In 1758 it attacked France and
Scotland ; in 1761 it prevailed widely in Ne)rth America and the West Indies.
   The epidemic of  the  year  1762 extended very  generally  through Germany
(scarcely a  tenth of  the population  remained  free from it), through Holland,
France, Italy,  and Great Britain.   In 1767 the disease again appeared in Germany,
France, Italy, England, Spain, and America ; in 1772 in North America.
   The epidemic of the  year 17753 again  overspread Europe.  In  Germany  the
" abdominal"  form prevailed.  From England the disease came to  America.   In
1778-80 we find the influenza  in France, Germany, and St. Petersburg; in  1781 in
Wilna, North America, and China  (?).
   That of the year 1782 belongs among the most remarkable of the  epidemics of
influenza.   It began in  Russia;  according to others  it must  have  come from
America (Webster), or from  Asia  into  Russia.  On January 2d, the thermometer
rose in the course of the  night from 35° below zero to 5° above zero,  and  on  the
same day about 40,000 persons fell sick with influenza, the explanation of which, it was
believed, was to be  sought in the sudden  change of temperature.   According  to
J. Frank, the epidemic must have shown itself in  St. Petersburg in February, and
have come there from Astrachan across Tobolsk.  From here it spread over Sweden,

        Fr. Hoffmann. Loon ; Ephemer, cur. nat. and others; conf. Schnurrer.
       2 Conf. the literature in Gluge. Hirsch. and others.
       3 Stoll, Rat. med. Vienn., 1777.  Saillant and  others. 
HISTORY.
521
Germany, Holland, and France;  in the autumn it was in Italy, Spain, and Portugal,
and did not even spare the English and Dutch ships upon the high sea.  In Vienna
the disease attacked three-fourths of the population, and occurred so  suddenly  that
it was called on this account "Lightning Catarrh."  Its course was marked  by an
extraordinary enfeeblement and  great pain in the back, throat, sternum, and larynx.
Children remained almost  exempt.   There were  often relapses,  pneumonias,  and
inflammations of the bowels.'
   To  continue:   the years  1788-90 were  marked by  numerous  epidemics in
Europe and America, some of which  returned,  and the years  1798-1803 by a  new
outbreak of the disease, which began in the north-eastern part of Russia, and  spread
over the whole of that country,  Germany, England and France, and a part of Italy.
From the year 1805 to the year 1827 we again meet with a great series of epidemics
in Europe and America ; only a  few years were free from them.
   The epidemics beginning in  1830 are distinguished for their universal diffusion
and  their rapid successiem.   The extensive literature on the subject points  to the
general interest which they  excited.  The reports state that the first outbreak of the
disease in 1830 occurred in  China; in  September it appeared in the Indian Archi-
pelago (Manilla), and in November and December  in Russia (Moscow); in January,
1831, upon the Great Sunda Islands,  and at the same time in St. Petersburg ;  in Feb-
ruary in Curland and  Livonia;  in March  in  Warsaw and the north of Java.
Further than this, in April  the  disease affected  East Prussia  and Silesia; in  May
Denmark, Finland, and  a  great part of Germany, also Paris;  in  the following
month also a great part of  England, Sweden, anel  at the same time  Farther India
(Singapore)  and the Indian Archipelago.  In July the influenza raged in Wiirtem-
berg, in Switzerland, in Toulouse, England,  Sweeten, and  Farther India (Penang) ;
and in the beginning of winter  in Italy and  in  certain regions of North America,
where also  it  was still observed in January and February, 1832.   After  it  had
become  extinct in Europe, it still prevailed  in Hindostan, and occurred  anew in
Russia in January, 1833; in February  it was in Galicia and East Prussia (Memel);
in March in Egypt and Syria, in Prussia, Bohemia,  and  Warsaw;  in April in
many districts  of Germany  anel  Austria, also in  Pesth,  Copenhagen, Jutland,
France, and Great Britain.  Up to  July the catarrhal fever was still diffused in
Germany and Upper Italy ;  and  in September in  Switzerland and France (Depart-
ment of the  Moselle), and in November in Naples.
   In the year 1836 the influenza showed itself in December in Russia, Sweden, and
Denmark; in January,  1837, in London, and in a very  brief time  spread over all
England, Germany, and France.   In January the disease  appeared in Berlin, some-
what later in Dresden, Munich, and Vienna.   At the beginning of February Switzer-
land and France were attacked;  at  the  end of  March Spain also (Madrid).  In
London almost the whole  population was attacked, and the mortality was  very
   1 Conf. Strack, Diss, de cat. epid. a. 1782.  Moyant. 1782.  Grant, Observat., etc.,
Lond.,  17S3.  Falconer, An Account, etc., Lond., 1782, and others, especially Wittwer. 
522
ZUELZER.—INFLUENZA.
great.   This epidemic also spread to the southern hemisphere, and prevailed at
Sydney and the Cape of Good Hope at the same  time that it visited the north of
Europe ; at directly the opposite season of the year therefore.  In the severe cases,
there occurred pains in the loins and joints, and very great loss of strength ; the
catarrh was suffocative, and many patients died asphyxiated. Most observers were
astonished at the great mortality of this epidemic.1
   From that time up to 1850-51 we find more or less extensive epidemics almost
every year, with few exceptions (Hirsch).  Also in 1857-58-60; in 1864 in Switzer-
land (Biermer) ; in the spring of 1867 in Paris (M. Martin);  and since then separate
outbreaks  in North America have been described  by Webster and  others. As
for the rest, the  more  recent epidemics  have run a less  dangerous  course, and
therefore, like the last epidemic of 1874 in Berlin, have been scarcely mentioned in
literature.

                            ETIOLOGY.

    Extensively as literature has been occupied with the histories
of  epidemics of influenza, the gain  in well-established facts as to
its etiology is still exceedingly small.
    In regard  to predisposition,  everybody is agreed in stating
that the epidemics attack  the population without distinction of
age, Sex, constitution, or condition,  no matter whether their occu-
pation be more in the  open  air or within  doors.  Only in one
direction a  great  portion  of the observers  have established  a
certain rule.    In places where the disease  occurs,  it  is  said to
attack first  the female population, next, the  adult males, and
lastly, the children.  In some epidemics the children, moreover,
remain strangely exempt.   Weakly and nervous  individuals are
said  to  be  more quickly  and  more  often attacked  than the
robust, and,  according  to  the views of some, aged,  infirm per-
sons are particularly liable to attack.   The latter view is perhaps
based on this, as Biermer supposes, that from the great danger
of  influenza in old age we pay greater attention  to it.   Neither
do those persons remain exempt who are suffering from the most
various  acute and chronic diseases,  internal  or external.  In
fact,  those dwelling in every latitude and belonging to every race
are equally subject to the influenza.
   In opposition to this there is only to be adduced a statement of Graves, viz., that
   1 Conf. Landouzy, Mem. sur Tepid, de 1837, Rebouillct, Heine, Gilnthcr, Piorry, and
various others in Canstatt, Hirsch, Faster, etc. 
                  QUESTION OF CONTAGIOUSNESS.              523
 influenza does not appear during the febrile stage of continued fever, but seizes the
 patients at the beginning of the period of convalescence.  According to some obser-
 vations made in Iceland1  and in the Antilles (according to Barclay), the natives
 only appear to have been attacked, while strangers remained free.

    No connection with  atmospheric  conditions  has been estab-
 lished,  althougli  some  observers  declare  particularly violent
 changes in temperature, or foggy weather and the  like, to  have
 been prevalent at the time of epidemics ; other observations show
 the direct  opposite of this.   Herein lies an essential  difference
 from  non-epidemic  catarrh,  since  this must  be  referred  to
 ''catching  cold,1'  and  therefore is pre-eminently  traceable  to
 damp, raw air.  Influenza, on the other hand, prevails in not and
 dry seasons,  as well as in countries where, in virtue of the high
 mean temperature and  the slight degree of dampness, catarrhs
 are exceedingly rare ; e. g., in Egypt and other tropical regions.
 One fact, however, is established in many ways, and is in accord
 with the observations as to the spread of many epidemics from
 east to  west, viz., that east and north-east winds have often pre-
 vailed at the time of the influenza.
    At all events,  the disease is unconnected with any local cir-
 cumstances whatever of elevation, condition of the  soil, and the
 like ;  without  assuming  this, its  wide distribution would be
 inexplicable'.
    Little is known of the exciting causes of influenza.
    The  assumption of contagiousness has been  abandoned just
 as  often as it has been  established;  the occurrence of cases in
 groups,  the fact  that often  all,  or  at least the majority of the
 inhabitants of a house,  of a street, or even of a quarter of the
 city  are attacked simultaneously, or  at  uncertain  intervals
 running through  days  or weeks, these may have  turned our
 thoughts in  that  direction.   This observation  also might be
 adduced in  proof  of it, that many  times in secluded places,
 although a considerable  number of persons  lived there together,
 e.g.,  in  cloisters,  prisons,  and  the like, no cases  of sickness
 occurred, so that it appeared that possibly even the seclusion pro-
cured immunity.   Other instances  point  in  the opposite  direc-
  1  According to Schleisner, in his Medical Topography of Iceland.  Copenhagen, 1849.
Schmidt's Jahrb.,  70. 
524
ZUELZER.—INFLUENZA.
tion—many of which were deduced especially from the epidemic
beginning in 1830—as that even complete seclusion from inter-
course,  or actual  shutting  up  in the  dwelling, furnished no
security against an  attack.   On  the  other hand, even such
persons as  came into  immediate contact with the sick  often
remained  wholly unaffected,  such as surgeons  and nurses, and
even  bed-fellows and  room-mates.   The spread of the disease,
too, is generally much too rapid  to  be  at all explicable by con-
tagion (Biermer).
    Moreover, it is especially worthy of note that the propagation
of influenza is not  determined by human intercourse.  Even the
most  crowded  highways and places have often been exempt or
only slightly affected  by the  catarrh, and dwelling-houses, bar-
racks, factories, and the like, situated at the very gates of cities,
remained  completely untouched, sometimes  in great epidemics
and in spite of uninterrupted communication.
    In their progress the epidemics of influenza show, as alleged,
a great diversity.  Some authors  estimate  that  it  moves for-
wards as fast  "as a rider;" at different  times it travels ex-
ceedingly slowly,  or with the greatest  rapidity; often  it even
attacks districts far removed  from one another with inexplicable
leaps, or appears simultaneously at different points of the earth's
surface.
    With such want of  agreement in the observations, no etio-
logical  theory whatever has been developed upon a satisfactory
basis.   The causes  of influenza seem completely sui generis, and
are as unknown to-day as they were centuries ago.   The  great
number of hypotheses is the best proof of this.
    The causation  of  the epidemics has most  frequently been
sought in atmospheric  agencies ; it has always and with good
reason been believed that so general a  disease could be dissemi-
nated only by means of the most general medium, the air.

   According to Crato and Mercurialis (compare Gluge) the air at the time of the
epidemics is " putrefied; " others speak of a " contagium " or " miasm " in the air,
of caustic, saline, sulphurous, or nitrous contaminations of it, which were referred in
part to volcanic influences and also  to fog, vapor, and the like, to phlogisticated
air,  to increased or  diminished electricity, terrestrial magnetism, and other causes.
The latter assumption especially was widely  diffused by Wittwcr, Schweich, and 
MARCn OF EPIDEMICS.
525
others.  Schonbein, Spengler, and others referred the epidemics to the altered con-
dition of the air as regards ozone, a view which met with a decided refutation from
Schiefferdecker, of Konigsberg, as the result of sufficient observations.  An animated
contagious material also has often been spoken of.  In the epidemic of 1782 the
idea was spread abroad that the air was infected by an insect, called therefore
" Grippe," a view which Grant refuted in a special paper.1  Elsewhere, as in Vienna,
where the Medical Council distinctly expressed itself to this effect, the disease was
referred to an insect said to  be swallowed with  the water;  and the philosopher
Kant imagines that we may believe with  much probability that the Russian trade
with China had  imported some kinds of injurious insects which gave rise to the
influenza.

    The most  important question, at all events, in the etiology is,
whether in the different great marches of the epidemic the indi-
vidual outbreaks are connected, are, in fact, the operation of a
common cause, or run their course independently of one another,
i.e., whether, as Biermer  is inclined to consider, the single local
epidemics are to be referred  to an indigenous origin.   It  seems
in  accordance with  this  idea that, while the  disease spreads
rapidly  in its local diffusion,  it  advances  comparatively  slowly
on a grand  scale over countries and seas  without being  essen-
tially influenced by human intercourse or the  direction  of the
wind.  In other cases again,  it  remains limited to narrow cir-
cuits.
    Again, these observations may easily  have a  different sig-
nificance.   Although  indefinite  intervals  often exist between
the single local  epidemics,  their  immediate connection  is  still
highly probable in the great  majority of cases, although often
difficult of demonstration.   The case  is just the same as it was
with cholera  before  we began to pay  attention to its etiological
relations ; and in the case of  an  affection which is, on the whole,
insignificant, like influenza, no urgent impulse has bidden us under-
take it.   Influenza, too, like cholera, does not occasion any inde-
pendent endemics.   The catarrh  now and then occurring in sepa-
rate places (as, e.g.,  in Iceland and  Faroe), besides being want-
ing in epidemic diffusion, presents no  serious symptoms.   Much
more does the complete correspondence of  symptoms  render the
association of single epidemics  within a definite  period  highly
1 Observ. on the late Influenza, etc.  Lond., 1782. 
526
ZUELZER.—INFLUENZA.
probable, the  more so as  they often move forward in a definite
direction (as a general thing from east to west).
    Many of the earlier authors  arrived  in this way at the idea
of a specific principle of disease, which  is developed from time
to  time  somewhere  in high northern or eastern regions,  and
thence travels abroad.  Besides, Biermer calls attention to this,
that  the  apparent contradictions of  rapid  diffusion  and  slow
migration, of general extension and local limitation in the his-
tory  of influenza would be easy of explanation on the theory of
a  living  miasm,  which  would  be  capable of  being  carried
onward by the air, but had an independent existence of its own,
and would find in certain places conditions more favorable  for
its development than  in others.   An  established  basis of  facts
is meanwhile wanting for this hypothesis, as well as for all the
others.

   Certain accounts are found in  the literature of the disease, according to which
other  epidemic or endemic  diseases have vanished on  the appearance of influ-
enza.  Thus, as Smart1 relates, an  epidemic of scarlatina became extinct during
the influenza, but afterwards returned.  Small-pox2 also, and spotted fever3 have
declined on the  appearance of influenza.  Gallicio  4 and Panum made the same
observations regarding  intermittent fever in the epidemics of 1831 and 1833.   On
the other hand, Escherich, Stosch, van Dembusch,  and  Galli assert the opposite,
that the influenza not seldom degenerated into intermittent. It is difficult to deter-
mine whether we are not here dealing with endemics of intermittent, wliich have
occasionally made their appearance at the end of the influenza  (Biermer).  In
addition to  this, Starck5 and others have discussed the  possibility of an analogy
in the  poisons of the two diseases.
   A connection of influenza with  cholera is  not probable, as Gluge and Hirsch
observe, in spite of the  epidemic of 1831 having preceded, and that of 1837 having
followed, that disease.
   A very widespread  epizootic sometimes occurs among domestic animals, espe-
cially among horses, which is designated as "influenza " by the veterinary surgeons.
Many of these outbreaks certainly do not  belong with this disease, since they may
be allied to  typhous, erysipelatous, and similar forms of  disease not satisfactorily
distinguished from influenza.  Without regard to the earlier epidemics, however,

               1 Med. and Phys. Jour.  Lond., 1803.
               2 v. d. Busch, Hufeland's Journ.  July, 1834.
               3 Currie,  Med. and Phys. Jour.  Lond.,  1803.
               4 Saggio sopra il morbo d. Russo.  Vicenza, 1782.
               6 Diss, de catarrh, epidem. 1782.  Mogunt, 1784. 
PATHOLOGY.
527
according to Woodbury1  and others, it seems that the pestilence of 1872, which
prevailed so widely among horses, and which in New York alone attacked about
16,000 of them, was influenza.  The disease continued for several weeks, but had
only a slight mortality; in New York 1.5 per cent. No special causes for it were
ascertained.  According to an older account of Hertwig2 the disease is not inocu-
lable.  It is not yet decided whether the epizootics  prevail simultaneously with
influenza among men.

                          PATHOLOGY.

   Genered Course of the Disease.—The influenza is, as Biermer
has properly described it, the sum of a series of catarrhal mani-
festations, which have developed under common epidemic influ-
ences.  The intimate association of  the various local  affections
ascribed to  influenza  follows  chiefly from  their  simultaneous
occurrence in large  numbers,  which allows us to argue a com-
mon origin.  Yet, as it seems to me, we do not find  a sufficient
explanation of  the various diseased processes in the assumption
of merely fluxionary  hyperaemic  lesions  affecting the mucous
membranes and the nervous system.   Many acute local diseases,
it is true, such, e.g., as bronchial catarrh, angina tonsillaris, etc.,
run  their course not infrequently in a  similar way to influenza,
with  fever, great sense of illness, and  nervous depression.   On
the other hand, the sudden onset and the  often critical termina-
tion of the disease, its general  seizure, the severe nervous sjmrp-
tonis, as well as  the decided disposition to cough which invades
the organs of respiration, with a proportionately slight increase
of the secretion of the mucous membrane,  all these are in favor
of a general agent which rapidly affects  the organism at large.
Also many complications which are peculiar to influenza point
in the  same  direction, especially the influence it exercises on
expiring neuralgias, which  by it are readily led to relapse, the
disposition to abortion,  as  well as  the disturbances  which  in
many cases remain behind long after the subsidence of the fever.
These symptoms are much more severe than in simple catarrhal
conditions, while they remind one  more of the analogous phe-

  1 Philad. Med. Times, December, 1872, and according to a report in the Lancet of
November, 1872.
  2 Magazin  f. d. ges. Thierheilk.  1854. 
528                ZUELZER.—INFLUENZA.

nomena in other acute infectious diseases.   For these reasons
we are surely justified in assigning influenza to this group.
   From the want of  sufficient pathological investigations  there
still exist many defects in our  knowledge of influenza, as in the
case of some others of the "great popular diseases,"  which have
hitherto engaged the  attention of the historian rather than that
of the clinical observer.
   The anatomical changes explain very little.   Uncomplicated
forms of influenza seldom lead to death.  As essentially belong-
ing to the disease we find only a more or less considerable hyper-
aemia and catarrhal swelling of the Schneiderian membrane, as
well as of the mucous membranes of the pharynx,  larynx, tra-
chea,  and bronchi.  The catarrh is often limited to the larger
bronchi,  but in  other  cases  it  extends even  into  their finest
ramifications, wliich sometimes may be filled  with  clear,  thin,
frothy mucus,   and  sometimes  with   thick,   viscid,  opaque
masses.   Catarrhal and croupous pneumonias  or pseudo-mem-
branous  capillary bronchitis, etc., are included  in the complica-
tions which generally bring about a fatal result.   In the stomach,
too, and more rarely in the intestinal mucous membrane, we find
more  or less extensive hyperaemia.

                      Symptomatology.

   Most  frequently the disease is localized upon the  mucous
membrane of the respiratory  organs, more  rarely upon that of
the stomach and intestines ;  sometimes nervous accidents are
said to exist alone, as Handheld Jones has recently  announced,
and their relation to influenza  is made certain  by the epidemic
character of  the affection.   In connection with these we also find
various modifications, according to the intensit}^ and the combina-
tion of these phenomena.
   The onset of  the  disease is generally sudden, as the name
"lightning catarrh"  indicates.   As a rule, it  is marked  by a
decided chill, or by malaise lasting several hours,  with  slight
chills  alternating with heat.   Only in rare  cases  are we apt to
have malaise for several days, and an  established cold before-
hand. 
SYMPTOMS.
529
   In the severer  cases the fever, even at the beginning, seems
to attain a rather noticeable intensity.   Accurate observations
are wanting ; according to the older views, it is remittent or sub-
continuous, and its course is lighter in the day, but in the even-
ing and at  night  marked by increase of  the various symptoms
and a rise  in the  frequency of the pulse  and heat of the skin.
Under some circumstances the temperature occasionally rises
transiently as high as in pneumonia or continued fever.
   The pulse exhibits a varying character; it may be full and
moderately accelerated (90-100), but is also described as  small
and weak.   It was not infrequently found irregular or very
changeable, so  that, as Graves observed, it was often completely
changed in from six to eight hours.
   Almost  invariably a more  or less considerable portion of the
mucous membrane, especially that of the respiratory organs, is
affected, and this is the characteristic feature of the disease.  The
symptoms  are  essentially of a catarrhal nature.  We  find most
frequently marked cold in the head, with considerable discharge
from the nose and sometimes epistaxis ; redness of the conjunc-
tiva, with abundant lachrymation ; catarrh  of the mucous mem-
brane of the throat, larynx, and bronchi; also sore throat, diffi-
culty of swallowing, hoarseness, tendency  to cough, and a burn-
ing or tickling sensation in the throat.  The mucous membrane
of the cavities of  the  nose, mouth,  and pharynx is  generally
found reddened, and the tonsils swollen.
   Haser, and recently Tigri,  observed spots like measles on the
mucous membrane of the palate, and the  latter, in a case which
ended fatally, saw also  a punctate redness of the mucous mem-
brane of  the trachea.   He  regards this phenomenon as just as
constant  as the eruption on the  skin in exanthematous diseases.
Ziegler1 infers the existence of a catarrhal oesophagitis, because
patients in  swallowing warm drinks had a scraping sensation as
if they had been burned with pepper.
   At the very beginning there sets in a very tormenting, convul-
sive, dry cough,  which becomes paroxysmal,  especially in the
evening and at night, not  infrequently leads to vomiting, and
      1 Schweizerische Ztschr. 1837, cf. Biermer.
VOL. II.—34 
530
ZUELZER.—INFLUENZA.
often leaves behind it pains in  the respiratory muscles.  The
sputa are very scanty and muco-serous.  In less frequent cases
they sometimes become more abundant towards the end of the
disease, and somewhat opaque and purulent.   In phthisical and
also in full-blooded persons they sometimes contain an admix-
ture of blood.  Auscultation frequently reveals sonorous, or in
places crepitant, rales, as in the case  of non-epidemic laryngo-
bronchitis;  still,  there  also occur  cases where all the auscul-
tatory phenomena are very  insignificant or absolutely wanting.
Yet many  patients show more  or  less important evidences of
dyspnoea.  According to Graves's  view, they sometimes  occur
with  intermittent or  rhythmically returning  remissions.   In
many cases they are probably the consequence of complications,
but sometimes no demonstrable lesions can be found in the lungs.
Graves assumes a disturbance in the function of  the vagus to
explain such cases; Biermer is satisfied that they  depend upon
congestions of  the lungs, which  furnish few indications to aus-
cultation or percussion unless oedema occurs.
    With many patients these phenomena go on to great oppres-
sion,  marked  dyspnoea, pain  in the  praecordia, etc.   Pleuritic
stitches, too, and pains under the sternum are observed without
any appreciable physical  changes.  In certain epidemics these
suffocative states are rather frequent.
    The mucous membrane  of the  digestive organs is likewise
affected in many cases,  although generally not to so high a de-
gree.  Loss of appetite, increased thirst, a coated tongue, a bad,
pasty  taste, sensitiveness of the epigastrium, and,  not  infre-
quently,  colicky pains  and  diarrhoea, or nausea and vomiting,
accompany the disease. In other cases there is persistent consti-
pation.
    Nervous Symptoms.—The prostration of the strength is very
great from the beginning ; the patients feel exceedingly weak and
exhausted, and soon  take to the bed.   They complain of  severe
headache,  especially in the forehead, in the neighborhood of the
root of the nose, and in the  sockets of the eyes.  It is  often
stated that the pains  are experienced in the passages and cavities
of  the head lined by the Schneiderian mucous membrane and
its processes, especially in the frontal  sinuses, but sometimes also 
SYMPTOMS.
531
in the antra of Highmore, the nasal ducts, the Eustachian tubes,
the drum of the ear, etc.  In some cases the whole head is in-
volved, or there is  a marked hyperaesthesia of the skin of the
head and neck.
   We  regularly find,  together with considerable depression,
very severe pains in the limbs.  At times they are limited to par-
ticular muscles, tendons, or ligaments, or are perceived as a gen-
erally diffused hyperaesthesia over  the  whole body.  Patients
complain particularly often  of hard dragging or boring pains
in the  calves, the  hollow  of the knee,  the shin bone,  or  the
back.
   In addition to these, there also occur in influenza severe ner-
vous symptoms, as happened very often in the epidemics of 1782,
1837, and others.  Patients are often unusually restless, sleepless,
and anxious.   If they get  up  they are frequently dizzy,  and
female patients especially are very much  inclined to fainting fits.
Mild delirium occurs not infrequently, but  more intense forms
are also observed.   In contradistinction to this, somnolent states
show themselves in some  epidemics; in the  epidemic of 1712,
which  was specially marked by this, the  disease  acquired the
name of sleepy sickness from  the  frequent occurrence  of  this
symptom.  In  the  most severe  forms there were sometimes ob-
served painful cramps  in  the  calves, and twitchings  of single
muscles, trembling  of the hands, subsultus tendinum, etc.  But
probably there were complications.
   The severity of the attack is also evidenced by the change in
the expression of the countenance.   The  patients have a suffer-
ing, anxious, and depressed look.  According to Landouzy  and
Biermer  they sometimes even have a typhoid appearance, while
in other cases the face is only a little altered, perhaps  only as
in simple catarrh.
   The secretion of  urine is not seldom diminished, sometimes
even completely suppressed.  It is concentrated, high-colored,
and deposits a sediment;  at the close of the disease it is often
discharged in large  quantities.  More complete investigations are
wanting.
   The skin at the  beginning of  the disease is often stated to be
dry and  hot, but sometimes frequent sweats show  themselves, 
532
ZUELZER.—INFLUENZA.
and generally the remission of the fever is ushered in by a pro-
fuse sweat of acid reaction and strong smell.
   In uncomplicated cases the disease generally ends in recovery;
its duration is three, four, or five days, seldom as much as one
to two weeks, and then only as a result of complications.  It gen-
erally terminates critically, either with sweat or epistaxis, abun-
dant diarrhceal discharges, or increased secretion  of  urine.  In
other cases  the remission  of the symptoms  takes place more
gradually.
   Patients  not seldom make but a poor recovery, in spite of
the apparently slight  affection, so  that  convalescence  is pro-
tracted.   Sometimes, too, there  are disturbances  left behind,
such as headache, muscular  debility,  cough,  etc., which delay
the complete restoration to health.
   Relapses are not  rarely observed, and  sometimes occur even
in the course of the same epidemic.
   These are the most  important phenomena of the disease, as
described in the majority  of cases.   But there  occur various
modifications of this picture in  different epidemics, and even
among the patients  in one epidemic, according to whether the
affection is localized more on the mucous membrane of the intes-
tines, or that of the organs  of respiration, or according to the
increase  of  the nervous symptoms, which sometimes  assume
special prominence.
   The  attempt  has many times been made to  classify these
different forms of influenza  according to their special  localiza-
tion.  So, e.g.,  even  in the epidemics of 1732-37, there were dis-
tinguished an influenza encephalica,  thoracica, and abdominalis.
Besides these a catarrhal, an  inflammatory and a nervous influ-
enza were assumed, a rheumatic-nervous, a  nervous-catarrhal,
and a gastric form.   There were also  described, from the peculiar
character of the  fever, a nervous, a synochal, and an erethetic
form.
   It is, however, seldom possible to bring all the special  cases
into such a classification, for the forms under which influenza
shows itself  are made up of various combinations.
   Apart from these, there are, in every epidemic, cases wliich run
a very severe course, and very  slight ones, which  are to be dis- 
COMPLICATIONS.
533
tinguished from  one another.  The latter often show themselves
only as a  simple coryza,  laryngitis, bronchitis, etc., but their
course is  always marked by a material change in the general
condition, so that even these patients generally keep their beds.
   Finally, we must call attention to the rudimentary forms, a
great number of which  are observed in every epidemic.   A con-
siderable part of the population, in fact, under the influence of the
"genius epidemicus," exhibits a  state of indisposition which
does not amount to a full febrile affection, but wliich is shown to
be a general  invasion of the system by slight coryza, by confu-
sion of the head, by one's quickly becoming fatigued, by disin-
clination for business, and often by sore throat, tickling cough,
etc.
   The  features  of  the  disease  acquire still greater diversity
from the various complications.   Many phenomena of  the dis-
ease, especially the nervous symptoms, exhibit important modi-
fications accordingly as  they affect more or less irritable indi-
viduals ; in  hysterical and such otlier patients influenza often
assumes a pronounced nervous or spasmodic character.   In the
case of hemorrhoidal affections, and in the rheumatic or gouty
diathesis  especially, the  muscular  pains will occur.   With
young children  symptoms of congestion of  the brain are often
seen, and this perhaps may be the explanation of the unfavora-
ble result sometimes observed in their cases.
   The  influenza process is  followed  by various sequelae,  and
these are so  frequent that many observers have indicated them
as immediately connected with the essence of  the disease; but
they may, on the whole,  be regarded  as  merely complications
occurring  accidentally   under specially favorable  conditions.
Among them are to be counted such cases as present an intense
catarrh  of the conjunctiva or of  the ear, as a concomitant local
affection, or  also tonsillitis, laryngitis, bronchitis, or pharyngitis
of considerable severity.  Not infrequently there is left after the
recession of the fever a hoarseness or tickling cough, lasting for
a considerable time,  or a chronic bronchitis or laryngitis.  Many
patients, too, show a tendency to  contract these affections again
easily on trifling exposures.
   The  serious affections of the  lungs which may accompany 
534
ZUELZER.—INFLUENZA.
influenza are of great  significance.   Frequently there are only
hyperaemia  of  the  lungs and intense  bronchitis,  but also fre-
quently catarrhal pneumonias, which are to be considered as a
continuation of the bronchitis into the vesicles of the lungs.
They do not develop before the second or  third,  generally the
fifth or sixth day of the disease, and  often slowly and insidi-
ously with the gradual increase of the bronchitic symptoms.
   Besides this, croupous pneumonias also occur, and are said
especially to involve the period of convalescence.
   These complications appear not  to be unusual.  Among 183
patients received into  the Hotel Dieu, in  the first two months
of the year 1837, there were forty cases of pneumonia (Copland).
Biermer believes that we may assume about five to ten per cent.
of the patients as the  average frequency  of this  complication.
For  some mild epidemics this may  be  too high; but others, on
the contrary, seem to have afforded a larger proportion, at least
the blood-letting so  frequently employed in former times indi-
cates that the physicians wished  to combat inflammatory com-
plications in the lungs.
   These pneumonic affections, which have, moreover, a tendency,
when the inflammation has once run its course, to establish them-
selves again in other parts of the lungs, are the cause of the real
danger, especially of  emphysema,  phthisis, etc.,  which influ-
enza leads to in the aged and in  persons  who are debilitated
from  any other cause.   All reports agree in this, that in such
patients a fatal result occurs with  great frequency, and that
the hyperaemia of  the rarefied lung-tissue,  or the cedema so
readily induced by the extensive bronchitic  changes, may essen-
tially contribute to it.
   Emphysematous and phthisical affections and heart diseases
are also considerably aggravated by influenza.  Many authors
assert, Petit quite  recently,  that  phthisis  often  runs.a rapid
course after influenza.   It is questionable  whether,  as many
suppose, influenza should be considered as a cause of phthisis.
Yet Leudet mentions that after the  epidemic of 1851, in Paris, a
remarkably  large number of cases  of  acute tuberculosis  came
under notice.
   Pleurisy,  without accompanying inflammation  of the lungs. 
DIAGNOSIS.
535
appears to be rare.  Croup and false croup are sometimes pres-
ent.
   Parotitis with salivation is sometimes observed.
   The  statements of the earlier observers about the complica-
tions of influenza with exanthemata, such as  miliaria, roseola,
urticaria, petechiae, scarlatinal  spots,  erysipelas, etc.,  seem to
refer, as Biermer  assumes,  chiefly to miliaria and urticaria.
Herpes labialis may occur as a favorable indication.
   Intermittent fever of tertian type is said to have been devel-
oped again and again from influenza.
   The  effect of  influenza upon neuralgias is  peculiar,  since
such as have previously got well will often relapse after recovery
from this disease.   It is also said to leave an unfavorable influ-
ence upon other nervous affections.
   Pregnant women frequently suffer abortion, and in many
who are  afflicted with amenorrhoea, the catamenia are estab-
lished.   This effect of influenza has been repeatedly verified in
many epidemics.   It is therefore very worthy of remark, because
it recalls analogous phenomena in otlier infectious  diseases, and
is indicative of an agency exerting an important alterative effect
upon the whole organism.

                          Diagnosis.

   A positive diagnosis will generally  be made with ease from
the  march of the epidemic,  from the great number of persons
attacked at the same time, as well as from  the relatively severe
nervous  symptoms, the prostration, and the obstinate  cough
with but slight physical signs.  In the differentiation from non-
epidemic catarrh  it is essential to make use of the etiological
facts at the  same time.   The catarrhs especially, which occur
regularly in changeable weather, in  the spring, etc., and which
are  distinctly influenced  by the season, although sometimes
marked  by severe  symptoms, are to be  distinguished from the
influenza by the fact that  epidemics of the latter are positively
developed in complete independence of the weather.
   Influenza is to be distinguished from a commencing typhoid
fever, the early symptoms  of which exhibit a certain resemblance 
536
ZUELZER. —INFLUENZA.
 to it, by the persistent elevation of the temperature, the absence
 of enlargement of the spleen and rose spots, the moderately fre-
 quent pulse, the peculiar character of the diarrhoea, etc.

                  Mortality and Prognosis.

   In uncomplicated cases the  disease commonly ends in recov-
 ery.  Only certain epidemics have shown a relatively large pro-
 portion of mortality ; perhaps these reports depend upon the fact
 that different forms  of disease have been erroneously counted as
 influenza,  as has  sometimes been  the case  with  typhus fever.
 Complete  and extensive reports  on a  large  number of cases
 are wanting.  Some authors, Gluge, e.g., endeavored to settle
 the mortality of influenza by inquiring whether the general mor-
 tality increased.  It  appeared, in fact, that in proportion to other
 periods,  the mortality in Berlin, London, Paris, etc., in 1836-7,
 and also at other times, during the weeks affected by the epi-
 demic, was on an average considerably increased.
   There is said to have been shown especially a striking increase
 of fatal  cases due to lung diseases, and among  aged persons.
 Still,  the reports differ about this even in  more recent epidemics.
 At all events,  it is proved  that  at a vigorous age  the disease is
 well borne ; but that it  may easily become dangerous from lung
 complications  in  the aged  and  in  persons debilitated by other,
 especially phthisical, diseases.   In young children, too, for the
 same  reason, the disease is not always unimportant.
   In prognosis,  therefore, aside perhaps from the character of
 the epidemics  and the complications, the  physical conditions of
 those attacked  are  essentially  decisive; viz.,  age,  state  of
strength, existence of other diseases, etc.
   Apparently severe cases,  too, reach a favorable issue, when
they  do  not affect small children,  the aged, the phthisical, or
persons otherwise reduced.

                        TREATMENT.

   In the treatment  of influenza blood-letting at  first played a
great  part.  Yet Buet (cf. Gluge and others) supposes that  it is
in no  respect contraindicated by  dyspnoea and bloody sputa, and 
TREATMENT.
537
Ozanam remarks that in fifty-two epidemics it was  useful in
thirty-nine, useless in three, and injurious in ten.
   Purgatives have been largely  recommended, yet have more
recently been advised against (Schweich and others).   Emetics
have been much esteemed, and Lombard, of Geneva, still believed
in the epidemic of 1837 that an emetic given at the beginning of
the disease shortened its course and rendered it milder.
   Diaphoretics have been  extensively employed ;  by determina-
tion of the blood to  the  skin  they effect a revulsion from the
mucous membrane involved.  The milder, unstimulating articles
especially are chosen, such as ipecacuanha, tartarized antimony,
spirit of Mindererus, Dover's powder, packing in wet cloths, etc.
   Good results from the employment  of quinine were men-
tioned by Rawling.1   At  all events, further trials of this remedy,
in large doses, are to be recommended.
   In general the treatment will not need to be especially pertur-
bating.  Quiet rest in bed, and, if necessary, as many think, mild
diaphoretic articles (elder or linden-flower tea, etc.) are generally
sufficient.
   An important question in treatment at all times, however, is
the control of the adynamia, which must be ranked among the
first indications in old people and those who are debilitated.
Stimulants and tonics, especially stimulating expectorants, such
as senega, camphor, benzoin, solution of ammonia,  anise, and the
like, as well  as Peruvian  bark, wine, etc., are indicated under
such circumstances.
   If no contraindication  exist, morphine and other  narcotics,
also an infusion of ipecacuanha, muriate of ammonia, etc., inha-
lations of warm steam, or cutaneous irritants  of  various kinds
may be employed  against the annoying cough.   Cutaneous irri-
tants, or perhaps subcutaneous injections of morphine,  inunc-
tions of narcotic remedies, etc., are to be prescribed for the relief
of the oppression of the chest, the pains in the limbs, etc.
   Tannin with nux vomica and similar means generally suffice
for the more serious diarrhoeas;  warm fomentations and the
internal administration of narcotics have been employed against
the colicky pains.___________________
                   1 London Med. Gaz., May, 1833. 
538
ZUELZER. —INFLUENZA.
   Foot-baths, sinapisms, and mild cathartics have been brought
into use to control the congestions of the head.  Cold applica-
tions are said not to be so well borne.  If the headache depends
upon coryza, relief will be afforded by inunctions of fat, repeated
several  times daily, or by snuffing up a few drops of a solution
of morphine in cherry-laurel water (1: 50-60).
   Great attention is necessary, especially in old people, so as to
recognize  the inflammatory affections of the lungs as early as
possible.  The treatment must be regulated by the circumstances
of the case,  the age of the patient, etc., on general principles.
   In convalescence it is needful to secure good nursing and
nourishment, to get rid of the debility which remains.  A tonic
treatment, too, is often indicated (quinine, iron, etc.); it also suf-
fices for the removal of the resulting  neuralgias.  Convalescents
must be protected for a considerable time against the influences
of the weather, so as to prevent the occurrence of sequelae from
the irritability of the respiratory organs.  The remnants of dis-
ease, especially chronic catarrhs, require  appropriate treatment,
and even frequently render a sojourn in the  country or in health
resorts necessary, and the use of milk cures or mineral waters.
   In the way of prophylaxis,  we must watch  the aged,  the
phthisical, and other persons  who are enfeebled by chronic dis-
eases, with especial attention at the time of epidemics. Although
we may not be able to prevent the disease, even by change of
place, still Biermer advises such persons to keep in their apart-
ments as much as possible, for it has always appeared that people
who moved about much in the open air were  attacked by the
disease sooner than those who kept in  closed rooms. 
HAY   FEVER.
(BOSTOCK'S  CATARRH, HAY  ASTHMA,  SUMMER  CATARRH  FROM
                IDIOSYNCRASY, CATARRHUS  ^ESTIVUS.)
John Bostock, Med.  Chir. Transact., Lond., 1819, Vol. X, p. 161,  and 1828,  XIV,
    p. 437.—John Maccullock,  Essay on the Remittent and Intermittent Diseases,
    etc.  Phila., 1830.—IF". Gordon, Lond. Med. Gaz., 1829,  IV, 266.—Aug. Prater,
    Lancet,  1830-31, II, 445.—J!  Elliotson, Lond. Med. Gaz., 1831, VIII, 411, and
    1833, XII, 164.—J.  J.  Cazenave, Gaz. med. de Paris, T. V, 1837, 630.-7*.
     Wilkinson King, Lond. Med. Gaz., 1843, XXXII, 671.—F. II. Ramadge, Asthma,
    its Varieties, etc.   Second ed.  Lond., 1847, 435-444.— F. Black, Brit.  J. of
    Homoeopathy, No. 28, Apr.,  1849, 242-3.—J!  Hastings, Treat, on Diseases of
    the Larynx and Trachea, etc.   Lond., 1850,  23.—G.  T. Gream, Lancet,  1850,
    692-3.— F.  W.  Mackenzie, Lond. J.  of Med.,  1851,  637.— W. P. Kirkman,
    Prov. Med. and Surg. J., 1852, July 21, p. 360.— Watson, Lect.  on Prin.  and
    Prac. of Med.  Second  ed.   Lond.,  1845,  II, 49.— Walshe,  Pract. Treat, on
    Diseases of the Lungs, etc.  Lond., 3d. ed.,  1860, 229.—L. Fleury, J. du pro-
    gres  des sc. nuld.,  etc.,  T. L, 1859,  4 Nov., 385-9.—Laforgue, Union m6d.,
    1859, 17 Dec, 550.—{Anon.), Abeille meU,  1860, 38 and 163.— A. Dechambre,
    Gaz.  hebd.,  1860, 67.—H. H.  Salter, On Asthma, its Pathol,  and Treatment.
    Lond., I860.— Cornaz,  Echo  med.,  1860, 1  Juill., 304 ct  seq.—Longueville,
    AbeiUe  meU, 1860, 23  Juill., 238.—E. Lawford, Brit. Med. J., 1860,  Aug.
    18, p. 657.—Perey,  Echo  med., 1860,  1 Dec,  595-8.—Hervier,  Soc. imp. de
    med., chir., et pharm. de Toulouse.   Compte rend, des trav., 61 Annge,  1861,
    19-21.   Gaz. hebd.,  1862, XIX,  p.  169.—The most  important compilation
    is  by Phoebus,  Der typische  Friihsommercatarrh.   Giessen,  1862.   It con-
    tains the older literature in full, and a great number of separate observations
    not elsewhere published.—Abbotts-Smith, Observ.  on Hay Fever.   Lond.,  1865.
    (1866, 4th  ed.)—Biermer, Virchow's Handb.  der spec. Path. u. Ther. 1865.  V.
    1st part, p. 635.—Pirrie, On Hay Asthma, etc.   Lond., 1867.—Strieker, Arch.
    f. path. Anat.,  1867,  Vol. 41, p. 292.—Ferber, Arch.  d.  Heilk., 1868.  Part
    VI, 8, and 1870, IV,  555.— Yeursley, Med.  Press and  Circ,  1868, p.  477.—
    Zojafmd. de Giovanni, Gaz. Med. Lombard., 1868, No. 38.—Binz, Virch. Arch.,
    46, p. 100, and Berl.  klin. W., 1869, 135.—67. Moore, Hay Fever or Summer
    Catarrh: its Causes, etc.   Lond., 1869.—Roberts, New York Med. Gaz., 1870, 
540
ZUELZER.—HAY FEVER.
   Oct.  8, Dec lO.—Kernig, Petersb. med. Zeitschr.,  1870, 17.- -Thompson, Brit.
   Med. J.,  1871, Jan. 21, p. 58.— Fergus, Ibid.,  1871,  Jan. 28,  p.  90.—A
   Smith, Med. Press and Circ,  1872, July 17, p. 43.— Waters,  Brit. Med.  J.,
   1872, Jan. 6, p. 4.—Stoeber, Gaz. med. de Strassb., Fevr., 1872.—Gueneau de
   Mussy, Gaz. hebd., 1872.  Nos. 1 and 2, pp. 9 and 35.—Barrat, Med. Times
   and Gaz., 1872, June 22.—Decaisne, M. E., De l'Asthme d'ete ou fievre de foin
   comrne entity morbide, Gaz. rngd. de Par., 1873, p. 501.—Blackley, C. H.,
   Exper.  Researches on  the  Causes and  Nature of Catarrhus  iEstivus  (Hay
   Fever or Hay Asthma).  Lond., 1873. (Contains the most  important experi-
   mental and pathological investigations.)—Morrill Wyman, Autumnal  Catarrh
   (Hay Fever), with 3 maps.   New York, 1872.

                    INTRODUCTORY REMARKS.

   By  the name of  Hay Fever, or Bostock' s  Catarrh,  is  desig-
nated a slight febrile  affection which  attacks  a certain,  not very
large, number of individuals whenever they are exposed to the
emanations of grasses in bloom, chiefly just before  mowing time.
The  disease appears in these patients in  single accesses  wliich
return every year, always running  a favorable course,  although
sometimes with threatening manifestations.  The symptoms are,
essentially, catarrh of the conjunctiva and of  the mucous mem-
brane of the nose  and  upper air-passages, and frequently, but
not  always, asthmatic difficulties, which sometimes are of great
intensity.
   The disease, which is more frequent in England than in other
countries, is now referred by Blackley to the operation  upon the
mucous membranes accessible to it of the  pollen of  grasses and
certain other plants while in bloom (at mowing time).
   Little  significant as the disease is of itself, it still acquires  an
increased  importance pathologically, because its connection with
the noxious influences causing it is established with a  certainty
common to few other diseases.

   The nomenclature of the  disease has  fluctuated very  much according as  our
ideas of its nature have changed.  Bostock named it catarrhus mtivus ; he wished
in this way to indicate its appearance in summer, and, moreover, he regarded  the
heat  of summer as the cause of the disease;  still, by this  name no distinction is
expressed between it and other catarrhs likewise occurring in summer.   In England
it is  called Hay Fever or Hay Asthma. It is also called  June Cold, Rye Asthma,
etc.  Phoebus prefers the name  Typical Early Summer Catarrh, as indicating its 
INTRODUCTORY REMARKS.
541
annual return and the usual time of its accesses; still the disease is not limited to
early summer.  Biermer proposes, in order to emphasize the element of idiosyncrasy,
to make the corresponding addition to the name introduced by Bostock, Summer
Catarrh from Idiosyncrasy. Blackley finally, from his investigations, recommends
the names Pollen Catarrh and Pollen Asthma, on etiological grounds.  The name
,:Hay  Fever,"  however,  has become most widely known, and this may still be
retained, unless it be preferred to call the affection, from its first observer, Bostock's
Catarrh.

    Our knowledge of this disease was  first founded in the year
1819  by  Bostock, who  was  himself  attacked  by  it,  and  first
gained a knowledge of twenty-eight cases (observed by himself
and communicated  to him) after the publication of the history
of his own disease.   He cites a statement  of Heberden's,' accord-
ing to which the latter had observed before him some undoubted
cases  of  summer catarrh ; and Phoebus  believes  him  to have
been  the  only author acquainted with the disease before Bos-
tock.   Still, Biermer adduces one  passage also  from van Hel-
mont'  and from Bosquillon,8 which probably refer  to this affec-
tion.    Other citations are not free from question.
    Up  to the year  1861, only a small number of works (twenty)
had appeared on this subject,  and these Phoebus  collates.   It
was only in England, however, that attention to this disease was
extensively aroused ;  upon the Continent,  and especially in Ger-
many,  it was little heeded, as proved by the absence of this head-
ing in  most of the  handbooks.   In 1854  Phoebus was  induced
from  special motives to  collect extensive material for  observa-
tion ; he therefore issued a circular to the medical societies, etc.,
by means of  which he succeeded in obtaining notes of 154 cases,
the larger part of which had never been published, and these
he carefully analyzed.   His book contributed essentially to
arouse  an interest in hay fever.
    Since the  appearance of Phoebus' s work there have followed

   1 I have known it (catarrh) return in four or five persons annually in the month of
April, May, June, or July, and last a month, with great violence.
   2 Vidi frequenter mulieres, quae suavi olentium odore prseter  cephalalgias et  syn-
copes, confestim in extremam respirandi difficultatem inciderent.
   3 Bosquillon relates (conf. Cullen's First  Principles of  Pract. Med.) that he has
known a strong full-blooded man who always had an asthmatic attack when rice was
threshed in the neighborhood of his dwelling. 
542
ZUELZER.—HAY FEVER.
quickly, one  after another, a large number of publications (in
part cited by Biermer, and to the latest period by Blackley).
   The case of Helmholtz (by Binz) is of especial interest, for he
himself was attacked by hay fever for  several successive years,
and referred it  to vibriones which were  found in the  nasal
mucus.
   The number  of cases which have  come  under observation
Phoebus  estimated as altogether  about 300.  Since then, per-
haps about 150 more may have been recognized.
   Very recently there has appeared on this subject the highly
important work  of Blackley, who, himself a sufferer from hay
fever,  has kept  up experimental  studies  in it for  ten years.
The result of his labors  is extremely important, because it puts
beyond question  the complete dependence of the disease upon
definite causes.

                         ETIOLOGY.

   In considering  the etiology of  Bostock's catarrh, we must,
more  than  in the case of almost any other disease,  draw a sharp
distinction  between the predisposing and the exciting causes; for
it must be strikingly apparent throughout that this  affection is
exclusively confined to  certain individuals, in whom, therefore,
certain definite predisposing influences are to be assumed.  With
these  persons the disease appears year  in and year out, in more
or less regular accesses, often under the most different external
conditions.
   It  has been made evident by the compilation of Phoebus and
by Blackley that the  disease only attacks individuals under
forty  years of age; up to  that, however,  no age escapes.  The
youngest patient among fifty-six cases in Phoebus,  was five and
a quarter years  old, and among sixteen cases in Blackley four
years. The majority of cases of the-former, viz., eleven, come in
the class from sixteen  to twenty  years, and  the next greatest
number, viz., ten, in that from six to ten years old.
   In regard to sex, the female is out of proportion less fre-
quently affected  than  the male; 104 male to 50 female patients
(Phoebus).  The ratio is similar in more recent authors.   It is
proved, at  any rate, that the hysterical impulse, to which  some 
ETIOLOGY.
543
authors attribute great influence, can play no important part
among the predisposing causes.
   The patients belong exclusively to the educated classes ; the
clergy, officers, physicians, merchants, and their relations.  The
number of physicians is relatively the most largely represented,
perhaps because they pay most attention to the disease.   It is
particularly noticeable that no person living in the country is
found among the patients.   Blackley  concludes from this, as
well as from the larger number of cases published very recently,
as opposed to the wholly isolated cases of  the previous century,
that  the  ever-increasing discontinuance of  rural occupations
and the longer stay in  closed rooms, occasioned by social con-
ditions, have  constantly increased  the  predisposition, and that
this tendency will  probably be still further developed in the
future.
   All constitutions  and  temperaments, but  particularly the
nervous, are  liable to the disease.    It appears from this, too,
as Phoebus  supposes, that hereditary tendency plays  a certain
part in the predisposition.
   To this must be added, that some patients at other seasons of
the year, independently of hay fever, suffer from urticaria.
   The  disease is known as especially prevalent in  England
proper.  Of the 154 cases of  Phoebus, 83 came from England, 34
from Germany, 16 from France, 7 from Belgium, 3 from Switzer-
land, only 2 from  Scotland, 3  from Ital}T, and the rest  from
other countries.   The more recent authors report  that the hay
fever is not very rare in America also.  Blackhy knows of some
persons from India. Some patients,  moreover, suffer their annual
attacks, even though far from home  (Phoebus).
   Among the exciting  causes  are to  be mentioned  only the
influence of the seasons, and the blossoming  period of many
grasses.
   The disease occurs only in early summer  and midsummer,
except under  certain circumstances in the latter part of summer
too, viz., up to the end of the second mowing ; in England in the
months of May, June, and July, seldom up to  September.  The
annual attacks keep invariably to these seasons; those who have
repeatedly been visited by it  of course fear its recurrence, which 
544
ZUELZER.—HAY FEVER.
they confidently expect, and in consequence the nervous excita-
bility in many reaches a high degree even before the time.
   The patients uniformly assert that the affection is not caused
by atmospheric conditions, but by certain vegetable emanations.
As  soon  as the patient approaches a meadow in full bloom, or
a field of rye, flowering grass  or  the like, or a heap of freshly
mown hay, he is attacked  by the disease.  A female patient
(Phoebus) related that she brought on her attack in two succes-
sive years by  receiving a bunch of grasses and wild flowers.
   These statements have from the beginning directed attention
to the emanations proceeding from growing plants.   Some even
assume that  the efficient cause is to be  sought  only in the
high  temperature which prevails at the same time, etc.  The
following influences may therefore be assigned  as causes of the
disease.
   1.  The influence of dust; 2. The odors of  various kinds of
flowers, especially the ethereal oils  which go along with  them ;
3. The cumarin which occurs in certain plants, and especially in
those grasses under consideration, such as anthoxanthum odo-
ratum (sweet-scented grass), and which is also developed perhaps
in the hierochloa and melilotus varieties in the fresh, but more
decidedly in the dry state ; 4. Benzoic acid, which is the source of
the  aroma in anthoxanth. odor., holcus odor., etc. ; 5. The influ-
ence of ozone ; 6. The effect of  sunlight and heat;  and 7. The
operation of the pollen of grasses diffused in the air.
   Many patients have  set on foot experiments in these direc-
tions.  Blackley carried them on systematically in  such a way
as to study the influence of the various  substances alluded to
upon his respiratory  mucous membrane   His  results are the
following:  a  thorough  observation of atmospheric  conditions
showed that the attacks do not run at all  parallel with extremes
of light and  heat.   Ozone, benzoic acid, and cumarin produced
only a very unimportant influence upon the respiratory organs,
and none wliich resembled the symptoms of hay fever.  Dust,
which besides is differently constituted in different regions, may
occasion  cough and  catarrhal  symptoms  at various seasons ;
but these have little similarity to hay fever, and are not at all
confined  to the summer season.   The fragrance of flowers of 
ETIOLOGY.
545
various kinds has little effect, although the smell  of  chamomilla
matricaria produces disagreeable symptoms, headache, etc.  The
effect  of  the spores of penicillium  glaucum was hoarseness in-
creasing  to  aphonia, bronchial  catarrh, etc.,  wliich lasted for
some days.
   On the other hand, there has been complete success in devel-
oping the  features of  hay fever  by the  operation  of pollen
upon  the organs of  respiration.   Blackley experimented  with
the pollen of seventy-four kinds of  plants, among  them many
grasses.  The investigations were undertaken at different seasons
of the year with dried and fresh flowers.  The great majority of
the pollens gave like results.

   The grains  of pollen present a simple cell formed of an external and internal
membrane,  which is filled with granular contents. The membrane often bursts, and
the latter become free.  The absorption of water effects a speedy bursting, with
vigorous dispersion  of the granules; this takes place somewhat more slowly from
the action  of mucosities and other substances.   The granules, when colored with
aniline and carmine, frequently exhibit an active molecular motion, lasting for a
considerable time.
   The mechanical operation of the grains of pollen upon the mucous membranes
probably depends upon these circumstances.  Besides this, they must have a chemi-
cal effect, too, a view which has not yet been closely  investigated, but which certain
experiments favor.  The mode of operation of  the  pollen grains is also somewhat
altered by oil, etc.  Dried pollen can be vitalized again by the absorption of water.

   The influence of the pollen upon the mucous  membranes was
investigated  in  the following way: If grains of  the pollen of
lolium italicum, e.g.,were placed upon the mucous membrane of
the nose  with the tip of the finger,  after  a few hours the symp-
toms of a cold  in  the  head appeared, completely corresponding
with what is observed in hay fever.  When a larger quantity was
used, there resulted the characteristic violent sneezing.  The inha-
lation of pollen through  the mouth  produced asthmatic symp-
toms,  with general illness.   A drop of a  one per cent, decoction
of the pollen of gladiolus, laid upon the conjunctiva, immedi-
ately excited a conjunctivitis, which lasted for thirty-two hours.
   Also,  the inoculation of  the pollen under the  skin gave evi-
dence of its irritating properties by inflammatory swelling of the
affected part.
           VOL.  II.—35 
546
ZUELZER.—HAY FEVER.
   At any rate, these experiments, which may be followed out in
detail in the original, prove that the pollen, as well in the fresh
as in the dried state, is capable of producing all of the symptoms
of hay fever.
   A further series of observations served to establish the relative
quantity of pollen present in the air, and  its relation  to the
intensity of the symptoms of the disease.   Small plates of glass,
covered with a viscid fluid (water and glycerine, each  100  parts ;
alcohol, 200;  carbolic acid, 2.5 parts) were exposed to  the air  in
a suitable apparatus, and  the pollen grains collected in a certain
time upon a square centimetre counted.  Observations,  continued
for several months,  gave, at a mean temperature of 23.5°  C, an
average of about 364 grains of pollen to one square centimetre in
a day.   The observations were continued  for two years, 1866 and
1867; in the former the mean number amounted to 472.5,  in the
latter, to only 46.8 pollen grains in a day.  The maximum, 880,
was attained on June 28 ;  the highest temperature in that year,
35.6° C, was  observed  on the day before.  In  the second year
the greatest quantity  fell upon  June 23.   In  both  cases the
number of the pollen  grains diminished continually on the one
hand up to July 28, and on the other to May 28, within which
period the observations were carried on.
   The maximum numbers given coincided in the city and coun-
try.  In large cities the number of the pollen grains was dispro-
portionately less than in the country, on an average in about the
ratio  of 1:4.4.  On June 28, 1866, the number for the country
amounted to 880 ;  for the city to only 104.
   Besides this, the observations  showed that  in  the  more ele-
vated strata of air the pollen grains are disproportionately more
numerous than in the lower ones, while we should have expected
the reverse condition.  For a considerable difference of height,
the relation of the places situated at a higher level  (1,500')  to
the lower is placed as 104:10.
   Rainy  weather notably diminishes the quantity of pollen, and
the strength and direction of the wind have also a great influence
upon it.
   In  conformity with these observations, it is shown that the
greatest intensity of the symptoms of hay fever in the case of 
SYMPTOMS.
547
Blackley himself always agreed with  the  maximum amount of
pollen diffused in  the  air.  The attacks are more violent in the
country than in the city, and regularly subside more or less sud-
denly on  the occurrence of rainy weather,—observations wliich
entirely coincide with  the statements of the  authors above
quoted.
   Further experiments show the reason, too, why all the symp-
toms  of  hay fever are worse  when  the  patient moves about
actively, but diminish when he keeps quiet.  Without consider-
ing the fact that we breathe more frequently when in motion, 4.4
times as much  pollen is deposited  upon the  same  surfaces
with a motion of  two  English miles an hour as when at rest (in
the one case,  e.g., 140,  in the other 28, in thirty minutes, on one
square centimetre).
   For the same reason probably the attacks are milder in-doors
than in the open air.  When  in good seasons there is a rapid
growth of  grass, and haymaking is favored by the weather, so
that two mowing times follow closely one upon the other, it may
happen that the attacks of persons dwelling in such districts are
unusually prolonged, so as to last from May to September ; while,
under  the  contrary circumstances, they  run a  much  shorter
course.
                      Symptomatology.

   Blackley makes use of the results arrived at to explain the
features of the disease, the symptoms of which have necessarily
seemed exceedingly paradoxical, and have  called forth the most
various hypotheses.
   Phoebus arranged the symptoms in six groups;  symptoms
referable  to the nose, to the eyes, to the throat  and mouth, to
the head,  to the neck and chest, and  the  general phenomena.
Still it is sufficient  to make an essential distinction of two classes,
between which all the  manifestations may easily  be represented;
the catarrhal form  and  the asthmatic.
   Patients may be attacked with both of these  forms,  or with
either one of them  alone ; sometimes it amounts merely to a local
affection of one portion of a mucous membrane.
   The catarrhal form runs its course with  little pain and no 
548                ZUELZER.—IIAY FEVER.
important symptoms, while the asthmatic sometimes occasions
very alarming manifestations,  but like the former  always ends
favorably.
   According to Phoebus, the  disease often begins with prodro-
mata of several days' duration, with weakness, coated tongue,
diarrhoea alternating with constipation, sleeplessness, etc.  Some-
times it begins after only a few hours' discomfort,  or else sud-
denly.  Blackley  observed  only the latter variety.   Records
of the temperature, taken at two periods during the time from
April 28 to June  28, showed  no elevation  of the animal heat
up to immediately before the beginning of the attack, and no
acceleration of the pulse.  If  previous indisposition exist, it is
probably generally unconnected with hay fever.  That is to say,
it is  quite  possible that one  and the same  amount of  pollen
bodies in  the  air will be well borne by  one  patient from  his
individual  capacity for irritation, while it  causes  lesions  in
another.
   The affection attacks exclusively, and indeed in the follow-
ing order,  the nasal mucous  membrane, the conjunctiva,  the
mucous membrane of the mouth and the  fauces, and that of  the
larynx, the trachea, and the bronchi.  When the wind is strong,
the conjunctiva is  often seized first; under such circumstances,
the wind is often  regarded as the cause ;  while,  according to
Blackley,  this should rather be sought in the  increase of  pollen
it brings with it.
   The first symptom,  just as in the experiments already men-
tioned, is  a rather marked tickling.  Then a  clear serous fluid
begins to flow  from the nose, and violent sneezing occurs, often
twenty or  thirty  times, one  after  another,  and  even  more;
lachrymation also occurs sometimes.  The nasal mucous mem-
brane swells up more or less quickly, according to the amount of
the pollen affecting it.   Not rarely the swelling is so great that
the two nostrils are closed.   If the patient lies on one side,  the
swelling goes down, since the oedematoas effusion is easily mov-
able, and gravitates.
   So soon as the  Schneiderian membrane is  highly swollen, it
becomes less sensitive,  even to the pollen, which, as stated, acts
as an active sternutatory,  and  the  sneezing  ceases.   At  times, 
SYMPTOMS.
549
  slight  bleeding occurs,  from which the nasal mucus appears
  of a rusty tinge, as in pneumonia.   Later on, it becomes thicker,
.  and ultimately even purulent, but  not  to a high degree.  The
  shedding  of epithelium seems to be less  considerable than in
  ordinary coryza.
     The eyes appear to be affected somewhat later, because the
  number of  pollen grains is  smaller in proportion  to the fluid
  which  washes  them away, than in  the  case of the  nose.  Still
  the affection sometimes even begins here.   The symptoms here
  are similar  to  those in the case of the nose,—tickling,  which
  increases to more decided burning,  swelling, and redness of the
  conjunctiva, as well as of the anterior portion of  the  globe.
  The tear passages are  sometimes completely closed by swelling.
  Shooting neuralgic pains are felt in  the  posterior portion of the
  orbits.  When very  many pollen grains  are present, a  slight
  chemosis is  established.   Sometimes the patient  presents photo-
  phobia, which,  however, is not very intense, and even allowed
  Blackley to use  his microscope.   In the morning there is oede-
  matous swelling  of the  eyelids.  The  secretion is at first thin
  and watery, then grows thicker, and may even become purulent.
      The mucous membrane of the fauces and mouth is less sen-
  sitive ; it becomes swollen,  to be  sure,  but  not markedly.  In
  the pharynx the patients are conscious of  a  tickling, a sense of
  dryness and pressure,  or, later, a slight burning feeling, which is
  perceived as far as the  Eustachian tube and the meatus audi-
  torius  externus.   Sometimes also there occurs a slight deafness,
  and this constitutes the only symptom which may sometimes last
  for a considerable time after the attack.  Rarely there exists a
  slight  cough.  Shooting  pains in the head probably have the
  same origin as in the case of the eyes.
      The asthmatic form, in the course of which alarming  symp-
  toms   sometimes  occur, is constantly accompanied by laryngo-
  bronchial catarrh.  The asthma is  of varying severity, from a
  moderate cough,  with  scanty expectoration and a feeling of con-
  striction about the chest,  to great dyspnoea, croupy inspirations,
  a sense of anxiety, and a  pale and disturbed expression of coun-
  tenance.
      In the most severe cases the  sense of suffocation is very con- 
550
ZUELZER.—HAY FEVER.
siderable.   The muscles  of  respiration  act with the  greatest
force,  the  patient sits  upright,  with the  hands convulsively
clenched, and is extremely anxious.
   As  a point  of distinction  from nervous asthma,  the attacks
of hay fever will be found to occur mostly in  the  daytime, in
the fresh air; and, while  they show brief remissions, they still
have a tendency to last with greater or less  severity during the
whole  hay-fever season.   In  one  case the patient had to  spend
twelve or fourteen nights in this condition, sitting up.  (She was
in the country  at the time, while  usually she lived in a suburb
of Manchester.) Blackley refers  this affection also to the  action
of pollen grains, wliich often burst as  soon as they become
moist,  and discharge their granular contents upon  the mucous
membrane.  It is proved  by  the  experiments that they quickly
cause a considerable  hyperaemia  or inflammation, and oedema-
tous transudation in the mucous membrane.   The proof that
they are retained  here  in large  amount is  found  in the fact
that the pollen is, out of proportion, less abundant in  the exjfired
air than in  that which is inhaled.
   But the high degree of  functional stenosis caused in this way
would be sufficient to explain the asthma.   The inhalation, too,
of pollenj undertaken  for experimental  reasons, induced the
same symptoms.
   The general symptoms are not characteristic ; some patients
are disinclined  to  work, being easily exhausted ; some are pre-
vented from sleeping by a  rapid stream of thoughts.   Sometimes
neuralgic pains occur, similar to those which are perceived  in the
thumb and forefinger on the inoculation of pollen under the skin
of the arm.  The fever is seldom considerable, except in asthma ;
the pulse in that case becomes frequent and full, the skin hot
and dry, and there are chills from time to time.
   For  reasons which are  easily perceived, these symptoms sel-
dom occur simultaneously ; generally only one group or another
is specially represented.  They last for three or four weeks, with
more or less noticeable intermissions, and do not lead to serious
lesions, but, as  a rule, vanish with striking rapidity,  perhaps  in
favorable weather  completely.  The asthma disappears as with
a blow, and the mucous  membranes of the nose, the eye, the 
TREATMENT.
551
  mouth, the pharynx, etc., return to their normal state in a few
  hours, after a night, or at most in from one to one and  a half
.  days.
     Whether the course of the disease is of greater or less inten-
  sity  and duration  depends, according to Blackley, upon the
  amount of  pollen distributed in the air, and upon the greater or
  less sensitiveness of the patients.
     Under some  circumstances  the attacks may extend over a
  space of three months.
     Patients are  generally visited  by these seizures  every year.
  The  earlier attacks are, as  a rule, milder than the later ones.
  Sometimes, too,  under the circumstances mentioned above, there
  occur secondary accesses at the time  of the second mowing.

                           Diagnosis.

     With regard to diagnosis,  our  only concern is  really with
  the distinction of the affection  from  sporadic catarrhs, and this
  depends  on our knowledge of the accesses  as annually recur-
  ring  at the regular season.   The attacks are always most violent
  during a stay in the vicinity of  blossoming meadows, etc.
     Besides this, hay fever  is  to  be distinguished  from  those
  catarrhal attacks which are due to the inhalation of  the dust of
  powdered ipecacuanha, and the emanations of oil of turpentine,
  of certain kinds  of pine, etc., but which are always merely acci-
  dental  and transient.  (Phoebus adduces a longer list of such
  instances.)
                           TREATMENT.

     Treatment is still powerless  against hay fever.  Phoebus cites
  a long list of remedies which have been tried in vain.  The injec-
  tion  of a solution of quinine into the  nostrils, as employed by
  Helmholtz, has proved ineffectual in  subsequent cases.
     Change of air does not always protect one  from  the attacks.
  Even a stay at the sea-shore is not alone sufficient, for the attacks
  return as soon as land-winds blow.   Sea-voyages alone furnish
  immunity.
     The English physicians often send their patients to the north 
552
ZUELZER.—HAY FEVER.
of Scotland, where  the meadows are not in  bloom at the time of
hay-cutting in England.  In America, they are in the habit of
resorting to an island named Fire Island, a little separated from
the mainland, near Long Island, where they remain free from the
disease during their stay.
   After all, then, the result of the researches of Blackley is, that
patients  had better remain in the city in summer, and as much
as possible in their rooms, where, at all events, they will have to
endure less severe seizures than in the open air.
   It is impossible  constantly to avoid the noxious influences.
No means of eradicating the tendency to the disease  by a pro-
cess of hardening, or the like, has yet been found. 
MALARIAL DISEASES.
HEETZ. 
 
MALARIAL   DISEASES.
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    Frankf., 1795.- -Pringle, Beobachtungen, a. d. Engl, von Braude.  Altenb., 1772.
    —Lind, Ueber die Krankheiten der Europaer in heissen Klimaten. Riga, 1773.—
    TrnkadaKrzowitz, Hist. febr. interm. 1775.— Strack,  Obser. med. de fob. interm.
    Offenb., 1785.—Grainger, Prakt. Bemerkungen.  Leipzig, 1785.—St»ll, Aphor-
    ismen, etc.  Vendob., 1785.—Thomson,  Treatise.  London, 1787.—von  Hoven,
    Das Wechselfieber und  seine Behandlung.  Winterthur,  1789.—Jackson, Ueber
    die Fieber in Jamaica, Uebers. von K.  Sprengel.  Leipzig, 1796.—Balfour, In
    various publications. —Dawson, Observat. on the WalcherenDiseas., 1810-Davics,
    A Scient.  and Pop. View,  etc., 1810.— Wright,  Hist, of  the Walcheren remit.
    1812.—Audouard,  Nouv. therap.  de fievres intern.  Paris,  1812.—Sebastian,
    Ueber die Sumpfwechselfieber in Holland.  Karlsruhe, 1815.—Alibert, Traite de
    fievr.  pernicieus. interm. 5. gdit.  Paris, 1820.—Monfalcon, Histoire  des marais.
    Paris, 1824.  Deutsch von Heyfelder.   Leipzig, 1825.—Bailly, TraitS anatom.
    patholog. de fie v. intermit.  Paris, 1825.—Bakker, De volksziekte van bet jaar
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    delle  maremme.   Pisa, 1839.—Shewardson, Amer.  Jour., 1841,  April.—Molo,
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    Fergusson, Edinb. Jour., Vols. 59 and 60.  Medic. Jahrbiicher f. d. Herzogthum
    Nassau,  1843.—Robertson, Mrd. Notes on Syria. Edinb. J., Januar.,1843, Vol. 60.
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HERTZ.—MALARIAL  DISEASES.
     No. 3.,  Gaz. des hopit.  1844, No. 45.  Traite de medec.  pratique, etc., 1845.
     Tom. Vl.—Steifensand, Casper's Wochenschr. 1853, No. 44.—Dietl, Zeitsch. f.
     wiener  Aerzte, 1844, Decbr.— Wilson,  Edinb. Jour.,  1846,  Vol.  66.— Jacquot,
     Gaz.  mgdic,  1848.—Heusinger, Recherch. de pathol.  comp.  L—Steifensand,
     Das  Malariasiechthum in den niederrhein.  Landcn. Crefeld,  1848.—Ij'cvfer,
     Zeitschr. fiir ration.  Medicin, 1849, 1 and 2. Heft— Canstatt,  Prager Vicrtel-
     jahrschr., 1850, Bd. 4.—Wolff, Annalen des Charitg-Krankenhauses, 1850, 1.—
     Grisolle,  Gaz. des hopit,, 1850,  No. 65.—van Been,  Nicuw Archief., Bd. Ill,
     p.  305.—Heschl,  Zeitschr. fiir wiener  Aerzte,  1850,  JuW.—IIcinrich, Med.
     Zeitung Russlands, 1850.—.Meckel, Deutsche  Klinik, 1850.—Rineker, Verhand-
     lung  der physik.-med. Gesellschaft in  Wurzburg,  1851.—Dundas,  Sketches.
     London,  1852.—Dietl,  Oester. med. Wochenschr., 1852.—Haspel, Maladies  de
     l'Algerie. 1852. Vol. 2.—Epp, Schilderungen  aus hollandisch Indien. Heidelb.,
     1852.—Panum, Verhandlg. der wiirzb.  Gesellsch. 1852.—Bonnet,  Traite"  de
     fievres  intermit.  Paris, 1853.—Bierbaum, Das Malariasiechthum. Wesel, 1853.
     —Clemens, Zeitschr. fiir Staatsarzneikunde. 1853.—Planer, Zeitschr. der wiener
     Aerzte.   1854.—Zimmermann, Clin. Untersuchung. zur Fieber-Entziindungs- u.
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     Frerichs,  Die Melanaemie, etc.,  Zeitschr. f. clinisch.  Medic, Breslau, 1855.—
     Jones, Assoc. Med. Jour., 1856, Aug.—Michael, Special-Beobachtungen der Kor-
     per-Temperatur im intermittirenden Fieber, Archiv fiir physiol. Heilkunde, 1856.
     Heft  1.  p. 39.—Griesinger, Infectionskrankheiten, in Virchow's Hdbch. der spec.
     Path. u. Ther., 1857 and 1864, Bd. II, Abth.  2.—Mouchet, Revue medic, 1857,
     April, Mai.—Sdwlz, Zeitschr. d. wiener Aerzte, 1857, Mai  u.  Juni.—Balfour,
     Baikie,  Edinb. Med. Jour., 1857, March.—Hirsch, Klinische Fragmente. Konigs-
     berg,  1857.—Heidenhain,  Virchow's Archiv, Bd. XIV, p.  509.—Redenbachei;
     Harnstoffgehalt des Urins, Henle und Pfeufer's Zeitschrift, III Reihe, 3 Band.
     —Rigler,  Wien. med. Wochenschr., 1858,  8.—Duchek, Prager Vierteljahrschr.,
     1858,  4,  Spitalszeitung,  1859,  12-20.— Hirsch,  Handbuch  der  historisch-
     geographischen Pathologic.   Erlangen,  1859.  Bd. I, p. 5.—Ringer, Lancet,
     1859,  Aug. 6.—Frerichs, Klinik  der Leberkrankheit,  Chapter on  Melansemia.
     —Jones, Observat.  on some of the Physical, Chemical, Physiol.,  etc.  Philadel-
     phia,  1859.— Oppolzer, Wien. med. Wochenschr., 1860, Nr. 25, 26.—Duboue,
     Moniteur dessc. m§d., 1861, Nr. 83 etseq.—Mayer, Wiirtemb. Correspondenz-Bl.,
     1861,  No. 34.—Heschl, Oester. Zeitschr. f.  prakt. Heilkunde, 18\2, Nr. 40-43.—  &
     Key,_  Prager Vierteljahrschr., 1862,  Bd.  III.—Friedmann,  Deutsche  Klinik,
     1863,  No. l.—Saint-Vel, Gaz. heb., 1863, No. 13.—Rosenstein, Allg. wien. med.
     Zeitung, 1864, Nr. 41.—Ritter, Virchow's Archiv, Bd. XXX, p. 273, Bd. XXXIX,
     p. 14,  Bd. XL,  p. 239, Bd. XLVI, p. 316, Bd. L, p. 164.—Boullet, Sur les causes des
-y.   fievres intermit. These de Pans, ^864.—Baxa, Wien. med. Wochenschr., 1866, 78.
     —Thomas, Archiv f.  Heilkunde, Bd. VII, pp. 225, 289, and 385.—Salisbury,
     Amer. Journ. of Med. Sc, 1866, Januar.—Schioalbe, Archiv f. Heilkunde, 1867,
     Heft 6,  p. 567—Colin, Union meU, 1867, Nr.  118 etseq.—Jilek, Ueber die Ursa-
     chen der Malaria inPola. Wien, 1868.—v. Frantzius, Virchow's Archiv, Bd. 43,p. 
HISTORY.
557
315.—Ruhle, Med. klin. Wocbenschr.,1868,Nr. 10.—Barat, Archiv. de MCd., 1S69,
Dec, 4ii2.—Barraut, Compt.  rend., 1869.—Schwalbe,  Beitrage zur Kenntniss
der Malaria-Krankh.  Zurich, 1869.—Lorinser, Eucalyptus glob., Wien med
Wochenschr.,   1869,  Nr. 43,  1870, 27.—Colin, Arch.  gen. de med., 1870
Jan., p. 5, and Traite de fievres intermit.  Paris, 1870. Gaz. heb. de mgd., 1872,
Nr. 35, p. 563.   Annal. d'hyg., 1872, Oct., p. Ml.' Annal. d'hyg. publ. et de
med. leg., 1872, p. 241-76.— Wenzel, Prager  Vierteljahrschr., 1870, IV, p. 1,
and Die Wechselfieber in ihren ursachl. Beziehungen wiihrend des Hafenbaues
im Jadegcbiet,  Prag., -1871.—Tessier, Brit. Med. Jour., 1870, Dec 31.—Blaxall,
Med. Times and Gaz., 1870, Jan. 8, p. 4%.—Treulich, Wien. med Presse, 1871,
Nr. 12.—Lacaze, Union med., 1872, Nr.  116.—Ber en gar, Gaz. des hop., 1872, p.
145.—The literature of eucalyptus globulus during the year 1872 :  Stube, Berl.
klin. Wochenschr., No. 52.—Keller, Wien. med. Wochenschr., p. 10.—Mosler,
Deutsches Archiv, X, p. 159.—Castan, Montpellier med., Mai, p. 385.—Papillon
Gaz. hebd. de med., No. 31, p. 501.—Bertheraud, Gaz.  med. d'Alger., Nr. 12.—
Armand, Traite de climatologie generale du globe, etudes  mexl. sur tous les
 climat.  Paris, 1873.—Curschmann, Bebandlung des Wechself., Mod. Centralbl,
 1873, p. 628, and Deutsches Archiv, 1872, Bd. IX.—Fiechter, Ueber die Wirkung
 der Tinct. Eucalyp. glob., Deutsches Archiv, Bd. XII, Heft 5, p. 508.—Mees,
 Over werking  van Eucal. Glob. Dissert, inaug.  Groningen, 1873.—Mosler,
 Wirkung des  kalten Wassers  auf die Milz. Virchow's Archiv, Bd. 57, p. 1.—
 Henoch, Febr. intermit, perniciosa. Berl. klinische Wochenschr., 1873, Nr. 26, p.
 301, and Nr. 34, p. 402.—EisenJohr, Carbolsauve gegen Intermittens ebend. 1873,
 Nr.41,  p. 487.—See, in addition, the literature in Virchow and Hirsch's Jahres-
 bericht and Schynidt's Jahrbiicher.
                              HISTORY.

   The history of this disease, in all its  various types, reaches
back to the earliest  period  of medical  science.  Not  only were
the  common forms then known, but also, and particularly,  the
uncommon and pernicious varieties of the malady.  Protagoras
describes the  drowsiness accompanying intermittent fever, and
the  tetanus which sometimes supervenes,  and tells of many cases
that terminated fatally, whence it would  appear that he may
have been the first  to observe  pernicious intermittent  lever
(febris int.  comitata).   Celsus  draws  the  distinction  between
quotidian, tertian, and quartan fever, and refers to the possibility
of a longer intermission in these words :-" Interdum etiam Ion-
Siore eireuitu quaedam  redeunt, sed  id raro  evemt."   He also
speaks of  the genus fr«Q,r<tiov, which he describes as a fever last- 
558
HERTZ.—MALARIAL DISEASES.
ing three days, with uncommonly long paroxysms reaching over
into one another.   (Lib. Ill, cap. 3).  Archigenes was the first
writer who recognized the complex nature of the hemitritsea, or
semi-tertian form,  as  consisting of a tertian  and a  quotidian
fever combined.  He also makes mention of masked intermit-
tents, especially when appearing in the form of dysentery or dia-
betes.  Rhazes,  the  Arabian, gives an account of febris subin-
trans.  Ebn Sina saw that rare type in which  the fever occurs
every sixth or seventh day, and  Yalescus, of Taranta,  refers to
a fever recurring every thirtieth day.  (Philos. pharmaceut. et
chirurg. lib.  V. ed  Hartmann Beyer, Francf., 1599.   Lib.  VII,
p. 596).  Rembert Dodoeus (Med. observat. exempl., C. 4, p. 9),
describes that form of intermittent fever designated as  " kato-
chus,"  and Diomedes Cornarus (Com.  Lips. 1599, p.  28), first
noticed combinations of  intermittent fever  with dysentery, or
rather the intermittent type of  dysentery.
    It was not, however, until after the introduction  of  cinchona
bark from Peru into Spain, in  the  year 1640, by the Viceroy del
Cinchon and his body-physician, Juan del Vego, that any con-
siderable degree of attention was given to the study of  intermit-
tent fever. This study was now stimulated in part by the conflict-
ing results following the use of the new drug, and in part by the
obstinate manner in which physicians generally clung to  the old
theories of Galen.  No truly reliable results we're reached in prac-
tice until after the apothecary's clerk, Robert  Talbor, or Tabor,
of  Cambridge,l  had introduced the use of larger doses and more
effective forms of administration (mostly macerations in wine, or
the tincture, with or without opium, which preparation he  sold
extensively as a secret remedy for ague) ; and until Sydenham
conceived  the idea of giving the cinchona immediately after the
first attack, during the intermission, for the purpose of forestall-
ing a subsequent paroxysm.  Hereupon followed the  classical
work of Torti (Therapeutice specialis ad febres quasdam pernici-
osas.  Mutin., 1712), in which the true nature of pernicious inter-
mittent fevers is recognized and their treatment given; and the
work of Lancisi, which is no  less valuable, especially  from an
   ' Pyrctology ; or, A Rational Account of the Cause and Cure of Agues, etc.  Lon-
don, 1G72. 
                 GEOGRAPHICAL DISTRIBUTION.             559

etiological point of view (De noxiis pallidum effluviis eorumque
remediis.   Geneve, 1716).   The  labors of Guisman  Galeazzi and
of Werlhof (Observat. de febrib., prajcipue intermitt.  Hannover,
1732) followed in the same direction as those of Torti.
   Malarial affections comprise a class of diseases that are usually
marked by a perceptible,  often a very considerable, rise of tem-
perature,  and which are  furthermore to be regarded as consti-
tuting different forms of one and the same morbid process, be-
cause of their origin in the same purely miasmatic  causes, the
fact of their frequently occurring simultaneously within  the same
area, the nature of their  anatomical products, as well as certain
peculiarities characteristic of their course.   In addition to this,
they frequently run into one another, and they all yield to pretty
nearly the  same remedies.  They may be divided into, 1st, simple,
benign  intermit tents;  2d,  anomalous or masked intermittents;
3d,  pernicious intermittents;  4th, remittent and continuous fe-
vers ; and  5 th, malarial cachexia.

                 GEOGRAPHICAL DISTRIBUTION.

   There  is probably no part of the torrid or temperate zones
in which greater or  smaller areas of country may not be found
where malaria is endemic, and where it  prevails  every year to a
greater or less extent.   Although it is foreign to the  purpose of
the present work to enter upon a minute investigation of  this
matter,  yet we may be permitted here to mention the most im-
portant foci of malarial infection.1
   Europe.—One of  the  most famous malarial  regions of Ger-
many lies  south  of the Carpathian mountains,  embracing the
major part of Hungary, what are called the greater  and lesser
Hungarian plains, Banat, Croatia, and a part of  Slavonia.  Not
less  extensive and  notorious  are the fevers  of Dalmatia  and
Istria, while they prevail under a milder form in the great plain
of the Danube in Lower Austria and in the marshes, as well as
in the northern  portion  of Galicia.  A second  very extensive
malarial region exists  iii the North-German flatlands: Northern
   1 A more complete account may be found in Hirsch, Handbuch der historisch-geo-
graphischen Palhologie, Bd. II, p. 5, whom, in the main, we have followed. 
560
HERTZ.—MALARIAL DISEASES.
 Silesia, the plain of the River Mark, the Baltic coast of Prussia,
 Pomerania, and Mecklenburg; the marsh and meadow regions of
 Hannover and Oldenburg; strips of the western coast of Holland
 and Schleswig; the lowlands of Westphalia, as well as the marshy
 plains of the Rhine and its  tributaries, including Holland, espe-
 cially its seaboard provinces of Groningen, Friesland, North and
 South Holland, and  the long-famed Zealand; furthermore,  the
 northern and western provinces of  Belgium,  particularly those
 of West Flanders and Antwerp.
    In the mountainous  regions of Upper Austria, in Tyrol,  Ca-
 rinthia, Steiermark, Bohemia, and Moravia, and in the hilly coun-
 try of middle and south-western Germany, malaria is entirely
 unknown, or occurs only in  single localities (as in Rhinegau and
 the Danube bottom-lands of Wiirtemberg and Bavaria).  Switzer-
 land is also free from it, except on the margin of some  of its
 lakes, as of Lake Zurich and Lake Constance.
    In Denmark malaria  is endemic only on the humid islands of
 Falster and Laaland.  In Sweden it is  to  be  found on the coast
 of  the  Baltic, in the  districts of  Carlskrona,  Sodermanland
 and Gestrikland, on the banks of the River Angermann (62° 20'
 N.  lat., the most northerly limit of the disease in  Europe), and
 on the shores of the three great lakes, Maelar, Wener, and Wetter.
   In Norway, Iceland, and  the Faroe" Islands, the disease does
 not seem to exist at present.
   In Russia it may be found in the provinces bordering on  the
 Baltic, especially in Esthonia; also  in Litthau and in Poland;
 furthermore, along the marshy banks of great rivers, such as the
 Danube, Dnieper, Dniester, Don, and Volga, on the coasts of the
 Black and Caspian Seas, and on the great steppes.
   In England malaria is encountered but rarely, and is endemic
 only on the  eastern coast and in some of the  lowlands  of  the
 Thames. Scotland and Ireland are free from it.
   In France the disease is confined principally to the western
and southern portions of the country.  It extends eastward from
 the mouth of the Loire as far as Tours, and in a southerly direc-
tion along the entire western coast, which abounds in swamps
and meadow-lands, almost to the Pyrenees.  The southern coast,
as far as the mouth of  the Rhone, the plain  at the junction of 
GEOGRAPHICAL  DISTRIBUTION.
561
the Saone and the  Rhone, including the city of Lyons, and the
Department of Puy-le-D6me, which abounds in swamps, are
all prolific fever regions.
   In Spain and Portugal, the most noted home of the malady is
along the south-western coast, in the bottom lands of the rivers.
Still it occurs, often in very malignant form, along the northern
coast of Spain, in Galicia and Asturia, in the northern provinces
of Portugal, and even on the uplands of Estremadura and Cas-
tile.   It is also to be met with on the coasts, and in the marshy
valleys and plains of Sardinia and Corsica.
   Italy is, beyond question,  the most malarious of all European
countries.  Aside from various humid regions in northern Italy,
and that belt of country now belonging to France, including the
cities of Milan, Mantua,  Pavia,  Nice, Venice,  and Verona, the
entire western coast constitutes a vast hotbed of malaria,  wliich
often extends eastwards as far as the foot of the mountains. This
region begins at Leghorn, and extends through the Tuscan Ma-
remma, the Campagna of  Rome, the Pontine marshes, the mala-
rious  environs of  Naples, and,  with  the  exception of  some
mountainous regions, as  far as the southern coast  of  Calabria.
The entire  eastern coast,  on the contrary, suffers but little from
the disease, the  States of the Church  being  the only portion
infested by malaria.
   Fever is endemic, over large regions and often in a very  malig-
nant form,  in the island of Sicily,  the Ionian Islands, Greece and
Turkey,  including Bulgaria, Albania, Roumelia, Moldavia, Wal-
lachia, and the vicinity of Constantinople.
   Africa.—Along the western coast of Africa, in  Senegambia,
on the Guinea coast, and on the banks and islands  of  the Gam-
bia, the Niger and the Senegal rivers, malarial  fevers flourish to
an extent and with a  malignity scarcely equalled anywhere else.
They also  prevail, although in a less virulent form, on the
eastern coast,  through Mozambique and Zanzibar, as far south as
Delagoa Bay ; on the greater part of the island of Madagascar,
and  on  the Comoro  islands  of  Anjouan and Mohilla.   They
are furthermore  to be found in  southern Nubia, at the  Upper
Nile  delta, at the  junction of the two  arms  of the  Nile, and
especially on the  banks of the White Nile; also in Egypt, par-
          VOL. II.—36 
562
HERTZ.—MALARIAL DISEASES.
ticularly in Lower Egypt, occurring, here again, on  the banks
of the Nile, and in the moist regions  of the  delta;  and also
extending  along the  coast  of  the  Mediterranean  Sea.    In
Algiers malaria is very widely diffused, and very pernicious, not.
only on the coast, but on the oases, in  the deep and damp val-
leys of the mountainous regions, and on the southern slope of
the Atlas range.
   It is said that the interior portions of Africa,  of  which but
little is known, are also, in part, infested with fevers of a grave
character.
   America.—Certain of the islands of the West Indies  rival
even the western coast of Africa in the extent and the malignity
of their fevers.  To this number belong  San Domingo, St. Chris-
topher's, Jamaica, Dominica, and Tobago, all of which abound
in humid valleys and marshy ground, while  other islands, with
more favorable conditions of soil,  suffer little  or not at all.  In
Mexico malarial diseases flourish on the  eastern as well as on the
western coast, whereas in Central America they are mostly con-
fined to the western coast, from Cape Gracias-a-Dios to Panama.
   In North America these  affections present themselves,  often
in very malignant form, in the Gulf States of Texas, Louisiana,
Mississippi, Alabama, Georgia, and Florida;  in the wide prairie
lands between the Missouri River and  the Rocky Mountains, and
in the valleys of the middle and lower Mississippi  and its tribu-
taries. In  the Middle States they are rare, and in the  Northern
States are probably unknown.
   There is a  dearth of reliable information with regard to the
northern coast of  South America, as  well  as concerning the
southern portions thereof.   We have accounts from Venezuela
showing a considerable prevalence of the disorder.   It is also to
be found on the western coast of Ecuador and Peru, along the
low banks  of  Brazilian streams, and  here often in a malignant
form, as well as in the interior of Brazil and Bolivia.   Further,
in the damp forest  regions, heights and valleys of the Peruvian
mountains  and on the eastern slope of the Andes.
   Asia.—A very extensive and malignant  malarious region is
to be found in the river districts of the Indus and the Ganges,
which are  annually overflowed by the water  of these streams. 
ETIOLOGY.                      563
This is particularly the case with regard to the delta of the Gan-
ges, and is also true of the shores of the Brahmaputra.
   On the western coast of Hither India the disease is quite prev-
alent, while the eastern coast seems to be comparatively exempt.
On the island of Ceylon, however, it prevails with a degree of
virulence worthy of the West Indies or the Guinea coast.   It is
universally prevalent in Farther India, as well as on the Sunda
Islands, especially in Sumatra, less so in Borneo, Java,  and Cele-
bes ; also on the Molucca and Philippine Islands.
   In China  the disease prevails along the entire southern  and
south-western coast, and on the banks of the larger streams, with
a severity characteristic of  the very worst malarious regions.  It
is endemic along the entire coast of  Syria; along  the northern
coast of Asia Minor ; in Arabia, on the shores of the Red Sea and
the Persian Gulf; along the banks of the  river  Tigris; around
the Caspian Sea in Persia, and most malignant  on the elevated
plateau of Teheran.
   Australia.— Malaria may be found on the mainland of Aus-
tralia, though in a mild form.  It assumes a severer type on
some of the  smaller islands,  as the New Hebrides and  the
Society Islands, and,  strangely enough, is entirely unknown on
the  Sandwich Islands and the Samoan  Islands, as well  as the
island of  New Zealand  and Van Diemen's Land,  in spite of their
marshy ground  and frequent inundations.

                          ETIOLOGY.

   Malarial diseases  are  usually endemic  in character,  rarely
sporadic,  and rarely advancing over large regions of country in
the form of an epidemic.
   Their  endemic occurrence is  especially common in marshy
regions, and the more extensive these are, the more frequent and
severe,  as a rule,  will be the diseases  in question.   But all
marshes do not bear this relation to disease, and there are even
extensive swampy regions, in hot climates, that  are entirely free
from malarial fever.  For their influence varies with the amount
of water they contain ;  where the latter stands high,  fevers are
more rare ; where the marshy ground is covered only by a thin 
564                 RTZ.—MALARIAL  DISEASES.

sheet of water, and the latter is exposed  to  the  heating influ-
ence of the sun, malarial diseases will abound, inasmuch as the
decomposition  of  organic matter,  and especially of vegetable
matter, seems materially to aid in their production.  Thus the
most favorable conditions for the development of this poison are
offered by marshes  that have dried up,  while  their injurious
influence is materially diminished  as soon as heavy rains once
more submerge the previously parched surface of the ground.
   Marshes that are  formed partly of salt water, especially delta
lands, are  far more  noxious than  those supplied entirely with
fresh water.  This is believed to be due to the action of the  salt
water,  in killing the fresh-water plants, and thus producing a
larger amount of decomposing material.   It is difficult to  deter-
mine whether  or  not other causes likewise  contribute to  this
result, such  as the  salty ingredients of the  soil,  etc.    Those
marshes, furthermore, that  rest upon a substratum of  peat or
sand are more wholesome than those resting on limestone, chalk,
clay, or mud.
   Instances occur,  every now  and then,  in  which, with every
condition present for the development of malaria, this poison is
entirely lacking.  We cannot account for these exceptions unless
it be on the ground of the disinfecting properties of ozone, which
is said to be largely developed  in some marshes.   Examples of
this sort are to be found in many of the islands of the Pacific,
in the warm  swamp-regions of the Australian coast,  and, accord-
ing  to the recent accounts  of Jourdanet,1 in the city of  Mexico,
and its vicinity, a region offering  all the conditions ordinarily
resulting in malaria.  Before the very gates of Mexico lies the
lake of Tescudo,  about twenty-five square miles in area, com-
posed partly of fresh and partly of brackish water, with a  clay
bottom, which is often  laid bare over large areas, as the result
of evaporation, with a temperature of from 122° to 140°  Fahr.;2
and, notwithstanding all this, malarial fevers are rare.
    The fact  that marshes  have a causative relation to malaria
may be proved by the disappearance of the latter when marshes
are  drained dry and cultivated,  and its reappearance when  they
         1 Union Medicale, 1862, No. 129.
          3 The original reads, "50°-60° Centigrade."—Translator. 
                           ETIOLOGY.                       5gg

 are allowed to relapse into a state of nature.1   This favorable
 effect of cultivation  is partly due to  the systematic removal of
 the surface-water, and partly to the absorption of decomposing
 organic matter by the growing  crops.  On the  same principle,
 Maury succeeded in  combating the malignant fevers that flour-
 ished in the marshes surrounding the observatory at Washing-
 ton, by planting sun-flowers, which have  an uncommonly great
 absorbing power.  Sebastian recommends  the culture of the cal-
 amus (acorus calamus aromaticus) for the  same purpose.
   Systematic  and thrifty culture of the soil,  then,  with  its
 ditching and draining, and  careful handling of all products, is
 the greatest enemy to malaria, which  is found more rarely and
 in more benign form the more thickly  inhabited is the land.  On
 the other hand,  it is very apt to be developed and to spread in an
 uninhabited region,  where  cultivation is neglected, where the
 ground remains untilled,  and a luxuriant  native vegetation is
 abandoned to its own destiny.
   But it is not swamps alone that cause malaria.  Damp bot-
 tom-lands, and regions that are  exposed to an annual overflow,
 such  as the  deltas of  rivers, with  the heaps o^ mire thrown up on
 their  banks, as well as lands with  a clayey or alluvial  soil,
 which presents an obstacle to the percolation of water ; all these
 produce the same results  as swamps.  In case  of the working
 over or  turning up of large portions  of soil, as in the building
 of fortifications, of dykes, or of  viaducts,  in the rooting  out  of
 timber and the preparation of virgin  land for cultivation—in all
 of which processes the animal and vegetable organisms hidden
 in the ground  are brought  to the surface,  and rot under the
 influence of warmth  and  air;  not only the laborers engaged  in
 such enterprises, but the inhabitants of the surrounding country,
 far and wide, are liable to be attacked with the most violent
 malarial fevers.  The "polders" of Holland, those portions  of
 land reclaimed from the sea by the building of dykes, are notori-
 ously of this character, and men  working upon them are subject
 to the severest forms of the disease.
   The sort  of  earthwork mentioned above may often  give  rise
  1 For instances of this, see Hirsch, Handbuch der historisch-geographischen Pathol-
ogie, p.  52, Note. 
566
HERTZ.—MALARIAL DISEASES.
to the appearance  of  malaria  at points where  it had not pre-
viously prevailed at all, or to but a slight extent.   As soon as
the work is completed, the previous condition of health may be
restored within the region concerned.   Wenzel has made a report
of the malarial diseases occurring in the Jade region during the
twelve years occupied in the construction  of a harbor, at the
height of which epidemic one-half or two-thirds of the popula-
tion were attacked during one  month.  The disease diminished
gradually during the twelve years, without any other apparent
cause  than the  changes taking place on  the  newly  exposed
surfaces of ground, whereby the giving off of the poison was pro-
gressively lessened.   The fact that malaria may appear in places
previously free from it, as soon as the conditions for its develop-
ment exist, is confirmed by the unanimous testimony of Tessier,
Blaxall, Lacaze, and others,  concerning the epidemic that pre-
vailed from 1866 to 1868 on the island of Mauritius, a spot pre-
viously exempt, and which  had served as  a health-retreat for
those suffering from the fever in  India.  The heavy rains and
inundations of one year had deposited great masses of vegetable
detritus on the plains, which  the unusually dry season of the
succeeding year permitted to decay.  In addition to this, great
earthworks were built,  rivers  were  cleaned out,  forests  were
uprooted, and the mountain streams, spreading  themselves out
in the depths of the prostrate  woods,  created vast swamps.
Finally, the crops failed, and  great distress prevailed in the land.
   It has  long been known that malaria may exist on  a dry
soil, or in mountainous regions, even at a  considerable height,
(although the dissemination of  the poison is more in a horizontal
than in a vertical direction), and that in the  latter case it is often
more extensive and severe than in  the adjoining low country.
On the Tuscan Apennines fevers are to be found  at the height of
1,100 feet; on the Pyrenees, at 5,000 feet; on the island of Cey-
lon,  at 6,500 feet, and in Peru, at 10,000, and even 11,000 feet.
At the same time the neighboring plains are either entirely free,
or are visited by the disease in  a much milder form.
   These apparent contradictions and exceptions to the rule  are
not always to be  accounted  for on the theory of the death and
decay of  organic matter.  This much, however, is certain, that 
                            ETIOLOGY.                        5(37

 an elevated and apparently dry region, with a stratum of loose
 sod on the surface, and a deeper floor of clay or some other im-
 permeable soil beneath, may present conditions favorable to the
 development of malaria, when a large amount of  surface-water,
 loaded  with vegetable ingredients, percolates through  the loose
 upper earth, and is retained  on the surface of the lower stratum.
 The best instances of this kind are found in  the oases of the des-
 ert of Sahara.   Hirsch describes these as consisting of trough-
 like depressions  or excavations in a rocky or highly hygroscopic
 soil, the receptacle or river-bed of  subterranean  waters, which
 are covered with a layer of alluvium,—the surface of the oasis.
    Here, and in other apparently dry regions, the intense heat of
 the  sun often  causes cracks and deep rifts  in the earth, which
 give free exit to the miasm from beneath.
    Whether similar conditions will be found to exist, explaining
 the origin of "mountain fever," such as a rocky soil, with clefts
 and chasms containing damp  and  decaying detritus, is not yet
 determined.
    Instances are on record where  earthquakes or volcanic erup-
 tions have been followed by  the appearance  of malaria where it
 was previously  unknown.   It is  difficult to  account  for such
 phenomena, all the explanations that have  hitherto been given
 of  them being purely conjectural.  It is equally difficult  to
 account for the  prevalence  and the disappearance of malarial
 fevers in certain places where no changes whatever have occurred
 in the relations of the  soil; and we are thus forced to the con-
 clusion  that standing water  and marshy soils  are not  the only
 factors concerned in the production of malaria.1

   1 According to the reports of Drs. Luden and Corson to the Pennsylvania State Med.
 Society  (Canstatt's Jahresbericht,  1863, IV, p. 76), intermittent fevers prevailed along
 the banks of the Juniata river and the Pennsylvania Canal until the year 1856, when
 they suddenly ceased, without any  known cause.  In one year they appeared four miles
 higher up, on both sides of the river, and have  never since been known  below that
 point.  In the same way, intermittent and remittent fevers were quite frequent in  the
 Plymouth  and Whitemarsh valleys  until the year 1832, when cholera appeared ; from
that time to 1849 they grew milder and more rare, and now they have  disappeared
entirely, without any  changes having occurred in the known  conditions  of the soil,
woods, or anything else.  Bbhm, Eine Wechselfieber-Epidemie.  Berl. med. Zeitung,
1860, No. 52. 
568
HERTZ. —MALARIAL DISEASES.
   The second important factor in the development of malaria is
heat.  The spread of intermittent fever is rare beyond the sixty-
third degree  of north  and the  fifty-seventh degree  of  south
latitude;  and from here to the  equator  the  disease  increases
gradually in extent and intensity.  Hirsch tried to determine
the northern boundary of malarial fever more  accurately, and
found that the extreme northern points at which it prevailed in
different parts of the world were at very various degrees of lati-
tude and of average annual temperature.  It  thus became evi-
dent  that in the production  of malaria it was not  the average
annual temperature, but the average summer  temperature that
was  of account, and that the  northern limit of this, for fevers,
lay between the isotheres of 59° to 59.8° Fahr.  This is  an  eleva-
tion  of temperature sufficient  to insure  the decomposition  of
vegetable organisms.
   It is furthermore well known that the development of the dis-
ease  usually takes place during the summer months,  and that it
disappears,  or at least  no new cases arise,  during the winter,
unless the latter is very mild. We know, too, that the form, type,
and intensity of the fever are usually in pretty direct relation to
the temperature of the atmosphere.  This is not only established
by the testimony of writers from warm climates, but instances are
not rare in  our own  land of  the influence of a hot summer in
multiplying severe forms of the disease, and in raising the mala-
rial poison to such a degree of intensity that  it overleaps the
limits  of its usual endemic abode, and spreads abroad in epi-
demic form.  No other instance of this need be given  than the
spread of remittent fever in the Netherlands during the hot sum-
mer of 1846.
   The theory that changes of temperature conduce  to the pro-
duction of malaria, which is still advocated even by some writers
of the present day, is abundantly disproved by facts.  On the
one hand, those countries where changes of temperature are most
extreme, such as Scandinavia  and the  British islands, are com-
paratively free from malaria;  on the other hand,  those regions
noted for an equable temperature are often the home of the most
intense and pernicious forms of the disease.
   Certain climatic relations, such as the season of the year, the 
ETIOLOGY.
569
amount of moisture in the atmosphere, and the winds, cannot be
ignored in studying the genesis of malaria.
   The  season of the year is of consequence whenever it brings
heavy rains, soaking the ground, which is subsequently exposed
to the influence  of a hot sun; and the period presenting  such
conditions  occurs in different months  at different  localities.
Although, as a general thing, this  rule holds good, yet, accord-
ing to  Hirsch, great differences occur among different tropical
regions, most of  which have  their fever season during and imme-
diately  after the rainy season.  For instance, fevers are  most
prevalent in Senegambia and on the Guinea coast in June, Sep-
tember, and October; in Zanzibar (Eastern Africa) from  March
to May, and from October to December ;  in the Bay of Delagoa
(northern limit of Caffreland)  from the beginning of  September
to the end of April; in the West Indies during the entire  sum-
mer and fall; in Central America from  November to May; in
Brazil from April to June.  In subtropical regions, and in the
more elevated and temperate portions  of the tropical zone, fevers
almost always arise daring the summer,  that is, at  some period
from the end of June to the  beginning of  August, or even as late
as September, and the maximum of their occurrence is  from July
to  October.   In colder climates  (German}^  the  Netherlands,
Russia, Scandinavia, Great  Britain, etc.), they most  commonly
appear in the spring, at the  time of the snow's melting, often as
early as February ;  the maximum here is reached in May,  a
decided diminution of the disease being apparent in summer, fol-
lowed by a more serious outbreak in the fall,  after harvest time.
In  the  more temperate and  colder  climates the  winters  are
usually free from the disease, though relapses and sequels of the
disorder may then be met with, especially  after repeated thaws
have taken place.
   According to the  observations of Wenzel in the  Jade region,
a diagram of the annual prevalence of  the disease [Erkrankungs-
curve]  showed  two elevations separated  by a  saddle-shaped
depression, the elevations  corresponding to the periods of spring
and summer, the summer rise, during the several  years, being
usually higher than that of spring.  The  steep and rapid rise of
the  summer  wave represents,  in whole  or in great  part, new 
570
HERTZ.—MALARIAL DISEASES.
attacks, while its gradual and terrace-like descent in the autumn
shows the diminution of new attacks, until it reaches the winter
line of mere relapses, to  be swelled again, although to  a less
height, by the new cases occurring in  spring.   The  smallest
number of new cases and of relapses  took place during the sum-
mer, previous to the summer rise.   It should be remembered
that the greatest summer heat did not correspond, in time, with
the greatest amount of  sickness, but that the former preceded
the latter  by from twenty to twenty-five days, making it evident
that about three weeks were required  for the influence of temper-
ature to make itself felt on the course of the disease.   This pe-
riod of time may be supposed to be divided between the develop-
ment of the malarial poison and its incubation within the organ-
ism.  Wenzel  considers that  about   from  six to eleven  days
should be assigned to  the former period,  and  something like
fourteen days to the latter, but it is evident that both periods
must be greatly modified by circumstances.   The various degrees
in which the conditions requisite for the production  of malaria
(organic matter, heat, and moisture) are present  must modify
the former;  and the quantity of the  poison  brought  to bear in
any given case, as  well as the susceptibility  of  the individual
attacked,  must influence the latter.
   It is hardly to be doubted that the degree of moisture of the
atmosphere and the amount of rain-fall have some influence on
fevers.  In the tropics the latter are found to be more extensive
and more  severe the more damp the year has been, and compara-
tively infrequent and mild after a prolonged dry season.  Even
with us, malaria is evidently fostered by a wet spring and  sum-
mer, followed by a hot autumn, or by a wet spring and a hot sum-
mer followed by a wet autumn, or by  a very rainy year succeeded
by a very dry one.  Jilek has demonstrated, by the following
table, that in Pola, a noted malarious district of Istria, the extent
of the epidemic corresponded with  the amount of rain that fell:

                                           Number  of persona
      Year.             Fall of Rain.             in every 100
                                           attacked with fever.
      1864   ..........   18.44"    ............    51.4
      1863   ..........   14.25"    ............   48.6 
ETIOLOGY.
571
                                             Number of persons
      Year.              Fall of Rain.              in every 100
                                             attacked with fever.
      1866   ..........   12.10"    ............    36.3
      1865   ..........     8.44"    ............    35.4
      1867   ..........     5.49"    ............    22.9
      1868   ..........     1.5"     ............    14.2

   A high degree  of atmospheric moisture, in a malarious dis-
trict, according to Bechi, produces an indescribable unrest, lassi-
tude, and muscular debility even in  strong, robust men, leading
to attacks of fever in more susceptible individuals.  This effect of
moisture  and of evaporation shows itself,  in the most marked
degree,  during the first few hoars after a severe  shower follow-
ing a prolonged dry season.
   This is true not only of  dry fever  regions (Griesinger), for I
have observed  the same thing  in damp Holland, during a dry
summer and autumn.   I cannot determine whether Boussin-
gault' s ' observations, to the effect that rain-water contains much
more ammonia after a long, dry season than after continued rain,
and that this is taken up by the atmosphere after rain, the more
quickly the warmer the air is, and the more the condition  of the
soil  favors evaporation, have any bearing on  this subject or not.
Griesinger believes that they warrant our attributing to ammonia
a special influence in the production of fevers.
   Lancisi was among the  earlier writers who recognized the
agency of the wind in aiding the spread of marsh fevers, by vir-
tue  of its power of  carrying material  disease-germs.   He attri-
butes to the influence of the winds the fact that the Roman Cam-
pagna became more unwholesome after the removal of the sacred
groves,  and its consequent greater exposure to the miasm  of the
Pontine marshes.  Similar testimony may be found in all ages,
and of the most varied kind.8
  1 Academie des Sciences, 1853. Session of the 28th of November. Griesinger, p. 9.
  2 Gessele  (Bair. artzl. Intelligenzblatt, 1867, No. 43) reports that only one case
of intermittent fever occurred among forty to fifty laborers, engaged for two years in
cutting turf, or peat, on the northern shore of the Chiem-see, some of which laborers 
572
HERTZ.—MALARIAL DISEASES.
   In later years, Barat accounts in  the same way for the  epi-
demic that arose in 1869, on the island of Reunion, believing
that it was borne  over by the wind from Mauritius.   From the
7th of April to the 23d of July, 4,118 people, out of a population
of 23,000, were attacked with  the disease, and  no other cause
could be found for it,  seeing that  the state of the soil,  and  all
other conditions that could exert any influence in its production,
had remained unchanged.  However plausible such reports may
sound, they  do  not always sufficiently  account for the  spread
of malaria.   Hirsch very  properly  calls attention to the fact
that cities and large stretches of country often  lie between the
original fountain of poison and the point where the disease has
broken out, and that  these, although apparently more exposed
to the malarial influence on account of their proximity, are often
entirely exempt.  We may admit the agency of  the wind as a
carrier  of miasm  for a  short  distance;  but when it comes to
stretches  of many miles,  it is no longer to be taken into account.
   On the other hand, it is well  known that in malarious dis-
tricts the disease  increases materially  during hot,  dry,  still
months that  have been preceded by moisture, and  that  it  is
often greatly diminished as  soon as fresh, strong currents of air
cleanse the atmosphere.
   It is claimed  that the wind from certain directions,1 the east
wind in England and the sirocco in Italy,  have an influence favor-
able to the development of fevers.   According to Hirsch, Sal-
cagnoli and  several other  observers  are of  the  opinion  that
malarial  diseases  increase in extent and intensity, in Italy and
had come from non-malarial regions.   On the other hand, a very extensive epidemic
of the fever broke out in the village of Truchtlaching, about an hour distant, which
was itself entirely free from marsh or moorland.  Gessele accounts for this fact by the
strong breezes that blew over the peat-bog, and which reached the village,  which lay
in a valley to the  south-west, open only on the side toward the contagion.
   1 Moffat (Assoc. Med. Journ., Aug. 30th, 1856) found, as the result of meteorologi-
cal observations, extending over  a period  of five years, at Hawarden, that the widest
spread of the disease was coincident with a fall both of the barometer and of the ther-
mometer, and with the prevalence of  southerly and westerly winds, including all those
points of the compass from south-east to  south, and from south to north-west; also,
that the maximum mortality was coincident with a falling of the barometer, and with
prevailing northerly and easterly winds, ranging from north-west to north,  and from
north to south-east. 
ETIOLOGY.
573
Sicily, on  the appearance  of the  sirocco ; that  these  diseases
then  penetrate further inland,  and that at such times even
strong,  healthy men lose flesh and  appetite, and  suffer great
bodily and mental prostration.   Hirsch believes  that the influ-
ence of  the sirocco, and probably also of other winds  that are
supposed to have some special relation to malaria, depends on
thermo-atmospheric conditions or  agencies,  that  is, on  changes
in the degrees of heat and moisture present.
   The fact that, during the endemic prevalence of malaria, only
a certain number of persons are  attacked  by it, the  majority
remaining  exempt,  although subject to the same telluric and
climatic  influences, forces us to search for individual predispos-
ing  causes,  which  may account for  this  difference.  Some
writers,  such  as  Schwalbe,1 believe  that the reception of the
malarial poison into the system is not enough to  produce dis-
ease, but that  some vice of  constitution must exist, in addition,
in order to destroy the equipoise of  the  organism and  call into
activity the latent poison.   In evidence of this, those cases espe-
cially are  adduced in which persons who have lived in a malari-
ous region for some time, free from the disease, develop  the same
after removing to a distant and entirely non-malarious district.
   In view of all this,  let us consider, briefly, the influence of
the following conditions.
   No race or nationality enjoys immunity from malarial  affec
tions, and if  it has been determined that the negroes are less
liable than others to be attacked by them, both  in their own
homes and in other malarious regions, it must be because they
possess greater powers of  resistance to the noxious influences
which predispose to malarial diseases, or, in other words, because
they have  become inured to them.
   All  periods of life, from infancy to  old age,  are  liable to
attacks  of malaria.   But  the  forms  of disease seem  to vary
somewhat according to the age of the subject.  Children under
five are said to suffer most frequently with intermittent bowel-
troubles.8  During the period of youth, either continued fevers
   1 Schwalbe, Einige Bemerkungen iiber Malariafieber.  Archiv  f.  Heilkunde, 1867,
Heft 6, p. 567.
   ' Wunderlich, Handbuch der Pathologie  und Therapie.  Stuttgart, 1854.   Bd. II,
Abth. 1, p. 562. 
574
HERTZ.—MALARIAL DISEASES.
or pure  intermittents, quotidian or tertian,  are  most common.
In middle life, when most of the cases occur, all  forms are to be
met with ; while old  men, though less  liable to  infection, when
once attacked, often  suffer from the disease in its most  perni-
cious form.
   Men  are  more  subject to  malarial affections than women,
which may be due to their greater exposure to the chances of
infection.  A certain degree  of  immunity has also  been claimed
for pregnant and puerperal women.  Thus Quadratl claims that
during an epidemic at Prague he saw only two cases of intermit-
tent fever among  8,639 pregnant  and puerperal women.  The
observations  of  otlier reporters, however,  are  at variance  with
this.   According to Ritter,  the most that can  be claimed is an
apparent immunity on the part of pregnant women, who are less
liable  to contract the disease  during the last months  of preg-
nancy.
    The statistics of the Lying-in Hospital  at  this place  would
also argue against the existence  of any such immunity.*  Mala-
rial attacks are not rare during childbed  or while nursing the
infant, although under these circumstances  they are most likely
to  be  relapses of a disease existing before labor.  Some writers
maintain (Ritter) that during the puerperal period the rhythm of
the attacks is irregular and the apyrexia not well defined.
    Women are more likely to be the subjects of a masked inter-
mittent, especially showing  itself as neuralgia in the branches of
the trigeminus nerve.  Men, on  the other hand, are more liable
to  the severer forms of pernicious and remittent fever, at  least
this is true in Holland.  This is doubtless because the men,  from

   1 Oesterreich. med. Wochenschrift, 1841, July 31.
   3 I owe the collection and analysis of all cases at this institution to the kindness of
my friend and colleague, Prof. Lehmann, who has also communicated to me his experi-
ence in  this matter cfrurmg the more than twenty years of his active service within its
walls.   During the years 1850 to 1871, 8,686 cases of labor are on record, with 182
attacks of intermittent fever in different  individuals.  This is about 2-,L0- per cent.; but
it must be remembered that very light cases were omitted from the account.  With a
business of about 400 labors annually, the lowest proportion of malarial attacks was,
for 1862 and 1869, each year two, or one-half of one per cent.; the highest ratio was for
1857, which showed thirty cases to 332 pregnant women—nearly 10 per cent.  Forty-
five of the 182 noted above (2,^- per cent) had relapses during the puerperal period. 
ETIOLOGY.                       575
the nature of their work, laboring in the soil and the " polders,"
are exposed for a long time to the influence of the most concen-
trated poison.
   Varieties of constitution are not  to be ignored, as influencing
the liability to the disease.  Weak and ansemic persons are the
ones  most liable  to  be  attacked.   According  to Griesinger,
marked differences in the character of the disease may some-
times be  recognized, according  as it  occurs  in subjects of a
plethoric or of an ansemic constitution.
   All weakening  influences must be reckoned among the speci-
ally predisposing causes: such are  hunger, thirst, loss of sleep,
various bodily and mental exertions,  emotional disturbances,
fright, anger,  exhaustion, and fatigue, and all such unfavorable
incidental  occurrences  as sea-sickness,  menstruation,1  etc.  In-
creased moisture of the atmosphere, from any cause, has the same
effect, such, for instance, as may result from the frequent wash-
ing of floors,  especially in bedrooms,  sleeping  in  damp beds,
excursions by water, promenades  at morning and evening during
fogs,  sitting  out-doors after  nightfall,  especially during damp
weather, when the ground is wet after rains,  or  in  the vicinity
of bodies of water, whether they be standing or flowing.  Resi-
dence in cellars and on ground floors, or anywhere in the  imme-
diate vicinity  of the  soil,  is injurious, especially if such  apart-
ments are used as sleeping-rooms ; the same is true of the imme-
diate proximity of high  trees to dwelling-houses, inasmuch as
they  prevent  the  free ingress of  sunshine, keep the ground
damp and cold, and prevent  the purification of  the atmos-
phere.
   An outbreak of the disease is sometimes brought about in the
inhabitants of valleys where intermittent fever prevails,  by their
removal to a cool mountain region.  In fact, every sort of cooling
down, dry as well as moist, especially if the body has been par-
ticularly heated, may give rise to the  development  of  malarial
affections.  The same is  true  of  excessive solar heat,  of indi-
gestion, of inordinate eating and  drinking, and of the imbibing
of stale drinks or of swamp-water.
   1 Sebastian, loc. cit., p. 48, says, that women are usually attacked by the epidemic
fevers at the time of menstruation. 
576
HERTZ.—MALARIAL DISEASES
   The action of many of  the  injurious agencies  mentioned
above, as regards their influence in the development of malarial
disease, must be explained by their disturbing the equilibrium
of the body,  increasing debility, and thus diminishing the power
of resistance to the malarial poison.  Whether moisture of the
atmosphere,  and remaining in the open air after sundown,  have
any other effect than what is exercised by their cooling down the
body ; whether, as  some  assert,  the  malarial poison exists in
more condensed form in the midst of fog and  dew, and at a low
temperature  ; or whether the absence of the sun's rays modifies
the chemistry of the marsh miasm, are questions that  are at
present hard to decide. x
   Undoubtedly previous  paroxysms of intermittent  fever  con-
stitute the greatest predisposing cause for renewed  attacks of
the same ; whence we must  conclude that, after the first inva-
sion,  some changes  unknown to  us are wrought  in the  organ-
ism, which are capable, without any intermediate manifestations,
of  leading to a new outbreak of  the disease on the  slightest
provocation,  and which gradually disappear  if no new infec-
tion takes place.
   We may thus speak of a certain latency, or period of incuba-
tion of the poison, which exists, for a greater or less period, also
among new-comers in a malarious region, before the first attack of
true intermittent fever occurs.  Sometimes this latent condition
of the poison persists until  the individual has again removed
from the fever region.  Such individuals, as well as those who
have suffered from the fever in a malarious region, but have  been
free from it for some months, may, after a while, be attacked by
the disease again, while in a part of the  country entirely free
from fevers,  or even while living in high mountain  regions.2
   This  doctrine of the latency of the poison accounts for re-
   1 Plagge, Deutsche Klinik, 1858, No. 1.
   21 have demonstrated  the truth of this in my own person.  Although, during the
first years of my residence in Holland, I had suffered  much from malarial disease, at
one time having an eight-days' attack of continued fever, yet I had been free from it for
several months when I took up my abode in a part of Germany that was entirely free
from malaria, and  in which no case of intermittent fever had evier occurred.   After
about four weeks I was seized with an intermittent attack, which yielded to quinine,
but which recurred some weeks later, though in a milder form. 
ETIOLOGY.
577
lapses, on the supposition that they are merely a new develop-
ment and outbreak of the disease-germs that have been  slum-
bering within the  system and are  now awakened to life.   This
awakening may  depend  on various causes,  such  as  " taking
cold,1' a fit of  indigestion, changes of  temperature, etc.   Per-
sons who have but newly arrived  in a malarious region  resist
these influences less successfully than those who are acclimated,
and  in the tropics this is particularly true of light-haired, blue-
eyed Northerners, while  negroes and  those  of  mongrel  breed
endure  the climate better.1   Strangers  are more liable  to  suffer
both from  simple intermittent and from  remittent and perni-
cious fevers, while  natives  present rather  a state of chronic
sickliness, or succumb to the acuter forms of fever only during
more than  ordinarily active epidemics,  and even then are not so
violently attacked.  It appears,  therefore, that there is no such
thing as absolute acclimatization,  which  would enable the or-
ganism  to  offer successful and continued  resistance to the spe-
cific influences of  the climate, but only a  comparative  power of
resistance against the less virulent poison.   The degree of  accli-
matization  which  is  attained  after a  prolonged sojourn  in  a
malarious region amounts merely to an accommodation  of the
system to the prevailing evil influences,  and this is accomplished
by the foreigner's adapting himself, as  early  and as completely
as possible, to  the habits  of the country, as regards  diet and
dress.
   Malaria sometimes breaks loose from its endemic haunts and
shows itself  in places  where it has  seldom or  never  before
appeared.  It thus loses its  endemic character and sweeps over
considerable regions of country as an epidemic, or over vast sec-
tions of the globe as a pandemic.
   In the present state of our knowledge,  we  have no thorough
insight  into the conditions that govern the  periodical rise  of
epidemics.   If we  take into account the observations that have
been made  in sundry smaller, more  circumscribed epidemics that
have occurred in some fever-lands, we shall  find that they point to
certain  atmospheric conditions as a probable  cause.  In several
   1von Frantzius. Virchow's Archiv, Bd. 43, p. 328.
VOL. II.—37 
578
HERTZ.—MALARIAL DISEASES.
murderous epidemics  that ravaged Holland during the seven-
teenth and eighteenth  centuries,1 uncommonly great  and pro-
longed heat existed, as well as  unusual dryness of the air and
absence of wind, so that the waters dried up, and exhalation
from  the swamps was immensely increased.   In other countries,
too, a great increase of moisture, with very hot seasons follow-
ing it, has been the signal for epidemic outbreaks of the disease.
Among familiar instances of this are the epidemics of fever that
occurred after the  enormous  floods on the north-west coast of
Germany  in 1717,  which were followed by  two years of great
heat and dryness;  and after the  vast overflow of the  German
Ocean and the Baltic in 1825, which was  also followed by two
hot summers.
   In view  of what  has  been  said before,  it does not  seem
probable that currents  of air are capable of  carrying the poison
which is generated in the breeding-places  of epidemics  to a dis-
tance of any considerable number of miles.   We  believe rather
that malarial poison is, in the  majority of cases,  generated  on
the spot;  inasmuch as the conditions necessary for  the decom-
position of vegetable matter may be furnished in a  non-malarious
locality by alterations in the conditions of the soil, by overflows,
great solar  heat, etc.   It  need hardly be said that we do not
claim thus to fathom  all the causes that contribute to this end.
The annual variations which are  found to exist in  the frequency
and the severity  of endemic outbreaks may  also  be attributed
to similar  telluric and atmospheric influences.
   It is a still more difficult matter to account for those isolated
areas of malarial poison  which are often confined to a single
street, or to one side of a street,  or even to single houses, unless,
indeed, we attribute them to the above-mentioned telluric influ-
ences,  supposing them to arise  from subterranean swamps and
collections of water, the exhalations from which reach the sur-
face  through rifts in  the ground.  The sporadic  cases of inter-
mittent fever found occasionally in non-malarious regions may
undoubtedly often  be  attributed  to previous infection in  some
   1 The epidemic in  1669 is described by Sylvius de Le Bo'e, Praxeos medicce app.
Tract. X, § 63, 65, 67.  Guidon Francois, Dissert, medica de morbo epidemic.  Leidaa,
1671, and Kokcr, De morbo epidemico, 1719. 
ETIOLOGY.
579
fever  district.  It  ma}T also be remarked here that some parox-
ysms  of chills and fever may occur which are not intermittent in
character, but are more of a nervous nature, attacking persons of
a very sensitive organism, or  which may depend upon some
unrecognized organic disease.
   Malarial epidemics and pandemics, of which a  considerable
number have shown  themselves during  recent centuries, seem
to stand in some thus far inexplicable relation to epidemics of
otlier  diseases, especially  to  those  of  typhus fever,  cholera,
plague,  dysentery, and influenza, which have either  preceded
or immediately followed the march  of malaria.  The  first epi-
demic of this character,  which spread over the whole of Europe,
took  place in the  year  1558; it was preceded by  a widespread
influenza in 1557,  and followed by the ravages of  plague from
1559  to 1563.  The second malarial  pandemic,  which was  fol-
lowed by an extensive visitation of the plague, lasting for three
years, occurred in 1678 and  1G79.  The third appeared during
the years 1718 to 1722, and was succeeded by a general  outbreak
of typhoid fever.  After some smaller  epidemics which occurred
during the  last century in Germany, Holland,  and France,  but
not simultaneously in all of these countries, the fourth pandemic
flourished from 1807 to 1812, again following influenza, spreading
over  nearly the whole  earth, and being itself followed by an
epidemic of typhoid fever.  The great malarial epidemic before
the last was in 1824 to 1827, and the last in 1845 to 1848, each of
them  being the forerunner of another scourge, viz., the  typhoid
epidemic that prevailed  from 1820 to 1831, and the cholera which
invaded Europe at the beginning of the third and the end of the
fourth decade of this century.
   A  certain interchange between malaria and the diseases men-
tioned above may  also be traced in some of the smaller epidem-
ics.   Thus influenza and malaria seldom prevail simultaneously,
although  they often follow and would almost seem to exclude
one another.  On  the other hand, intermittent fever and dysen-
tery often occur side by side, both endemically and epidemically,
the former even being  complicated by the latter,  without  our
necessarily supposing that there is any relationship between the
two miasms.  Epidemics  and  endemics of intermittent  and 
 580               HERTZ.—MALARIAL DISEASES.

 typhus  fever  are not rarely to be met with at the same time, and
 in  the course of  my  professional life in  Holland I  frequently
 observed that, during the  extensive prevalence of intermittents,
 cases  of typhus fever,  some of which are always  to be found
 there, became more numerous.   The same  thing  does not hold
 true with regard  to typhoid fever, the epidemic  appearance  of
 wliich is not often simultaneous  with that of intermittent fever.
 I do not assert that there is a law of complete mutual exclusion,
 as to time and place, between these  two diseases,  but this much
 I can declare, from my own experience,  that in  Amsterdam,
 where all forms  of malarial fever are indigenous, typhoid fever is
 among the  greatest of  rarities.   The amiual  statistics  of 2,000
 cases of sickness, in the division of medical diseases, show barely
 one or two cases of typhoid fever.1  An entirely different relation
 exists between cholera  and malaria; for we find certain regions,
 as in India,  where the two flourish  side by side.   In the cholera
 epidemics of 1831 and 1848, on the other hand, intermittent fever
 disappeared, to  break out again on the cessation of the cholera,2
 or to remain  suppressed for years, in  some places where it  had
 previously been endemic.
   The question of  the  immunity from tuberculosis  due to the
 influence of  malaria, which has been claimed and fought over by
 various  writers  (Wells,3 Xasse, Heusinger, Boudin,4 et al.), has
 assumed an  entirely new aspect under the light of  recent investi-
gation.  (Buffalini,8 Ritter.6)   The most striking evidence in  this
   1 Similar reports are made by Stiefensnnd floe, cit.), with regard to the rarity of
typhoid fever in the malarial regions of the Rhine ; by Spengler (Casper's Wochenschrift
1848, Xo. 21), with regard to Rheingau, where typhoid fever increased on the diminu-
tion of the malarial fevers which had previously been endemic; and by Volz (Haeser's
Archiv. D7, p. 531), concerning the rarity of typhoid fever in malarious regions.
   2 Wunderlich (Handbuch der Pathologie und Therapie, n, 1 Abth., p. 591) has been
able to demonstrate this by the varying use of quinine before, during, and after the
cholera epidemics of 1831. 1837, and 1848.
   3 Transactions of           Society.  London, 1872. HI, p. 417.  Horn, Archiv,
1818, Bd. 2, p. 330.
   4 Traite de fievre intermit. 1S42.
   'Gaz. Toscan., 1847.
   6 RitUr claims (Virchow's Archiv, Bd. 41, p. 239) that miliary  tuberculosis exists
alongside of intermittent fever in all malariou* regions.  On the other hand, he asserts
that cheesy pneumonia, which derives its origin from solid foreign bodies suspended in 
                 RELATIONS WITH TUBERCULOSIS.             5S1

matter is  furnished in  Holland, as is shown by the reports of
Dutch and  Belgian  physicians (Nieuwenhuis.1  Schneevoogt/
Grooshans,' Schedel* and GouzeeB), as well as by the latest obser-
vations of Masse6 in Algiers.   According to my own experience.
tuberculosis and the phthisis resulting from cheesy pneumonia
are  very frequent  diseases in the fever districts of Holland, and
especially in Amsterdam, affecting not only the  lower classes but
also those in good circumstances.  These pulmonary  affections
are  often associated with repeated attacks of intermittent fever,
followed by the malarial cachexia.   The fact that  intermittent
fever also  occurs later in the history of  these affections (as was
observed ninety-nine times  in 3S1 phthisical patients by Schnee-
voogt), is not difficult of  demonstration, if we regard the heavy
chills and fever  which regularly  recur at a  given day and hour,
usually assuming the tertian or quotidian type.7  I must disagree
with the statement of Nieuwenhuis, that the course of phthisis in
Holland is not so rapid as in southern German}'; if  intermittent
fever is grafted on to the pulmonary affection,  the progress of
the  latter seems to be accelerated.  The many  conflicting views
that obtain  with  regard to  the existence or non-existence of
phthisis and tuberculosis in malarial regions show us something
of how we should regard the question of  an antagonism between
these diseases.  The non-existence of one or another  disease is to
be accounted for. not  by the presence of intermittent fever, but
by certain characteristics of the climate.  According  to Duchek,8

the air, which irritate the lungs mechanically and chemically, necessarily does not exist
in malarious regions,  as malaria is developed in the presence of abundant moisture and
of decomposing vegetable organisms, which are unfavorable to the development of pul-
monary tuberculosis.
   1 Topographie med. d'Amsterdam.  1817.
  2 Gaz. med.. 1845.  Xo. 32.
  3 Verslag over de inwendige Klinik, etc  Utrecht, 1847.
  4 Gaz. med., 1845. Xo. 32.
  6 Arch, de Beige, 1842. Juill.
  B Rec. de mem. de med. milit., 136S. Fevr., p. 124  Compare also the  bibliography
of Griesinger's Infectionskht.. p. 13, note.
  7 Ward. Lectures  on Intermittent Fever. Lancet, 1864, Oct. 16th, and  29th, saw
sailors, in the  marine hospital  under his charge, suffering at  the same time from
malarial fever and tuberculosis.
  5 Wiener Spitalszeitung, 1859. 
582              HERTZ.—MALARIAL DISEASES.
epidemics of intermittent fever are often preceded or followed by
the prevalence of bronchial catarrh, while pneumonia, rheuma-
tism, and scrofula are very frequent in malarial regions.
   In case of the extensive endemic spread of intermittent fever,
or during a true epidemic  of the same, other diseases catch its
typical feature, that is, the symptoms belonging to them assume
a  pretty  well-marked remission and  exacerbation, which can
easily  be controlled by  quinine.  Intermittent  fever  may also
simulate other diseases, inflammatory and non-inflammatory ; it
even sometimes localizes itself in. single organs, as will be shown
more clearly under the head of symptomatology.
   The different forms of malarial disease differ from one another
only in degree, being all dependent on one  and the  same poi-
son, subject to variations in quality and quantity.  They may
be arranged in a progressive scale, from the lightest to the most
severe, beginning with the quartan  intermittent, passing on to
the tertian, the masked intermittent,  and  the  double  tertian,
and thence to the remittent, the continued,  and the pernicious
fevers ; the different grades bearing  a pretty direct ratio to the
intensity of the poison.
   As a rule, the grades  of disease last mentioned belong to the
tropical and subtropical regions,  while the first, or lighter forms,
exist in temperate and cooler climates.  But this rule is by no
means  without exceptions.  Although the quartan intermittent is
one of  the greatest of rarities in tropical climates, yet the simple
tertian occurs often enough ; and again,  severe and pernicious
forms  of  the disease may be  developed in temperate and cool
climates.  From all of which it would appear that this matter
is  determined not by degrees of  latitude, but  by telluric and
atmospheric influences, as well as individual tendencies.  Unfa-
vorable conditions of the ground, moisture, and great heat,  favor
the production of malarial poison in the highest  degree.  When,
therefore, these conditions arise in temperate climates, as has been
the case in a number of epidemics, we  must not be surprised to
meet with the most  severe tropical forms of fever.  On the other
hand,  a cool season,  with favorable conditions of the  ground,
resulting in the production of but a  small  amount  of poison,
may lead to a mild form of the disease, even in the tropics. 
ETIOLOGY.
583
   The concentration of the poison, then, determines the severity
of the disease.  During the twelve years' epidemic in  the Jade
district, according to Wenzel, very hot summers were accom-
panied by severe forms of the malady, such as remittent and per-
nicious fevers.  The warmer months were characterized by those
attacks which  approached the  continued  type, viz.,  quotidian
intermittents;  the cooler  months presented those types which
show a longer interval, viz., the tertian and  quartan.  In study-
ing the malarial fevers of  the Caucasus, Papoff * found  the quar-
tan type to prevail from November to January, the tertian early
in the spring, passing,  towards  the  end of that season into the
quotidian, and giving way to the remittent and continued forms
during the summer; in autumn the tertian type  reappeared, to
be  followed, in turn, once more by the  quartan.   The same
changes  in  type may be observed in individual  epidemics, the
height of which, accompanied by the  severer forms,  is usually
reached during the summer, while their decadence, characterized
by milder attacks, takes place in the cooler months.  For, during
the  hot  season, the concentration and intensity of the poison
are heightened by the  far more rapid decomposition  of organic
substances, by  more active exhalation,  and by the greater capa-
city of the atmosphere for taking up these exhalations.
    The intensity and rapidity with  which the morbid processes
in the body are developed depend on the more or less powerful
as well as the more or less continuous influence or working of the
poison.  It is hardly necessary to remark that  these conditions,
as well as the very  form of the disease itself, are greatly influ-
enced by the peculiarities of  the patient, the fact of his having
previously had malarial fever, his powers of resistance to specific
injurious influences, general debility, antecedent  illness, organic
disease,  mental or bodily fatigue, unfavorable habits  of living,
etc.
    It appears that during the course of pernicious fever the par-
ticipation of certain organs in the processes of disease depends
partly on individual peculiarities (that is, the diminished powers
of resistance of one or another organ), and partly on the temper-
1 Med. Zeitung Russlands, 1857, No. 32 et seq. 
584
HERTZ. — MALARIAL DISEASES.
 ature and the time of year.  During the summer-time, when the
 temperature  is high, we may  observe a  marked tendency  to
 implication  of  the nervous system and  the digestive  organs,
 showing itself in diarrhoea, dysentery,  choleraic and  bilious
 attacks, as well as in typhoid forms, while during the winter the
 tendency is more to catarrhal and inflammatory affections of the
 respiratory apparatus.
   Up to the present  time but little is known of the nature of
 the malarial poison.  The older observers (Mascati, Yaucquelin,
 Fontenelle)  merely demonstrated the presence  of decomposing
 organic matter in marsh-exhalations, and the  theory has  long
 been  generally accepted that malarial poison is exclusively the
 result, in a gaseous form,  of  the decomposition of vegetable
 organisms (such  as  carbonic acid  gas, carburetted hydrogen,
 and, according to Schwalbe, carbonic oxysulphide).
   In opposition to this view stands the fact that some  marshy
 regions which present  all the conditions for the development of
 such  products  of decomposition (some  districts in Alabama,
 Peru, and elsewhere), some of which are even surrounded by the
 most notorious malarious regions, remain exempt from the dis-
 ease.   It is  no  rare  occurrence, where malaria  prevails, to find
 that the sort of weather which, according to this theory, should
 favor its  production (moisture, a  high  temperature,  etc.) is
 accompanied, not  by an increase, but by a diminution of the
 disease.  Furthermore, a number of extensive malarious districts
 are known which are entirely free from the influences attributed
 to marsh-lands, from surface-water, dampness, etc.  Among this
 number, according to Hirsch,1 may be reckoned the high pla-
 teaus of Castile, the plains of the Araxes, the  terrace lands of
 Persia,  the Tuscan marshes,  the Roman  Campagna, Calabria,
the table-lands of India, the island of Kutch, and the island
of Ceylon.
   The necessary conclusion from all this is, that the telluric and
atmospheric influences referred to  above are  not sufficient  to
account for the origin of malaria, and  that there must be  addi-
tional causes at work, thus far unknown to us.   Some think that
1 Hirsch, Handbuch, I, p. 54. 
ETIOLOGY.
585
they find  these causes in the exhalations from  living plants, in
the ethereal oils,1 inasmuch as the prevalence of the disease cor-
responds,  not with the decay, but with  the highest development
of the plants.  Others attribute the poison to subterranean exha-
lations, to the gaseous effluvia from a volcanic  soil; still others
deny any  specific cause, or, again, believe it to consist in an accu-
mulation  (Eisenmann) or modification  of the electricity of  the
earth and the  air.2  None of  these views  have as yet been estab-
lished  by sufficient proof;  and  even  the supposed microscopic
vegetable  organisms,  of low grade,  the  spores  and  algge,1 with
regard to  the influence of which in producing malaria  so  much
has been said, lack, as yet, all practical  confirmation.
    Another question,  on which opinions are very much divided,
   1  Vaughnn. Philadelphia Med. and Surg. Reporter, Dec. 16th, 1871.
   2  According to Armand (Traite de climatologie generale, Paris, 1873), the thermo-
and  electro-hygrometric phenomena  of the atmosphere,  by  their combined action,
their intensity and changeability, constitute the  remote causes of fever; while the
immediate causes lie in the changes produced in the entire organism, and especially in
the nervous system, under these influences.
   s  This  theory  has been brought  forward  again,  of  late, by various observers.
Thomas (Archiv f.  Heilkunde, VII, p.  225).   Scoda (Clinique Europeenne, 1859. Canst.
Jahresber., 1859. IV,  p. 73) believes them to be either living or in a state of decompo-
sition.  Baxa (Wien.  med. Wochenschr., I860, p.  78) saw low, cell-like structures in
drinking-water.  Balestra (Compt. rend., LXXI, Xo. 3, p. 235) discovered a species of
algao in the Pontine marshes.   Salisbury (Amer. Journ.  of Med. Sc, I860, Jan., p. 51)
found in his investigations in the valleys of the Ohio and Mississippi,  that the sputa
of the sick contained  small elongated cells, presenting themselves singly or in rows,
which he considered to be alga-cells of the species palmella.  These he also found and
collected on glass  plates set up  over marshy ground, and in  great quantities on the
clods of an upturned marshy  soil. According to  his observation, these alga-cells do
not rise over 100' above the level of the sea.  He was able to produce the most intense
attacks of intermittent fever by means of the fresh  clods, if allowed to place them
within  the open window of a sleeping-room in a house lying about 300' high.  The
attacks, in four persons, the subjects of two  experiments, followed in ten,  twelve,
and fourteen days, and were broken up by quinine.   Hannon (Journ. de Med. de Brux-
elles  18G6, 3Iai, p. 497; says that when he was devoting himself to the study of the
sweet-water alga?,  during their fructification, he was attacked with an intermittent
fever of six weeks' duration.  In opposition to Salisbury, Harkness states (Boston Med.
and Surg. Journal, 18G9, Jan. 14th) that he has found the  palmella spores in the snow
and at the summit of the highest Alps, and  claims  that they may very readily become
mixed with the saliva and the urine from without, at the same  time having nothing at
all to do with malaria. 
586
HERTZ.—MALARIAL  DISEASES.
is, in what way the poison enters the organism, and what  organ
is first and prominently attacked by it.   It appears as  if the
most natural way for the reception of the poison was through the
respiratory apparatus, and  yet some observations  indicate that
the same thing may take place through the intestinal tract.'
   The disease has  been observed to arise  from the use of foul
drinking-water; and yet it is a question worthy of  considera-
tion,  whether the use  of  such water  has  been  the direct  and
immediate cause, or whether,  with its  injurious, but not specific
ingredients, it has only served as an  occasion for the outbreak of
the disease, in a  person already infected with malaria, a view
which has, of late,  been especially advocated by Colin, and with
which my own experience leads me to coincide.
   The  doctrine  of the communicability  of intermittent fever
from man to man, as is taught by some, has little in its  favor,
and much against it.   The direct demonstration of this, with the
exclusion of all other  possibilities of infection, would be a diffi-
cult matter.2
   Some  believe in  the   communicability  of  malarial  fever
through the mother or wet-nurse to  an  infant  at the breast.
Boxa 3 declares,  that in Pola ninety  per  cent,  of the children
suckled by mothers or nurses with malarial fever,  were attacked
with the disease.
   1 Merieu de Saint  Gilles  (Influence  des miasmes marecageuses sur l'cconomie
animale.   Montpellier, 1829, April 9, und Canstatt's Jahresbericht, 18G5, IV, p.  65)
produced  trembling and  stupor in  three young  squirrels by the administration of
two spoonfuls of the "dew" or condensed vapor  collected from  over a pond.  His
father drank half a glass of this fluid, which immediately  produced  nausea and cardi-
algia.  In subsequent  experiments, in which the swallowing of the water was imme-
ately followed by the use  of quinine and opium, no such effects were produced.
   Boudin (Traite de fievres intermit.   Paris, 1842, p. 66) says, that of 120 soldiers
who returned from Bona to Marseilles  on the ship Argo, in the year  1834, 103 were
attacked with the  most  various forms of malarial fever, some of them pernicious,
because during the voyage they drank of the marsh-water that was taken on board
at Bona.   On the other hand, the sailors of the same ship, who had good water, and
780 men who were  embarked on two other vessels, remained well.   Those soldiers on
the Argo who were not attacked bought their drinking-water of the sailors.
   2 B'uchner (Aerztliches  Intelligenzblatt, 1860, Xo. 26) reports, that a  man travelling
from a malarious region slept with another man, and the latter was seized with malarial
fever.
  3 Wiener med. Wochenschrift, 1865, Xo. 42. 
PERIOD  OF INCUBATION".
587
   The tendency of domestic animals, in malarious regions, to be
attacked with the disease is much less  than that of men.   In
Holland, East  Friesland, and Westphalia,  there  seems to be
nothing of  this, but more of it is found  in  southerly latitudes.
Common intermittent fever,  usually of the tertian type, has been
observed in horses, cows, dogs, and hogs ; pernicious forms have
also been  seen (Rivolta mentions nine in  cattle), as well as
malarial cachexia, with a tumor of the  spleen, and spontaneous
rupture of  the tumor.

                         PATHOLOGY.

   Careful observation appears to show that the period of time
which intervenes between the introduction of the malarial poison,
or the infection of the system, and the outbreak of the disease,
in  other words,  the period of incubation,  may be of  variable
length.   It is commonly reckoned at from six to twenty days,
that is,  an  average of fourteen days ;  but exceptions to this  rule
are by no  means rare.   I have repeatedly satisfied myself  that
the disease may  appear immediately after the reception of the
injurious influence.  For this  purpose I have sat  down beside
marshy ditches wliich were  in process of drying,  selecting those
in particular that  were distinguished  by their putrid exhala-
tions.  As  soon as within half an hour I  would  experience a
slight disturbance of vision, ringing in the ears, dizziness, a feel-
ing of roughness and  burning in the throat,  nausea,  choking
sensations, and chilliness, and a few hours later an attack of
fever, which was usually light.
    Salisbury states  that when, in the pursuit of  his investiga-
tions, he passed over a stretch of marshy moorland, almost bare
of water, the soil of which was thrown up by the cattle that
grazed there, he uced to experience a peculiar  sensation of heat
and dryness in the fauces  and throat, extending down to the
bronchi, and accompanied by  a constant impulse to  hawk or
clear his throat.  On the other hand, the  period  of incubation
may very  easily  exceed, by a good deal, the time mentioned
above as being normal; some trustworthy observations to  this
effect having  been  made quite recently.  Blaxall reports four 
588              HERTZ.—MALARIAL DISEASES.

cases among the crew of a man-of-war that had spent five days in
the harbor of Port Louis.  Two of these were attacked,  with the
quotidian type, in twelve and fourteen days, two others, with
the tertian type, at the end, respectively, of forty-eight and one
hundred and  eighty-four  days  after embarkation.   Pfeiffer1
states, from his own observation, that among the Weimar troops
which were quartered near Flensburg, in August and September
of 1848, besides the  occurrence of a few cases of the disease on
the way home, an extensive  outbreak of intermittent fever took
place after an interval of nearly six months.  He also shows the
same state of things to have existed among the troops that were
quartered in  the casemates of Rastatt in 1866, and who did not
succumb to the disease until April, May, and June of the follow-
ing year.  Similar cases are mentioned by Braune.2  He was able
to obtain  information with regard to  the  subsequent history of
twelve of the bathers who were on the island of Borkum, belong-
ing to  East Friesland, in the autumn of 1868.   Eleven of  these
had intermittent fever,  two  suffering with it before leaving the
island, and afterwards having relapses, the remainder not being
attacked until the following spring and summer, at their homes,
in wholesome, and, for the most part,  elevated  localities.  To
this may be added the  communication of  Fiedler 3 concerning a
lady in Dresden who developed the  disease nine months  after
being at Borkum; and concerning five other persons, who had
been at the sea-baths of Norderney, and who developed malarial
fever after a period of latency of one, six, and ten months.

     General Course of the Disease.   Simple Intermittent.

   An attack of simple, benign intermittent fever is not seldom
preceded, in persons inhabiting a malarious region, by a prodro-
mal stage lasting from  six to  eight days,  or even longer, which
in itself shows  but little that is  characteristic, and justifies  no
conclusions as to the disease which is to follow.  The  symptoms
consist in general disturbances,  such as occur also in  other

             1 Jena'sche Zeitschr.,  Bd. IV, Heft 1.
             2 Archiv f. Heilkunde, 1870, XI, Jahrg., p. 68.
             3 Archiv f. Heilkunde, 1870, p. 425. 
            PHENOMENA  OF SIMPLE INTERMITTENT.         589

acute infectious  diseases, and often  suggest typhoid rather
than intermittent fever.   They may show various modifications.
The symptoms are often so insignificant that the patient is sub-
jected to no  disturbance in his  business, consisting  of  short
attacks of frontal  headache, darting pain in  the eyes,  slight
twitching of both eyelids, diminished  appetite, chilly, creeping
sensations over the body, a disposition to stretch and yawn, and
finally,  profuse sweating  at night.   Sometimes the first manifes-
tations  occur in a previously diseased organ ;  thus, persons with
weak digestion suffer first from pyrosis, with fulness and pres-
sure in  the epigastrium, giving rise to the suspicion perhaps of a
relapse  of their previous difficulty.   Generally, however, the pro-
dromal  symptoms are much more severe.   They consist of lassi-
tude, a  feeling of exhaustion, and  unwillingness to move  about
much, which is usually followed by copious sweats.  Combined
with this  is a feeling of depression and mental confusion, a dis-
taste for  mental or physical effort, frontal headache, dizziness,
vague, wandering pains, shooting pains in the  limbs, especially
in the calf of  the leg, and pain in the back.   Sleep is uneasy,
often disturbed, and accompanied by distressing dreams.  The
patient  feels a sensation of fulness and tension in the epigas-
trium, is obliged to draw  deep inspirations, complains of nausea,
and often actually vomits.  The taste is stale,  bitter, often metal-
lic, rarely acid ; the mouth and gums  are dry, the tongue and
teeth often covered with  a slimy coating,  and the former white
around  the edges and yellow in the centre.   At the same time
there is loss  of  appetite, repugnance to animal  food, a foul
breath,  constipation or diarrhoea, and considerable thirst.  The
patient  is very sensitive to changes  of temperature ; sensations of
heat and cold alternate in the body ; the skin is generally hot
and dry, the complexion pale and muddy, growing yellowish and
slightly icteric about the sixth to the eighth day.  The pulse is
regular, though small and frequent.  The urine is scanty,  dark-
colored, and turbid,  containing an abundance  of urea, and often
causing a burning  sensation on micturition.   Even as early as
this, the spleen is usually a little tender on pressure, or during a
deep  inspiration, and somewhat swollen.   The foregoing phe-
nomena usually assume remissions and  exacerbations in such 
590
HERTZ.—MALARIAL  DISEASES.
manner as to  become developed into true characteristic parox-
ysms of fever, with chill, fever, and sweat in due form, these
paroxysms gradually becoming divided from  one another  by
more distinct  intervals of apyrexia.  Or, when these symptoms
have  been maintained at about a  uniform grade for  several
days, a violent chill may  intervene, marking the beginning of the
actual attack.
   In other instances the prodromal  stage may be entirely lack-
ing, and the disease may  begin with a pronounced chill, wliich is
subsequently repeated at regular  intervals.  This  is especially
liable  to be the case with strangers, who have  moved  from a
region where  malaria is  unknown into one where it prevails, or
with persons who are attacked in a non-malarious region.
   The actual paroxysm of fever is characterized by three stages,
wliich are  generally easy to distinguish.   The first, the stage of
chill, begins by the patient feeling uncomfortable, wearj^, worn
out,  and sleepy, often yawning, stretching, and feeling like lying
down.  In addition  to this, he suffers from headache, dizziness,
dragging pains in the neck, back, loins, and extremities, as well
as a  subjective feeling of  cold ; a sensation of chilliness running
over  the surface of  the body, usually beginning  in the back or
loins, sometimes in the extremities, and spreading in every direc-
tion, this being at first relieved by intervals  of warmth.  These
gradually  disappear, and the  chill, which is very variable in
intensity, becomes constant;  in the  lighter cases  it may merely
amount to a hardly recognizable shudder, in the graver ones there
is trembling of the lips, chattering of the teeth, twitching of the
extremities, and a convulsive shuddering of the entire body ; at
the same  time the  pain in the head,  back,  and extremities
increases in intensity.
   The skin is dry, pale,  and shrunken ; the muscles of  the skin
are contracted, producing the peculiar condition known as goose-
flesh (cutis anserina). The face is pale, the eyes sunken, the nose
pointed, the lips and nails blue, the fingers white and cold, and
the skin on them wrinkled and numb, as  if dead, from deficient
arterial circulation.   The mouth is dry, the voice weak and indis-
tinct, and,  by  reason of  the  trembling of the lips, broken and
tremulous.  There  is  often nausea, retching,  and vomiting  of 
HOT  STAGE OF THE PAROXYSM.
591
recently ingested food.   Patients complain of  anxiety, palpita-
tion of the heart, constriction of the  chest, and thirst.   The
pulse is small  and frequent, hard, and often irregular.  Respi-
ration is short and rapid, often anxious and sighing; the eyes
are dull and tearful, the pupils dilated.  Fainting, delirium, or
stupor are very rare in simple intermittent fever; when they
occur, it  is  in very irritable  subjects.  The  urine is usually
increased in quantity, clear, and watery, of low specific gravity,
and without sediment.  The temperature of the remote portions
of the body is below the normal standard; in  the  mouth, arm-
pit, and rectum it is above.
   The duration of the stage of  chill is quite variable, ranging
from a scarcely noticeable period to from  a quarter of an hour
to one or  two hours, and  may even last  for from four  to six
hours.
   The  second, or  hot stage, also develops  itself gradually.
Trembling of the limbs becomes less, or, for a time, ceases alto-
gether,  to be renewed  now and then, either  spontaneously or
from slightly uncovering the body, moving the bed-clothes, etc.
Between times, sensations of heat are experienced; at first slight,
afterwards stronger, which travel from the extremities  to the
trunk, and here, according to the statements of the patients, feel
as  if they were working from within outwards.  At  last this
warmth permanently replaces the feeling of cold.  The trunk
becomes burning hot, the temperature  of  the  periphery  is ele-
vated, and the appearance of the patient changes.   His  face
becomes flushed, his eyes red  and fiery, the tip of his nose—for
a long time stone-cold—grows warm,  the livid color of the hands
and feet disappears, the skin of the body becomes smooth again,
its natural turgescence returning, and  the volume  of the limbs
is increased.   Herpetic  vesicles  sometimes appear  about the
mouth.  Pain  in  the  back, loins,  and extremities is  relieved,
while the upper portion of the abdomen and the regions of the
spleen and kidneys are often painful,  either spontaneously or on
pressure.   The head is in  a  glow,  the headache increases, the
impulse of the heart is augmented, the carotids throb, the pulse
rises in frequency, and is  full and hard.  Respiration is accel-
erated and noisy,  but the feeling of oppression is relieved.  The 
592
HERTZ.—MALARIAL  DISEASES.
 patient complains of a roaring in his ears, and of seeing sparks ;
 he is very restless and much excited, a condition which, in chil-
 dren or very irritable persons, may increase to delirium.  The
 lips, tongue, and  mouth  are dry and hot, there is urgent thirst,
 and the pupils are often dilated.   The urine, which is voided but
 sparingly, is red, and of high specific gravity.
   This stage usually lasts from  three  to four hours, sometimes
 only one or two, or  even less, and, in severe cases, six, eight, or
 twelve hours.
   After a longer or shorter time the third, or sweating stage,
 begins,  with a diminution of the burning heat.  The skin  in the
 axilla and groin, on  the forehead  and the breast, becomes gradu-
 ally moister, and  finally the entire body is covered, at first with
 a gentle perspiration, afterwards with a copious,  steaming, sour-
 smelling,  and sometimes sticky  sweat.   The skin at the same
 time grows  paler, the tongue and mouth moist, and  the thirst
 less  annoying.   The  patient's intellect  is undisturbed ; he feels
 relieved, as  to  his head; the unbearable  pains  diminish, and
 eventually disappear; the breathing becomes freer and easier,
 and  the general condition of the patient is  so improved that,
 during this stage, he often drops into a quiet sleep.   The pulse
 becomes softer, wave-like,  and regular,  and diminished  in fre-
 quency.   The temperature  rapidly  sinks to the  normal  point.
 Urine is passed freely; it is of high specific gravity, rich in solid
 ingredients, and throws down a brick-dust sediment of the urates.
   The  duration of  this stage is not easily determined, as  the
 transition to a  state of apyrexia is usually gradual, and  the
 patient feels  tolerably well even during the sweating stage.  As
 a rule,  this  stage materially exceeds  either  of  the  others  in
 length.
   The  entire paroxysm, with its  three  stages,  generally lasts
from four to twelve hours, more rarely from eighteen to twenty-
four, or even longer, thirty  to thirty-six.  The  latter scarcely
occurs in the ordinary fevers, but only in the malignant quartan
type, with scarcely recognizable periods of apyrexia.
   With the diminution in sweating the patient passes into a
state of apyrexia, and commonly falls into a quiet  sleep.  On
awaking,  in  the lighter  attacks and in short paroxysms,  he 
              IRREGULARITIES  OF THE PAROXYSM.          593

usually feels quite well, except a little weakness  and weariness,
and can ordinarily pursue his avocations with no great difficulty.
Often, however, especially in cases of more prolonged attacks,
the head is a good deal disturbed ; dizziness and certain gastric
disturbances remind the  individual  of the  ordeal  he  has just
passed through.   The tongue is then coated, the taste  metallic,
the appetite diminished, the epigastrium slightly distended and
full, the bowels irregular, and the skin  a little yellow;  there
is also  marked sensitiveness to  changes of temperature.  The
patient feels  tired  and exhausted, complains of pains  in  his
limbs, ringing in his ears, and dimness of  vision ; he is  very irri-
table, and  on moving about or making the least physical effort
he breaks into a sweat. The regions of the spleen and  liver are,
as a rule,  somewhat sensitive  on pressure ; the urine  is  some-
times dark, and throws down  a brick-dust  deposit. Now and
then the pulse may become  frequent and the nights disturbed.
Such imperfect intermissions, with a rapid pulse, occur after the
first attack of fever, and  may  be repeated in case the disease is
prolonged.  In this  way an intermittent fever may pass into one
which is only remittent.
   Certain deviations from  the  course  above  indicated may
occur, but they are  of such a nature  that while they modify the
features of the disease they do not alter  its essential character.
There are  cases,  usually of the  quotidian  or  tertian  type,  in
which, at a given hour of the day, a slight feeling of chilliness is
experienced, followed immediately by heat, glowing cheeks, diz-
ziness, headache,  and redness  of the eyes, lasting  for several
hours, and not succeeded by a  sweat; or  the chill lasts  for a few
minutes and the patient  thereupon begins to sweat profusely;
or, chill and heat  may both be absent, and the fever paroxysm
betray itself only by a periodical sweat, which usually  occurs at
night, and during which  the thermometer will indicate a rise of
temperature of from one to two degrees.   Such instances are not
rare among  people living in  a  malarious  region, who are but
slightly influenced by the poison, either from the latter being of
low intensity or from the individual possessing unusual powers
of resistance;  they also  occur as a species  of  relapse during
recovery from fever.
           VOL. II—38 
594              HERTZ.—MALARIAL  DISEASES.

   The  intensity of the several  stages may differ widely in  the
same individual in successive paroxysms, the stage which was
longest  in one paroxysm  being,  perhaps,  shortest in the  next.
Even in severe  cases of intermittent  fever, some stages  may be
very short or entirely lacking, and this has usually been regarded
as an unfavorable sign.  The disease may begin with the period
of heat, the missing chill being  replaced  by some  severe brain
symptom,  as  delirium,  sopor, or convulsions.1   Saint-Vel2 re-
ports instances, in  the intermittent fevers  of Saint-Pierre, Mar-
tinique, in which the chill was entirely absent, or consisted of a
slight shudder,  and the hot stage lasted from twelve to thirty-
six hours, often accompanied by the gravest symptoms, and fol-
lowed by but  slight sweating.  It is more  rare to find an inter-
mittent fever, of any considerable  gravity, presenting the chill
and heat without sweat, and still more  so  to find the sweating
stage alone present; at least, none of the latter cases have come
under my own observation.  It is claimed  that intervals  of sev-
eral hours sometimes occur between two stages of a paroxysm, as
between chill and  heat, or between heat and  sweat (febris dis-
secta).   According to  some  isolated reports  there may be a
reversal of the order in which the stages follow one another, as,
for instance, where the chill  follows the heat and sweat, or where
the  attack begins with heat, followed by a chill and ending in a
cold sweat.3   Griesinger,4 it is true, believes that most  of these
are  cases of quotidian fever,  in  which  the  night  sweat  of  one
paroxysm ceases shortly  before  the morning chill  of the next.
When successive paroxysms follow one  another so rapidly that
the  chill of the second occurs during the  sweating stage of the
first, we designate  it as febris subintrans, and it constitutes a
transition  stage to the remittent  and  subcontinued   type of
fevers,  in which  only remissions and exacerbations,  or  only
slight, hardly perceptible  fluctuations occur.
  1 Graves, Clin.  lee. soc. ad 1848,  I, p. 357.  Mold, Vereinszeitung, 1856, No. 4.
Giinsburg, Giinsburg's Zeitschrift, Bd. VII, Th. 5.
  2 Gazette hebdom., 1863, No. 13.
  3 Canstatt, Prager Vierteljahrschrift, 1850, p. 92.
  4 Inf ectionskrankheiten.  Virclww, Specielle Pathologie und Therapie. Bd. II, Abth.
2, Ed. I, p. 19; II, p. 23. 
                    TYPES OF INTERMITTENT.                595

    The  older physicians were perfectly familiar with the par-
 oxysms, recurring at regular intervals, which constitute the essen-
 tial characteristic of intermittent fever.  We divide the fever into
 types corresponding to the length of these intervals.   For the
 attacks  recur pretty regularly every twenty-four hours (inter-
 mittens  quotidiana), or every forty-eight hours (int. tertiana), or
 every seventy-two hours (int. quartana).
    The type which occurs most frequently, in temperate climates,
 is the tertian; it is  the one in which the paroxysms are most
 clearly  defined  and the intermission (apyrexia)  usually com-
 plete.
    With us  the quotidian, with  its  imperfect intermissions, is
 more rare, though it is  a form  under which the disease not infre-
 quently begins.   This, as well  as all short types approaching the
 continued form, is more commonly met with in the tropics, or in
 our climate during  a  hot  summer.  The quartan  type is still
 more rare,  and is said  not to exist at all in the tropics.   It is
 more likely to show itself  in the  course1 of a prolonged attack,
 and is accompanied  by certain irregularities in the course of the
 different stages, as well as  by  an  imperfect intermission, due to
 the existence of the malarial cachexia.
    Those types of fever which present a still longer interval
 between the  paroxysms are even  greater rarities; in fact, their
 existence is denied by many.  Such are  the fevers which occur
 every fifth,1 sixth, seventh,2 eighth,8 or even every thirtieth day.4
 In addition to the simple types of fever, double types may also
 occur.   Two  paroxysms may appear daily, at  different times of
 day, and of  different intensity (int.  quotidiana duplicata) ;  or
 one attack may appear daily, but of such  form that the par-
 oxysms of the first and  third, and those of the second and fourth
days correspond with one another as  to time of day and inten-
   ' Referred to, among older writers, by Marcellus Donatus, Tulpius, Joh. Matth. Mid-
ler,  Werlhoff, Stoll, and Kurt Sprengel.
  2 Thilenius, Nassauer Jahrbiicher, 1863, Heft 19 and 20, p. 221.
  3 Binz, Deutsche Klinik, 1867, No. 24, observed an octana in a boy six years old.
  4 Valerius,  of Taranta, described the thirty-day form as early as the end of the four-
teenth century.   Saint-Vel, Gaz. heb., 1863, No.  13,  after seeing quintan, sextan,
septan, and octan types, finally also found one recurring on the thirtieth day. 
596
HERTZ.—MALARIAL DISEASES.
sity, presenting not the quotidian type of fever, but two tertians
combined (int.  tertiana duplicata).  Some claim to have seen also
a double quartan, in which two fevers, recurring on the fourth
day, and distinguishable from one another by the time and the
intensity of their duration and symptoms, occurred in the same
individual on different days, being  so arranged that the first and
fourth day belonged  to  one fever, and  the second and fifth to
the other. This brings two successive fever days together and
leaves every  third day free.  To these may be added  one more
form, which  does not occur with  us, but wliich, according  to
Sprengel,1 prevails  occasionally as an epidemic in Italy, Hun-
gary, the West Indies, and Bengal, and which was alluded  to
by the oldest writers, although not correctly interpreted by them.
It is the  semitertian intermittent (the ^/jbtTptralo^), which consists
of a quotidian and a tertian combined, so that on the first and the
third days there are two attacks each, while on the second day
there is but one.
   The double types seldom appear as such primarily, but arise
in the course of  a  prolonged attack, or appear  in  the form  of
relapses.
   It often happens that the paroxysms,  while maintaining their
rhythm,  recur a few hours too soon (anticipating)—and this is
the more usual form—or too late (postponing).
   If the  anticipating  or postponing  process  is  frequently
repeated, it does alter the rhythm of the  fever.   Thus, by antici-
pating,  a quotidian is  changed  into a  remittent or  a subcon-
tinuous form, a tertian into a quotidian, and  a  quartan into a
tertian; the reverse  of  all this being accomplished by postpon-
ing.
   In other and rarer instances, especially among persons who
have  suffered repeatedly from  malarial disease,  it is liable  to
show the greatest irregularity and variety in the  occurrence and
character of  the paroxysms (intermittens erratica).   It is often
observed that after apparent  recovery from intermittent fever
a relapse will take place at the end of  a  week or a month, the
patient haying in the meantime felt well;  and this relapse will
i Handbuch der Pathologie.  Leipzig, 1807.  II Band, p. 156. 
                INTERMITTENTS IN  CHILDREN.              597

fall on a day which would have been a regular fever-day had the
original  attack  continued its rhythm.   This  holds  true with
regard to the tertian type, the paroxysms recurring on odd days,
and  still more with regard  to the  quartan type (Graves, Grie-
singer), which often  suddenly reappears on the  regular  day,
after an interval of a month.
   The attacks of tertian fever usually take place towards noon,
those of  the quotidian variety in the morning or at noon.  As a
rule, they fall into the hours between midnight  and noon, much
more seldom  into those  between noon  and  midnight.   Parox-
ysms beginning in the afternoon and evening hours are rare,1 and
were considered by the older writers as of ill omen, Peter Frank
believing that they were indicative of a hectic origin.
   In  children intermittent fever  shows some  deviations from
its ordinary course.   As  a. general rule, children suffer from the
quotidian type much more frequently  than from the  tertian
or quartan.   The  differences worthy  of mention  are  seen in
children in  the first two years  of  life,  after that there is but
little difference between children and adults.  The disease may
appear in infants  two months old.  At the beginning of the
attack the child becomes quiet and sleepy, the  skin grows cool,
pale, and wrinkled, the  lips and  nails  become blue,  the nose
pointed,  and  the eyes sunken;  at the same time the pulse is
small,  often scarcely to be counted, and the respiration short and
frequent. The  trembling and shaking, which is so well marked
in adults and older  children, is  altogether absent.  After  a
period of from  ten minutes to an  hour, the hot stage follows.
The  patient becomes restless  and excited, the face grows red and
glowing, the  pulse stronger  and  fuller (120 to 130), the carotids
and  fontanelles pulsate strongly,  and the skin is dry and  hot, as
are also the lips and tongue.   Sometimes children fall into a stu-
por,  or older ones may be  seized with convulsions. After an hour
to an hour and a half the  pulse falls, and a slight, generally par-
tial,  perspiration breaks out, this never being so  general and pro-
fuse  as in older children and adults.   Aside from these fully
developed paroxysms, it  is not uncommon to  find incomplete
  1 Mold (loc. cit.) observed them in  the epidemic of intermittent fever which pre-
vailed in Nicolai in the months from July to September, 1855. 
598
HERTZ.—MALARIAL DISEASES.
forms in  which the chill is lacking, and the hot stage with a
very light sweat constitutes the attack.  The intermissions are
rarely complete.   Children generally remain sleepy,  irritable,
and morose, with  the appetite poor, and the functions of the
bowels disturbed.
   The most severe cases may run their course under the guise
of eclampsia, with  extreme pallor and  coldness of the skin, un-
consciousness, dilated pupils, convulsions, etc., ending in death.
   It is claimed  that cases of intra-urine malarial disease have
been observed' in which the children were born with oedema of
the feet and an enlarged spleen ; it is said that they slept  much
and cried but little, that they were alternately cold  and hot,
pale and red, that they afterwards suffered again with oedema of
the face, hands,  and feet, and showed  all the evidences of the
malarial cachexia,  which, however,  yielded  to quinine, though
not without occasional relapses.


                      Masked Fevers.

   Masked malarial fevers—the name is not happily  chosen—
are those attacks of disease which, bearing the type of an ordi-
nary  intermittent,  present  symptoms foreign to this  malady;
which ordinarily run their course without fever, or are accom-
panied by partial febrile manifestations, as  slight chilliness or
heat,  with a rapid pulse or  sweating ; and which depend on an
affection of certain nerve-tracts.
   These  masked fevers usually assume the quotidian  type,
more rarely the tertian or quartan ;  still, other types may occur,
and it is not uncommon to find remissions in  the place of  inter-
missions.   They appear both by  day  and  by  night,  usually
during the morning hours, and are, as a rule, of about two
hours' duration.
   These fevers either appear as independent diseases, in persons
otherwise  well, or they are  associated with other forms of sick-
ness, or they may precede or follow ordinary intermittent fever,
or alternate with the latter in a regular manner, so, for  instance,
lBazin, Gaz. des hop., 1871, No. 72. 
                     MALARIAL NEURALGIA.                  599

 that the first day shall present a regular attack of fever  the
 second the masked form, the third again the regular paroxysm,
 and so  on,  assuming  the character of a double tertian.  The
 spleen is  seldom enlarged, and the urine does  not  often throw
 down a sediment.1  Masked intermittents usually  show them-
 selves as  typical neuralgias, in  the course of one or another
 nerve trunk, not to  be distinguished by any means from  other
 neuralgias.  The character of the pain is very various.   It may
 break forth suddenly in its fullest violence, or it  may, for several
 days,  give warnings of its approach and gradually increase in
 intensity.   According  to  Griesinger, masked malarial attacks
 are most frequent in  persons  over  forty  years of age, only
 exceptionally occurring in those under twenty.
    The  most common seat of these neuralgias is  in the course of
 the trigeminus nerve,  especially  in  the  frontal branch  of  the
 ophthalmic division.  They are liable to appear daily, during  the
 morning hours, and are often associated with throbbing pain in
 that side of the forehead,  swelling of the upper  lid, injection of
 the conjunctiva, and running at the nose, as well as nausea, retch-
 ing and vomiting, or, it may be,  with general malaise, chilliness,
 heat, and sweating, and an elevation of temperature demonstra-
 ble by the thermometer.   The earlier attacks usually last but a
 short  time, hardly half an hour, the later ones, which are very
 likely also  to be anticipating  in character,  continue for  two,
 three,  or four hours.  More rarely the neuralgia will be found
 located  in the superior or inferior  maxillary division  of  the tri-
 geminus, in the occipital  nerve, or  in  the   intercostal  nerves.
 Typical  neuralgia of the sciatic nerve, a not infrequent affection,
 is either intermittent or continued, though,  in  the  latter case,
 having decided remissions; it is sometimes accompanied by tonic
 or clonic spasms, is usually one-sided, occurring more frequently
 on  the  right  side  than  on  the  left, seldom  on  both sides.
 Schramm,2 in thirty-four cases of this affection, found it to exist
 twenty-two times on the  right  side, nine times  on the left, and
 three times on both sides.   The instances in which this disease is
  1 Griesinger,  loc. cit., edit.  II, p. 47, discovered albumen in  the urine in a case
of supra-orbital neuralgia.
  2 Aerztl. InteUigenzblatt, 1859, No. 34. 
C()0              HERTZ.—MALARIAL DISEASES.

found located  in the  crural, the peroneal, the  popliteal,  or the
tibial nerves, in the mammary gland or the thoracic organs, are
more rare.  When occurring in the  latter region it usually con-
sists  in attacks of pain, more or  less severe, about the region of
the heart, shooting down the left arm, accompanied  with violent
palpitation, anxiety,  a cramp-like  sense of constriction,  ster-
torous breathing, cold skin, pale or livid countenance and  lips,
fainting, and loss  of  consciousness.  Ward ' reports a typical
case of precordial neuralgia, or angina, wliich lasted for several
hours, and Bierbaum,2 a  similar one of neuralgia of the vagus
nerve, which began with  yawning  and stretching of the limbs,
and was followed by dyspnoea,  cough,  aphonia, and dizziness.
Neuralgia of  the  tongue occurs  but  seldom; cardialgia,  on
the  contrary, is common, especially in  Holland, and is often
ushered in by a slight chill.  It sometimes begins with a feeling
of  unpleasant oppression, which  gradually increases until it
amounts to the most  severe pain, frequently accompanied by a
scare* 4y perceptible pulse, cold extremities,  great anxiety, eruc-
tations, vomiting, and thirst.  These attacks are usually of the
anticipating quotidian type, sometimes tertian, and occasionally,
in the gravest  cases, remittent;  they are as likely to appear in
the evening or night as during the morning.   Typical colic, with
obstruction or diarrhoea,  is of very uncommon occurrence,  and
the  same is true of  neuralgia of  the pharynx,  the  scrotum, the
urethra (with occasional retention of urine), and of the uterus.
    Anaesthesia' along the course of various nerves is a condition
arising much less frequently than neuralgia.  Among the ills of
this  nature seldom met  with are  typical  cramps,  attacks of
sneezing, coughing (sometimes with sibilant rhonchi), hiccough,
eructations, tremors, and  convulsions in single  limbs, clonic and
tonic spasms in the course of the facial nerve, and hysteriform
and chorea-like seizures.   It is  claimed that typical cramp of
  1 Lancet, Oct., 1864.
  2 Deutsche Klinik, 1862.
  3 Schramm, loc.  cit.. saw a crural neuralgia, of seven days'  standing, disappear
under the use of leeches, but during the following night it appeared in the sciatic nerve
of the same side,  with the greatest violence, and the outer surface of the thigh presented
a condition of complete anaesthesia (anesthesia dolorosa typica). 
MASKED IXTERMITTEXTS.
601
the vessels supplying certain extremities has  been  observed.1
Now and then intermittent paralysis of  certain  limbs is met
with, hemiplegia, paraplegia, or  paralysis of the tongue and
organs of deglutition.2
   We may, furthermore,  meet  with cases of  typical mutism,
aphonia,  aphasia, macropia and micropia,3 amblyopia,  amauro-
sis,4 night-blindness, and deafness ;  as well as certain  psychical
disturbances,  delirium with hallucinations, maniacal attacks,
especially during the  puerperal state,   and typical  vigilance
(Trousseau), in which the patients, without any special evidences
of sickness, spend every second or third night, according  to the
type, entirely without sleep.
   Masked fevers may,  furthermore, manifest themselves in the
form  of  intermittent  hyperemia,   hemorrhage,  oedema,  and
inflammatory disturbances of nutrition.   Among  the  latter are
typical  coryza, bronchial catarrh, swelling of  the tonsils,  the
tongue,5 and the liver, the  latter being accompanied with severe
intermittent pain ; various skin affections,  as erysipelas, purpura,
roseola, urticaria, and pemphigus ;  hemorrhages from the nose,
the  lungs,  the  kidneys, the  uterus, the intestines,  and  the
stomach ; oedema of the lower  extremities or of the mamma,
ascites, and anasarca ; furthermore, typical iritis and ophthalmia
(which latter,  if prolonged, may lead to atrophy of the globe),
usually introduced  by fever, severe pain,  photophobia, and con-
traction of the pupil.
   Finally,  we must mention certain  still more rare distur-
   1 Raynaud, Canstatt's Jahresb., 1862, IV, p. 69.
   a Macario (Gaz. med. de Paris, 1857, No. 6) reports an interesting case of this kind,
in which a woman was seized, two days after her confinement, without any known cause,
with formication in the feet, which then spread to the thighs, the trunk, and the upper
extremities, these becoming,  at the same time, paralyzed and anesthetized, and her
tongue also becoming paralyzed.  These manifestations were repeated three times, after
the quotidian type, and were then arrested by quinine.
   8 Retsin, Moniteur des Hop., 1859, No. 29.  Canstatt. Jahresb., 1859, IV., p. 85.
   4 Richard, Gaz.  des Hop., 1863, No. 107.
   » Rxcardi (Moniteur des Hop., 1857, No. 21.  Canst., 1857, IV, p. 177) describes a
case of glossitis, in which severe pain in the tongue arose during the chill, this organ
becoming greatly swollen during the  fever, which swelling subsided after the sweat.
These appearances were shown again during a second attack, and quinine prevented a

third. 
602
HERTZ.—MALARIAL DISEASES.
bances, such as typical attacks of severe thirst, typical diarrhoea,
intermittent vomiting of the  contents of the stomach and small
intestines (typical merycismus),1 expulsion of gas by the mouth
or by the anus,2 which is  often introduced by a slight chill and
dizziness.  Intermittent jaundice also is sometimes encountered.
During the year 1859, Martin 3 saw a whole epidemic  of intermit-
tent jaundice,  of the tertian type, among  the French garrison of
Pavia.   On the fever days, the  spleen and liver being swollen,
the  discomfort was  greater,  and the urine, conjunctiva,  and
skin were darker colored than on the days that were fever-free,
and the disease was rapidly subdued by quinine.
   It was stated above, that masked fevers might  alternate with
regular intermittents, according  to  some definite  type; in the
same way the  different forms or localizations of  masked fever
may alternate  with one another, or with  the pernicious variety
of the disease.   I once had under treatment a lady who was suf-
fering  with quotidian supra-orbital  neuralgia,  and  who,  when
this was relieved, was attacked with  sciatica of the  same type.
Borelli4  reports a similar case.  A woman suffered from period-
ical  spasm  of  the neck of the bladder,  of  the double tertian
type ;  after this had been cured by a few  large doses  of quinine,
and she had  felt  perfectly  well for five or six days,  she  was
seized  with all the  symptoms of cholera,  and upon recovery
from that developed typical sciatica.

                     Pernicious Fevers.

  Malarial fever  may become dangerous to life  when it attacks
individuals who,  on account  of  their constitution  or their  age,
are unable  to  offer sufficient resistance to  its assaults ; or,  be-
cause the symptoms belonging to the disease are developed with
especial violence, and the  individual stages are of  too prolonged
  1 Clemens, Deutsche Klinik,  1857, No. 51.
  21 met with a case of this kind about a year ago,  in the person  of a man some
thirty-five years of age, who suffered daily, at a given hour, with general discomfort and
chilliness, accompanied by the most prodigious escape of wind by the anus lasting for
several hours, a condition which was cured by the use of quinine.
  3 Moniteur des sc. med., 1861, No 144.
  4 Canstatt's Jahresber., 1860, IV, p.  74. 
                    PERNICIOUS FEVERS.                  603

and  exhausting duration ; or,  again,  because the disease has
localized itself,  in a tln-eatening manner,  in some  important
organ.
   Simple, uncomplicated malarial  fever may end in death, in
the case of children, very old  people, or those who  have been
reduced  by previous disease, when the intervals  between the
febrile exacerbations are  short, the fever temperature is high,
and medical aid is not summoned in good time.  In weakly and
irritable  children eclampsia is very liable to supervene, the little
patients  lying unconscious, with dilated and sluggishly reacting
pupils,  frequent pulse,  and elevated temperature,  while the
muscles of the face,  the neck, and the extremities are subject to
violent convulsive twitchings.   Such  paroxysms may last for
several hours—as  long  as six—and be  repeated, with  greater
violence, on the next day or the third day.   With timely help,
the milder forms may recover, but paresis or paralysis  frequently
remains as the result.
   In aged people, and those  otherwise enfeebled, the  disease
sometimes becomes dangerous by exhausting the  last  remaining
powers of life, rapidly assuming the adynamic character.   But
occasionally the duration  and intensity of the individual parox-
ysms or stages may be so  considerable as to threaten  life by the
collapse  thereby induced,  growing weakness and  irregularity of
the pulse finally terminating in paralysis of the heart.
   The extreme  hyperemia and swelling of  the spleen, common
during the chill and  the hot  stage,  may lead to apoplexy of the
spleen, to rupture and the escape of blood into the peritoneum,
or to gangrene of the organ.   Some years ago I treated a wo-
man in my clinic who  had  for a  long  time  suffered with the
most violent intermittent  fever.  At the autopsy of her case, we
found the spleen covered  with a greatly thickened capsule,  and
the organ itself  the  seat  of an  extravasation of  blood  half as
large  as  a man's fist, which had led  to  suppuration, perfora-
tion, and fatal peritonitis.
   Those fevers which are benign in form,  and only  terminate
unfavorably on account  of peculiar  circumstances, often depen-
dent on the individual attacked,  are sometimes  reckoned as per-
nicious fevers, although pernicious  fevers,  in the proper sense 
604
HERTZ.—MALARIAL DISEASES.
 of the term, are only such as are characterized by special, dan-
 gerous, local affections in important organs (febres intermittentes
 perniciose, sen comitate).   These local affections, which usually
 assume the intermittent type, but wliich may also appear irregu-
 larly and entirely mask the malarial fever, are liable to simulate
 a good many other diseases, and thus to obscure the diagnosis.
   It is held by some that under such circumstances we have to
 deal with two  distinct diseases, viz., an organic  disease and an
 accidentally coincident intermittent fever, or vice versa.   There
 is, however, no doubt that the former is developed under the
 influence of the malaria  poison, and  is to be considered merely
 as a  peculiar localization of the disease, one of the best  argu-
 ments in support of which lies in the favorable results of quinine
 treatment.
   Pernicious malarial fever  not infrequently  appears in  the
 form  of an epidemic, though sporadic cases of  it  may be found
 in the somewhat more intense epidemics of ordinary  intermit-
 tent.  In some malarious regions, as in Holland and in Hungary,
 as well  as  in the warmer climates of Italy, northern Africa, and
 the tropics, especially in the  East and West Indies, and  west-
 ern Africa, numerous instances of the disease may be observed,
 without any epidemic influence.
   The prodromata of pernicious fever, when there are  any, are
 generally not to be distinguished from those of simple intermit-
 tent, and it is  but seldom that the  dangerous paroxysms  are
 preceded by special  symptoms, such as severe headache,  dizzi-
 ness, great drowsiness, convulsive twitchings, or grave intestinal
 disturbances.   The pernicious  symptoms rarely accompany the
 first attack, usually appearing  with the second or third parox-
 ysm,  or after  several paroxysms of a simple character  have
 supervened.  Thus, in the quotidian type the pernicious attack
 is usually after the second to the fifth days ; in the tertian  type,
 often  later yet,  sometimes not  till the end of two or three weeks.
 The simple forms either gradually pass into the pernicious by a
 progressive aggravation of their symptoms ; or a simple attack,
of not unusual length and severity, may suddenly be  followed
by a very pernicious one, this seldom proving fatal the first time,
but only on being repeated for the second or third time. 
PERNICIOUS  FEVERS.
605
   The paroxysms  of pernicious fever are usually of  the same
duration as those of a simple  character; sometimes, however,
they are longer,  lasting for twenty-four hours or more.   The
separate stages of chill, heat, and sweating may be more or less
well marked, or  they may be lacking in  part or in whole,  and
may be followed  by complete or incomplete intermissions, which
are often very brief and hardly perceptible.   They  sometimes
assume the quotidian, at other  times the tertian type, very sel-
dom the quartan, or one having  a longer interval.
   Pernicious  fever occasionally passes  back  into  the simple
intermittent form again; when treated early it is also liable to
show evidences of the former affection on  the regular fever-days.
   The form and the local affections of pernicious fever appear
sometimes to depend on external or individual causes.  During
the hot  season of the year disturbances  of the nervous system
and of the digestive apparatus  are most common,  during  the
cooler  season, those of the respiratory organs.   Present or pre-
vious disease of certain organs, or special influences brought to
bear upon them, may determine the localization of the symp-
toms.  I have  seen this produced, as regards the brain, by inju-
ries of 'the skull, through a  fall or a blow,  or after  unusual
exposure of  the  head to the sun's rays, or after emotional  dis-
turbances, or finally, after the excessive use of spirituous drinks.
An epidemic influence seems  sometimes to be an element in the
matter, inasmuch as all the fevers of  a given  epidemic present
the same or similar characteristics.
  In general, the  following forms of pernicious intermittent may
be distinguished.
   The  one most  frequently observed is accompanied with severe
symptoms of disturbance of the nervous system, producing pro-
longed attacks, very irregular in then course, and terminating in
a tedious convalescence.   One of the most common forms is the
comatose, which has also  been designated as  intermittens apo-
plectica.   This seldom shows  itself in  persons  after simple
intermittent fever without complications ;  as a rule, the last ordi-
nary attack and  the intermission following it show some  not
unimportant  signs  of impending ill.  Excessive headache and
dizziness are  liable  to exist, as  well as disturbances of speech, 
606
HERTZ.—MALARIAL DISEASES.
 apathy, and extreme drowsiness, which tend  to  increase.  The
 expression of  countenance, at the same time, becomes stupid,
 and  the features relaxed;  answers are given slowly, briefly, im-
 perfectly, and finally not at all.  After the chilly stage, which is
 sometimes accompanied by convulsions, the patient, during the
 fever which  ensues, falls into a state of sopor, unconsciousness,
 and  coma.   He lies there with a hot, flushed face ; eyes closed ;
 pupils wide and immovable ; the skin hot, dry, and often yellow-
 ish ;  the tongue and mouth  also  dry, and  often covered with a
 fuliginous coat; the breathing rapid and stertorous ; the pulse
 sometimes fast and sometimes slow, full or small;  the body gen-
 erally insensible, and the limbs fully relaxed.  The patient may
 remain in this condition for ten,  twelve, or twenty-four  hours,
 until he comes to himself in the midst of a profuse sweat, weary,
 worn out, confused, and complaining of  headache and dizziness,
 all of which disappear  after a while  under appropriate  treat-
 ment.  Sometimes a certain impediment in speech remains for a
 time, or even permanently—a stuttering, a  certain obtuseness—
 paresis in  some one of the limbs, more rarely muscular contrac-
 tion ;  or  the comatose condition  may last without  change for
 several days, the  heart's power  sink more and more, tire pulse
 grow weaker and  irregular, and the patient die, at last, in such
 an attack.  Even in case of a favorable issue, the prospect becomes
 worse with each successive paroxysm, and aid should therefore
 be furnished promptly.  The disease may also assume a different
 form, the  patient,  during the cold stage, falling into a succession
 of fainting fits lasting for about a quarter of an  hour, and accom-
 panied by a small,  frequent pulse (febris  intermittens synco-
 palis).  Sometimes the first attack of this nature proves fatal,
 but the patient may recover from it, and, after a  short stage of
 heat  and  of  sweating, may fall into a refreshing sleep, free from
 fever.  Usually, even if the first attack does terminate favorably,
 the patient succumbs to one of the succeeding ones.
   Under  this  form of  pernicious intermittent must  also be
classed those cases of apparent death, which may last from half
an hour to four hours.  Persons  subject to such attacks may
remain entirely conscious, seeing  and hearing everything that
occurs or  is said  around them, but unable to move or to utter a 
PERNICIOUS  FEVERS.
607
sound;  or  they  may  be  entirely  unconscious,  respiration
arrested, pulse and heart-beat not to be recognized, and even the
sharpest irritants applied to the body calling forth no signs of
life until, at the beginning of the sweating stage,  the patient
comes  to himself, and  the various organs again slowly manifest
their activity. Trousseau reports the case of a man who had had
fainting  fits  on two occasions in Algiers, and in a subsequent
attack fell into  this condition of simulated death.  It was not
until he had  been carried into the post-mortem room that evi-
dences  of  life were observed about  him, whereupon  he was
returned to his bed, and recovered under quinine treatment.
   A still  more uncommon form of pernicious  intermittent is
that which shows great cerebral disturbance with  delirium.
This form,  too, seldom appears  entirely unannounced,  but is
introduced by severe headache with dizziness, seething and roar-
ing in  the head, rushing and ringing sounds in the ears, restless-
ness and vigilance. The delirium varies from that of the lightest
grade  to the  most violent maniacal attacks, with wild screams,
curses, and blows,  and hallucinations of sight, hearing, and touch.
The face is flushed, hot, and streaming with perspiration, or,  in
reduced and  anemic  persons, pale and sunken.  The  eye is
glazed,  the pupil  dilated, the carotids beat violently, and the
skin of the entire body  is hot and dry.  This  condition lasts, at
the outside, for a  few hours.   The patient may die suddenly of
collapse during the attack, or, on the gradual lowering of the
excitement, may fall into a deep coma from wliich he never wakes.
In favorable cases the  delirium  becomes gradually  milder, pro-
fuse perspiration  follows, and the patient falls into a prolonged
sleep, from which he awakes quiet, though still very weary, with
headache and dizziness, but  without the slightest consciousness
of what has taken place.  In this form of the disease, too, a repe-
tition of the attacks is in the highest degree dangerous.
    Severe  nervous symptoms,  in pernicious intermittent,  may
show themselves in other ways, too, giving evidence, apparently,
of a simultaneous affection of the brain and spinal  cord.  Such
are clonic and tonic forms  of spasm, which have even a more
unfavorable prognosis  than the varieties we have hitherto con-
sidered, and  which, according to their special  manifestations, 
608              HERTZ.—MALARIAL DISEASES.

are classed as febris intermittens  eclamptic^ epileptica, tetan-
ica, and hydrophobica.
   The  eclamptic form  is found  mostly among children  and
puerperal women, and often begins, as  does the  epileptic form,
with headache,  lassitude, restless nights, and not seldom with
delirium, to  which the  convulsions are then suddenly added,
often beginning with a piercing yell, followed by complete loss of
consciousness and  sensibility,  with  dilated  and immovable
pupils.  Tetanic spasms,  undoubtedly the most pernicious variety
of the disease, and known to the ancients  under the name of
katochus, are comparatively rare.   They  sometimes begin with
weakness in  the legs  and convulsions of the extremities, or with
trismus,  and are not  infrequently accompanied with delirium.
The patient  lies unconscious  and insensible, with a  red coun-
tenance, and frothing at  the mouth, an irregular pulse, the hands
clenched, the jaws  set, the neck stiff, and the body bent either
forward  or backward.  Sometimes opisthotonos  and empros-
thotonos alternate, pleurosthotonos being of less  frequent occur-
rence.
   Still another form of  the disorder has been found sometimes,
generally amongst  women, and causing serious psychical dis-
turbances, which has  been designated as intermittens  hydropho-
bica.
   It manifests itself  as violent maniacal delirium, with a  fre-
quent  pulse, red, glowing face,  and clonic  spasms of the mus-
cles of deglutition  on drinking, or even at the  sight  of  water;
these spasms then pass to the  muscles of the face,  the eyes, and
the neck, and finally  to those  of the entire body,  a disposition to
bite being at the same time  developed.  These  attacks usually
last some hours, passing gradually into a  state of  sopor, and
may be repeated several times, according to some regular type.1
    Aside from  these  severe  nervous disturbances, intermittent
fever may assume a pernicious  character  by  virtue of other
alarming symptoms.   Under this head  comes the choleraic form
of the  malady,  which is of  quite  frequent occurrence, and in
  1 Waton, Gaz. med. de Lyon, 1857, No.  6.  Canstatt's Jahresber., 1857, IV,  p.
178, describes two such cases. 
ALGID INTERMITTENT.
609
which burning thirst, severe vomiting of yellowish matter, and
greenish, diarrhoeal passages appear during the continuance of
the  fever,—the  passages from the bowels becoming more and
more watery, and sometimes  resembling bloody water.   Subse-
quently, just as in real cholera, general oppression and the most
tormenting precordial distress are felt;  cramps in the calves of
the legs, coldness and a livid appearance of the skin follow, with
a small, hardly perceptible pulse, sunken eyes, and a true Hip-
pocratic countenance.  Convulsions are not infrequent.  Death
supervenes with all the evidences of asphyxia.  Another variety
that bears a striking resemblance to the foregoing is that known
as algid intermittent, characterized by a coldness of the body
like that of marble, while the  temperature in the mouth is from
86° to 88° Fahr.,  and  that in the axilla 84°.   The attack begins
with the usual chill, which is  not of  abnormal severity or dura-
tion.   It is not until during  or after  the hot  stage that  the
patient grows  cold,  while  at  the  same time  he complains  of
burning heat within, and of thirst;  the skin turns pale and livid,
is stiff  and covered with a cold sweat, the pupils are dilated,
the eyes expressionless,  the lips blanched and dry,  the tongue
smooth, pale, and soft, and the region of the stomach sensitive.
Muco-bilious vomiting is liable to occur, with occasional green-
ish-yellow stools, though both of these  may be absent, and  are
of subordinate importance.  The urine is scanty, dark-colored,
turbid,  of  high  specific gravity, and  free from albumen;  the
pulse is irregular, often much retarded, as slow as forty in a min-
ute, small and thready ; the respiration is shallow, as  slow as ten
in a minute ; the voice feeble, hoarse, and  broken.  Conscious-
ness is  preserved intact, though the patient is  apathetic,  and
there is nothing  in his condition to wrest from him any outcry
or complaint.
   This form of pernicious malarial fever is  usually confined to
warm countries, and is, as a rule, preceded by some paroxysms
of simple intermittent.  Even in these simple paroxysms, how-
ever,  according to Rigler,1 there  is an  unusual prostration,
reaction is imperfect, and the coldness of the face and extremities
       1 Wiener Wochenschrift, 1858, No. 18.
VOL. H.—39 
610              HERTZ.—MALARIAL DISEASES.

during the paroxysm is striking.  It is said that in exceptional
cases these attacks may terminate in spontaneous recovery ;
usually, however, death takes place, either in the first attack,
or, if they are repeated, in the second to the fourth.  Recovery
follows  through  a  reaction, like that from cholera; it is not
unusual, either, to find a typhoid condition supervene, like that
after cholera.   Convalescence is said to be slow,  accompanied
with headaches, dizziness, wakefulness,  irritability of temper,
and  partial loss  of memory.   In case of  death, the patient
usually maintains his  consciousness to the very last; while the
pulse grows smaller, slower, and more irregular, until it entirely
disappears, and the chest expands more and more feebly, until,
at last, the heart and respiration come to a complete stand-still.
   In connection with  the preceding, we  may consider another
form but little  known,  and designated  as febris perniciosa
diaphoretica, in which a very colliquative and  continuous sweat
appears at the end  of  the stages of chill and  heat, lasting  dur-
ing the succeeding intermission, and producing great coldness of
the surface.  The skin assumes a waxen  hue, the lips and the
buccal mucous membrane grow pale, insatiable thirst and  great
prostration supervene, the heart's action becomes feebler, respira-
tion  more labored, and the patient dies.
   What  is known as febris perniciosa cardialgica is accom-
panied with severe burning, darting,  contracting pains in the
region of the  stomach, during the stage  of chill, with nausea,
retching, and  vomiting; great anxiety and restlessness; a red,
dry tongue ; the skin being at first cold, afterwards hot and dry.
This form, it is said, after passing through  the stage of sweating,
usually ends in recovery ;  still, some claim that the latter parox-
ysms, if  there are such, may terminate fatally.   In febris per-
niciosa dysenterica, a  localization of the malarial disease in the
intestinal canal, colic and tenesmus, as a rule, appear suddenly
during the febrile attack, with very copious dejections, first of a
serous character, afterwards  consisting of  blood  and mucus, or
of pure blood; these passages cease after the attack is passed, to
reappear again during  a subsequent paroxysm.   Such attacks,
which may also sometimes be associated with cerebral symptoms
(Bierbaum), present themselves in the quotidian or tertian  type, 
           PULMONARY PERNICIOUS  INTERMITTENTS.        611

and  during the intermission the  dejections are bloodless and
normal.
   It sometimes happens that serious hemorrhage from the stom-
ach or bowels takes place during one or another stage of a parox-
ysm, endangering the life of the patient, or leading to deep faint-
ing fits.  Cases of typical gastritis have also been  observed, in
which, during the hot stage, violent vomiting resulted in the rejec-
tion  of a brownish or bloody fluid, while at the  same time there
were copious watery passages  from the bowels,  and the  abdo-
men was distended and very painful.   Waton 1 saw one case in
which the  symptoms  of peritonitis were developed at  seven
o'clock in the evening ;—intense pain in the abdomen, vomiting,
a haggard countenance, and a small, compressible pulse.
   Aside from  the cases  in which a pre-existing bronchitis,
pneumonia, or  pleurisy is aggravated in its symptoms or  modi-
fied in its course by an intercurrent malarial fever, it also appears
possible  for such  a fever  to localize itself in the bronchial
tubes, the lungs, or the pleura,  and there to call forth  mani-
festations in no degree inferior  to those of the genuine dis-
eases  of these  organs.   We  may  thus  meet with a  sudden
outbreak of hyperemia of the bronchi, in which the patient,
with  livid  countenance and  distended  jugular veins, suffers
from the most  intense anxiety and constriction of the chest.
Or, in persons  predisposed  thereto, especially those  who suf-
fer from frequent  congestions of the lungs, or give evidences
of scurvy, the  most violent pulmonary hemorrhages may ensue,
wliich, if often  repeated, reduce  the vital powers to the utmost,
and  may result in death.   More interesting than these, how-
ever, are the cases of  intermittens perniciosa pneumonica and
pleuritica.   During the chill  and  the hot stage, the  patients
are seized with  dyspnoea, they cough much, without expectora-
tion, and complain of  the most violent  pain in the breast.  The
pulse  soon  becomes full, rust-colored sputa  appear,  dulness
on percussion and increased vocal fremitus are  manifest,  while
auscultation reveals, at first crepitant rhonchi,  then bronchial
breathing and  bronchophony.   During the sweating stage a
1 Gaz. med. de Lyon, 1857, No. 6.—Canstatt's Jahresb., 1857, IV, p. 177. 
612
HERTZ.—MALARIAL  DISEASES.
decided remission  of  the fever takes place, as well as  an abate-
ment of  the symptoms,  subjective  and  objective,  wliich  may
almost entirely  disappear during  the  intermission  that  fol-
lows.   In case of  a renewed paroxysm, however, of the quoti-
dian or tertian type, these symptoms will recur.   The infiltration
will now increase somewhat in extent, and remain stationary dur-
ing the intermissions.  Griesinger compares the filling up of the
lung that takes place under the paroxysms of malarial fever to
the enlargements of the spleen, which at first  recede,  during the
intervals of the fever, but afterwards remain constant.  The lower
lobe of the left  lung appears to  be the one generally involved.1
If timely recourse to treatment  by quinine  is  neglected, these
cases are apt  to end fatally at about  the fourth or sixth par-
oxysm.

   Some years ago I  had the opportunity of  observing a  case of intermittens per-
niciosa pleuritica, which is even more rare than the pneumonic form.  The subject
was a very powerful man, thirty-eight years of  age, who was seized, about two
o'clock at night, with slight chilliness, very severe pain in the left side  of the chest,
and a dry cough.  Towards eight in the morning, while the  symptoms were all
present in the highest  degree,  I discovered a distinct, rough, friction sound, the
temperature  being moderately elevated and the skin hot.  Wet cups and an opiate
were ordered, and I was not a little surprised the next morning to find the man
entirely free from pain  and from all  tendency to cough, and nothing  wrong to be
discovered on auscultation.  At twelve o'clock that night, however, the attack was
repeated.  At nine in the morning I found the same symptoms as two days before,
although in greater intensity, and the friction sound was not only more plain but
more widely extended.  As I found  the patient, at 4  p.m., bathed in  perspiration.
almost free  from  fever and from pain, and as  I found him well again the next
morning, I ordered a few large doses of quinine, whereby the disease was cured
without another attack.

    It remains for us to notice the icteric form of malarial fever.
This is usually developed from  a simple  intermittent, and pre-
vails endemically in certain localities,  as on the island of Mada-
gascar2 and at Nosse Be.3  It often seems to give certain warn-
ings of its approach, twelve to twenty-four hours in advance, such
   1 A case recently occurred in my clinic, in  which the lower portion of the right
upper lobe was the part involved.
   2 Daulle, Gaz. des Hop., 1858,  No. 2.
   s Faymoreau, Canstatt's Jahresber., 1860, IV, p. 78. 
PERNICIOUS  FEVER WITH GANGRENE.
613
as headache, lassitude, nausea, chilliness, and sometimes a slight
icteric coloring of the conjunctiva or of the ale of the nose.  The
actual attack always begins with a violent, long-continued chill,
during which the icteric color either first begins, or, if already
present, grows more intense, spreads over the  entire body, and
soon  assumes  a saffron or olive  hue.  Intense nausea is now
felt, with  copious vomiting  of bile, and often bilious diarrhoea.
Thirst is urgent; the tongue is coated white and yellow, and the
patient  suffers with excruciating  headache, pain in the  spleen
and over the liver, and a feeling  of numbness in the limbs.  The
pulse is small, frequent, and hard;  the urine is of a deep red
color, resembling porter or Malaga wine, though free from blood,
and owing its color to the abundant presence of  biliary coloring
matter; it is quite scanty,  and  the effort to void it causes dis-
tressing tenesmus.   During the hot stage the pulse grows  fuller
and more frequent, the respiration anxious and noisy, the skin
hot, and the thirst more tormenting. Bilious diarrhoea and vomit-
ing continue, and the urine grows still more scanty.  During this
stage, which lasts from three to five hours, death often occurs;
otherwise the  disease passes  on to the third  stage, or that of
sweating.  The skin is now  bathed  in a profuse perspiration,
which, like the urine, stains the linen yellow, and the symptoms
gradually improve.   During  the intermission the head is gene-
rally clear and the intelligence  perfect; the  icterus persists,
although the urine regains its natural color.  With proper treat-
ment recovery may follow, though an unfavorable termination
is, even then, frequent.  In that case the intermissions are not
complete, the disease showing a tendency to assume the remittent
or continued  type.   All the symptoms are aggravated in the
subsequent attacks, vomiting  continues without interruption, the
bowels  and bladder are emptied involuntarily, the patient gradu-
ally  sinks into coma, and  death usually follows in the  second
or third paroxysm—seldom later.
    Malarial fever may have a pernicious character given to  it  by
the occurrence of gangrene in some portion of the body.  Scholz
reports one case of death in a man, from gangrene of the leg, and
one in  a  woman, from gangrene of the genitals.  Poumier saw
gangrene of one leg developed in a woman who had  suffered four 
614
HERTZ.—MALARIAL DISEASES.
or five days before from  intermittent fever; and Lafaye reports
the case of a girl, five years old, one of whose hands grew black
and gangrenous after  a few paroxysms of malarial fever; two
days later, on the occurrence of a new attack, the  other hand
became similarly involved.

   Some years ago a man about twenty-five years of age, a worker in the " polders,"
was brought to my clinic at evening in a comatose condition, the  result of a
malarial attack.  He had been  the subject, a few days before, of two ordinary
attacks of intermittent fever. Large doses of quinine, stimulating enemata, and
derivation to the skin brought about a rapid recovery ; but on changing his linen
the next morning a bluish-red spot, about as large as the palm of one's hand, was
discovered in the right gluteal region, which became gangrenous in a few days, and
penetrated to an alarming depth.  He had no more attacks of intermittent fever,
but was obliged to remain in hospital several weeks for the cure of his bed-sore.

          Remittent and  Continued Malarial  Fevers.

   This class consists of fevers which present no intermissions or
apyrexias during their course, but only  more or less marked
remissions  and exacerbations; but wliich  must  be reckoned as
amongst the diseases due to malarial infection, because of their
frequent  transition into  ordinary intermittent fever, their ana-
tomical lesions, their occurrence in malarious regions,  and the
fact that the same remedy is required for the cure of both condi-
tions.
   Remittent and continued fevers prevail chiefly in the most
intensely malarious regions, especially in the tropics, as well as
in more northerly latitudes during the spread of a powerful epi-
demic.   They also occur  sporadically, and in a mild  form,  in
the latter regions, during the hot months, especially after heavy
rains and inundations.
   According to Griesinger,  the topographical  distribution  of
these forms of  the disease seems to differ from that  of  simple
intermittent,  in districts where malaria is endemic ; inasmuch as
the  remittent variety  prevails in the humid coast regions, and
ordinary intermittent on  higher lands, a circumstance undoubt-
edly due to the varied intensity of the morbific  agent.  When,
as is frequently the case in epidemics, we see, now the remittent, 
REMITTENT AND CONTINUED FEVERS.
615
and  again the intermittent form prevail, without any special,
demonstrable  cause, we are justified in attributing this also to
the varying intensity of the poison;  just as we often see epi-
demics begin with the intermittent form, change to the remittent
while at their  height, and  return to the intermittent again dur-
ing their  decline.   Where both forms coexist within a given
area, individual predispositions and peculiarities of constitution
may occasion  the development of the one or the other in a given
person.
   There  are  various ways in  which  intermittent fever may
assume the remittent or  continued type.   The intermission may
be shrouded,  or may be made  completely to disappear, merely
through the persistent anticipating of the paroxysms ; or through
a relatively long  duration of the same as compared with the
usually brief  apyrexia,  due  to the  simultaneous  existence of
some other febrile affection, such as gastric disturbances, bron-
chitis, pneumonia, etc.
   The remittent forms of  disease, however, so far as they are to
be regarded as a distinctive class, show some peculiarities, other
than the mere absence of  an  intermission, which are entitled to
special  mention, and this is particularly true of  those varieties
which are peculiar to the  tropics.  But not all  those diseases
which are regarded as remittent or  continued malarial fevers, in
the tropics or in  more northern malarial districts, could main-
tain their claim to this title if  subjected to the test of scientific
criticism.   Even  the physicians of  our own lands are too liable
to designate as malarial diseases attacks  of pneumonia accom-
panied  with jaundice,  or simple gastric  disturbances, with or
without jaundice,  or mild  grades of  typhoid  fever running an
irregular  course.
   The pernicious character of remittent fever either shows itself
from the  very beginning,  or appears on the  third,  fourth, or
sixth day, or later, even as  late as  the  second week.   The
exacerbations usually recur in the quotidian, more rarely in the
tertian  type ; they  are sometimes patent, sometimes hidden,
and  only to be discovered by  careful observation and thermo-
metric observations.
   The division of remittent and continued fevers into those of 
616
HERTZ.—MALARIAL DISEASES.
light, heavier, and  highest grades, as it is made by Griesinger,
finds its  justification in  the fact that it isolates certain pictures
of disease, and facilitates our study of  their features.  But we
must never forget that it is not intended thereby to designate
distinct forms of disease, for an interchange in the several grades
of intensity is frequent, and, in some epidemics, the rule.
   The first grade, that of the lighter forms, embraces the bilious
or gastric remittents, which often appear in great numbers during
a  hot summer, in malarious districts,  associated with  gastro-
intestinal catarrh and icterus.  It not infrequently happens,  as I
have observed in Holland, that the actual attack is preceded for
several  days by gastric  disturbances, loss of appetite, nausea,
irregularity of the  bowels, with occasional irregular rigors  and
dizziness.  Usually,  however, the attacks begin suddenly,  and
without  warning, with a moderate  chill, followed  by loss of
appetite, nausea, the raising  of sour material from the stomach,
a general feeling of sickness, with severe headache, dizziness,
ringing in the ears,  sleeplessness, and restless nights.  Jaundice
and  a colorless diarrhoea follow  afterwards.   Sometimes an
herpetic  eruption is developed  about the lips; bleeding  at  the
nose is not uncommon,  neither is a light grade  of bronchitis.
With all this, sensitiveness  is developed over the region of  the
spleen, with an enlargement of that organ not difficult of demon-
stration.   The disease usually reaches its end  in  three, five, or
ten days.  More rarely it does not  terminate for some weeks,  and
then it runs  the following  course.  The exacerbations  which
occur daily, twice a day, or every other day, and which are not
infrequently ushered in by a new chill, are followed by more
and  more distinct remissions, with sweating and an abatement of
the general ill-feeling, these remissions  not  seldom passing, by
degrees,  into  actual  intermissions.   I have occasionally seen
patients  in whom, after the temperature had fallen to its normal
standard, the gastric disturbances  would  persist for  several
weeks, accompanied by no small degree of jaundice.
   The second grade, that of the severer forms,  is especially
characterized by a more continuous  course, with only here  and
there marked remissions, especially  at  the beginning  of  the
attack.   Although  beginning as a sthenic fever, they not infre- 
ADYNAMIC REMITTENTS.
617
quently early assume a  typhoid or adynamic character,  and
may, aside from the greater intensity of the general disease, be
associated with particular and pernicious local affections, as with
dangerous  nervous symptoms,  with delirium, with  eclamptic,
epileptic, tetanic, paralytic, or comatose seizures; furthermore,
with algid  and dysenteric conditions, as well as with parotitis,
pneumonia, and  inflammation  of the spleen, all  of  which are
likely to end in death.
   The disease usually begins with severe headache, delirium,
and a heavy chill.  The primary disease, when not complicated
with any of the conditions mentioned above, lasts, according to
Griesinger, from seven to fourteen days.  Recovery follows, with
marked remissions and sweats, or by transition to a simple inter-
mittent, although relapses are said to be frequent.
   The third grade, that of the severest forms, depends, accord-
ing to Griesinger, either  upon  specially unfavorable constitu-
tional or external conditions (debilitating treatment, septic influ-
ences,  etc.),  or  on the too  great  intensity of the  pernicious
features.  They are  particularly distinguished  by  the most
marked and extreme adynamic character, by a tendency to rapid
collapse, and by the early condition of apathy into which their
victims fall.
   These attacks sometimes begin in a mild form, soon, how-
ever, showing indefinite and  irregular exacerbations and remis-
sions, the former of wliich become constantly shorter and the
latter longer and more exhausting, with the temperature of the
body below the normal standard, thus indicating the adynamic
character  of the disease.  Patients  complain of pain in their
limbs and joints, with difficulty of  moving the same; but the
feeling of pain is soon blunted, sight is sometimes dimmed, mem-
ory is weakened, drowsiness and stupor are prominent, or, very
rarely, delirium and wakefulness.  The patient falls into a state
of mental apathy, and death usually follows while he is in an
algid and comatose condition.  At other times the disease shows
the gravest symptoms from the very commencement, beginning
with a chill and heat,  followed in a few hours by a state of com-
plete exhaustion, with disturbed intellect, which state is some-
times accompanied by great restlessness and delirium.  Respi- 
618
HERTZ.—MALARIAL DISEASES.
 ration is apt to be sighing;  the pulse small and rapid,  100 to
 140 ;  the tongue coated white, or clean,  pale and  rough ;  the
 skin hot  and dry; the abdomen distended and painful; thirst
 extreme,  and the spleen  enlarged and sensitive.  There  is  fre-
 quently vomiting, and the strength gradually declines, so  that
 death, through exhaustion, may occur at  the  end  of five  or six
 days.   In  a malignant epidemic which was observed by GibbsJ
 on the west coast of Nicaragua,  in May, 1868, the attacks were
 never introduced by a chill.  Death occurred within a few days,
 at the height of the disease, without any reaction having  fol-
 lowed,  the symptoms being severe headache, delirium, yellow-
 ness of the conjunctiva, continuous severe vomiting, a cool skin,
 a bad  and sometimes  slow pulse, and deep collapse.  Occasion-
 ally,  during the course of  the  disease, other pernicious local
 symptoms are developed,  such as enormous swelling of  the liver
 or spleen, with the occasional formation of abscess, purulent col-
 lections in the serous  cavities, pneumonic infiltration, icterus of
 the skin, partial oedema, bed-sores, gangrene of external  parts,
 petechie, epistaxis, hemoptysis and hematemesis, or dysenteric
 and choleraic dejections.
   Most of the cases of this severest form of  remittent fever ter-
 minate fatally;  the  few patients that recover  remaining weak
 and sickly for a long time.
   In  the  above  sketch I have  merely delineated  some of  the
 leading types of the disease in question ; these could,  without
 difficulty, be largely increased, for almost every epidemic  shows
 some variations in form peculiar to itself.  I  shall only permit
 myself, however, to notice  one  special form, which, although
 long known, has not met  with general recognition until of late
 years,  when it has been most carefully observed and described.2
 It is  that  affection  called by the French, from its prominent
 symptoms  of a bilious  condition and bloody urine, fieme bilieuse
 h'ematurique.
   This disease is found,  as a rule, only in  the most intensely
malarious portions of the tropics, and then only at the height of

  1 Virchow's and Hirsch's Jahresber., 1868, II, p. 199.
  2 Barthelemy-Benoit, Arch, de med. nav., 1865, p. 5.  Veillard, De la fievre bilieuse
hematurique.  Paris, 1867.  Hirsch and Virchow, Jahresber., 1868, II, 200. 
               FIEVRE BILIEUSE HEMATURIQUE.            619

an epidemic, during  and immediately after the rainy season;
still it may occur in more northerly latitudes, and has even been
met with in Holland at  the time of a malignant epidemic.   Of
late years, so far as reports have been received, this affection has
been  endemic in  Senegambia,  at  Mayotte in  Madagascar, in
Cochin-China, Cayenne,  on the Lesser Antilles of  Guadeloupe
and Martinique, in various portions of Alabama, Louisiana,  Ar-
kansas, Florida, Texas, and along the banks of  the Mississippi.
It is  usually developed  in persons who have been  exposed to
malarious influences for a long time, and have often suffered with
intermittent fever, or in whom a true malarial cachexia has been
established.
   It has always been a matter of doubt whether this affection
should  be recognized as  an independent form  of disease or be
considered merely as a modification of some otlier familiar forms.
Some writers  consider  it identical with the icteric  pernicious
fever, others look upon it as a modification  of yellow fever, while
still  others believe that it  occupies a middle ground between
common malarial and  yellow  fever.   The disease ordinarily
begins as a simple intermittent, the symptoms of  which, how-
ever,  undergo an unusual aggravation after the occurrence  of a
few paroxysms.   They then manifest themselves in  the form of
severe, long-continued chills, severe pain in the head, back,  and
loins, burning  pain  in the pharynx, the oesophagus, and the
region of  the  stomach,  urgent  thirst,  nausea, and persistent
vomiting of biliary matter.   At first there is usually obstinate
constipation, and afterwards,  bilious  diarrhoea.  The urine is
usually voided  in great  abundance, is dark brown, and rich in
blood. Veillard was never able to  demonstrate  the  presence of
biliary coloring matter in the urine.  The skin is slightly jaun-
diced and covered with  a cold sweat, the features are sunken,
and  the pulse  grows gradually smaller,  running at the rate of
from 80 to 130 beats.  The liver and spleen are greatly enlarged.
The fever assumes the remittent or continued form.   Under early
and appropriate treatment, and with a patient of good constitu-
tion, recovery is possible ; usually, however, coma supervenes as
early as the second day, or, it may be, not until the fourth to the
sixth day.  The pulse grows smaller, becoming hardly percep- 
620
HERTZ.—MALARIAL DISEASES.
 tible, dyspnoea increases, the urine becomes scanty or is entirely
 suppressed;  then  ecchymoses  appear,  hemorrhages  from the
 nose, the lungs, and the stomach ; and death ensues, usually
 during the second week.

     Chronic Malarial Infection,  or Malarial Cachexia.

   Although the condition  known as malarial cachexia is usu-
 ally classed among the sequels of ordinary malarial disease, yet
 there are reasons that justify us in taking up its consideration at
 this time.  For  not only is this condition developed  after fre-
 quent repetitions  of simple intermittent, or in case of the long
 duration or neglect of, or incomplete recovery from the same, or
 where certain organic diseases or anomalies of constitution exist,
 or after severe attacks of remittent fever; but a primary chronic
 affection is very often observed, in malarious regions, without any
 antecedent attacks of malarial fever, and this primary  infection,
 after having  existed for a long time, often  comes gradually to
 present symptoms similar to those  of the secondary  cachexia.
 These primary affections  are only to be met with in  the most
 intensely malarious regions, and it  is not going too far to assert
 that most of  the inhabitants of such regions actually do suffer
 from this infection without its having been preceded by  any
 outbreaks of intermittent fever.
   In the interior provinces of Holland this state of things is
 familiar to every one, and is designated by the vulgar name of
 "binnen koorts," inward fever.  It betrays itself by the most
 varied  manifestations, changing frequently  in the same indi-
 vidual, often  showing a tendency to assume a definite type,  and
 involving  certain nerve-tracts, so that for a long  time I was in
 doubt whether some  of these  cases were not, properly speak-
 ing,  masked  intermittents.  The paroxysms, however, are  only
feigned, and  their apparent periodicity depends upon the  fact
that, owing to certain  injurious influences  affecting  the indi-
vidual, some  single symptoms are rendered more  prominent at
given hours of the day.   In  general, however, the course of the
affection is continued.
   During ordinary times, when no intense malarial diseases pre- 
MALARIAL CACHEXIA.
621
vail, the persons attacked are usually those who have been  con-
tinuously exposed  to malarial poison, or in whom certain  inci-
dental causes have been  at work,  such as imprudent  methods
of living, damp, low dwellings,  or bedchambers, etc.,  or those
who for some unknown reason present a special  predisposition
thereto.  Great heat and a damp atmosphere exert their influence
here also, and increase the amount of the disease.
   Patients  thus  affected complain  of dizziness, a symptom
which, according to Schramm, is so general in his neighborhood
that there are but few people not familiar with it; they also have
ringing in the ears,  musce volitantes, and disturbances of visual
accommodation ; they lose their appetite, have a  metallic taste
in the mouth, nausea, and a disposition to vomit, with eructa-
tion of gases ; there is  dryness of  the lips, mouth, and throat,
the tongue, in  the middle and behind, being coated with a yel-
lowish-white fur.   Sometimes there is an increased secretion of
saliva,  roughness in the  throat, and a disposition  to clear  it,
which usually produces nausea and retching.   A feeling of  pain
and oppression  in  the  epigastrium is frequent, especially when
the stomach  is  empty; also rumbling in the bowels  and a fre-
quent desire to go to  stool, with or without tenesmus.  The
condition  of  the  bowels is  usually normal; constipation  is
rare, and  oftener  there  are several  diarrhoeal passages during
the  day,  generally during the morning hours.   Patients  per-
spire quite copiously after every little movement of the body,
and during the night.  Sleep is often disturbed, and even inter-
rupted  for hours, or it may be very  profound  but unrefreshing,
the  individual feeling  in the morning as if he had  been up  or
had travelled all night, with his head confused and a general
feeling  of  discomfort.  Many complain of tickling and burning
in the feet and hands, of formication and a sensation of deafness,
of pain in the shins, or of  dragging pain in the course  of the  scia-
tic nerve, in the loins, in the small of  the back,  and over the coc-
cyx, which latter is also painful on pressure, and after prolonged
standing or walking becomes the seat of  the most unendurable
burning.  Others mention pains in the joints, often of the knee-
joint, or in the muscles of the extremities, or they  experience
stiffness in the limbs  and the back, become easily fatigued, 
622
HERTZ.—MALARIAL DISEASES.
 especially in climbing stairs, are short of breath, and have palpi-
 tation of  the heart.   The complexion quickly assumes a yellow-
 ish, pale hue, the conjunctiva  is of normal color, as is also the
 urine, which is often excessively abundant,  and in  that case as
 clear as water, of low specific gravity, and without any abnormal
 constituents.   With  many patients, temporary attacks of melan-
 choly arise from  time  to time;  with  others the  hypochondriac
 condition  is a constant one.  All such  imagine themselves very
 ill, they suspect disease of the heart, of the  spine, or of the kid-
 neys, and in one of my patients even a light form of agoraphobia
 was developed, which yielded to quinine.
    I  have never found the temperature  to  be  elevated  in  this
 condition ; the pulse is normal, or a little  rapid,  or, in many
 cases, a little below the average  frequency.   The spleen is gener-
 ally enlarged, and patients often complain of sensitiveness in the
 left hypochondrium on pressure or when they cough.
    This  light form of  malarial intoxication often disappears
 spontaneously as  soon as the predisposing  and exciting condi-
 tions are removed ; it is quite sure to disappear under the use of
 quinine, but, as in all malarial  affections, relapses are frequent.
 Otlier patients, in whom the infection continues, and these means
 are neglected, may suffer with it for weeks  and months, and  it
 may gradually pass  into  the more severe  forms.  It also  not
 infrequently happens that attacks of true intermittent vary the
 course of the disease.   Ritter,1 who practises  in the Hannoverian
 moorland colonies, and to whom we are indebted for some inter-
 esting reports on  malaria, likewise  describes a primary chronic
 malarial infection, which begins with headache,  loss of appetite,
 a bitter or salty taste in the mouth, lassitude, pain in the limbs
 and back,  a coated tongue, and constipation, and which eventu-
 ally brings the patient to  his physician  with some  complaint,
 whether of the alimentary canal (gastric or intestinal catarrh or
 salivation), of the respiratory organs (chronic bronchial catarrh),
or of the  nervous system;  for the  constant disturbance  in  the
head  finally brings the individual into a hypochondriac condi-
tion.  At  the  same time, Ritter's description of  the subsequent
1 Virchow's Archiv, Bd. XXX, p. 273. 
MALARIAL CACHEXIA.
623
course of these attacks resembles, in many respects, that which I
shall give as belonging to the severe forms of primary infection.
   These severe forms also begin with a diminution  of  appetite,
with sluggish digestion and constipation, which may soon be fol-
lowed by uncontrollable diarrhoea and  frequent  vomiting—in
graver cases by all the symptoms  of dysentery.  Patients are
easily fatigued and exhausted, and get short of breath, the com-
plexion is pale and grayish yellow, and the conjunctiva slightly
jaundiced. The urine is scanty, dark-colored, free from  albumen,
and sometimes contains a  considerable amount of biliary color-
ing matter, in which case  the  skin and  conjunctiva are icteric
and the feces colorless from the absence of bile.  The  spleen  is
but very rarely of normal size, it is generally  enlarged, and
indeed to such a degree, as to half fill the cavity of the abdo-
men ; x the liver also may show an immense enlargement; both
organs are hard and sensitive.   The abdomen is  greatly dis-
tended by  the enlargement of  these organs and by meteorism.
Ascites is developed, as well as oedema of the face and extremi-
ties,  with a  tendency to sores; furuncles appear  in  the  skin,
and  portions  of the body may become gangrenous.  Patients
complain of palpitation of the heart,  the pulse is feeble,  though
not frequent, a venous murmur may be heard in  the neck, and
blood-murmurs in the heart.   Hemorrhages from the nose are
frequent,  those from the female genitals,  or  from  the stomach
and  bowels,  rare; petechiae appear upon the skin,  and a scor-
butic condition is sometimes developed about the  gums.  It is
 claimed that in very severe cases, such as I have never seen, pro-
 founds disturbances of the nervous system arise, such as  trem-
bling, choreic movements, paralyses, delirium, and disturbances of
vision and of  intelligence.  All these  symptoms show no period-
 icity ;  nor can any rise of  temperature be demonstrated at any
 time, unless, indeed, what is not infrequent, regular attacks  of
 intermittent fever supervene, which then assume the usual quo-
 tidian, tertian, or quartan type.   Sometimes this  type is not
 assumed, and the disease maintains the  character of a remittent
 or continued fever.______________
   1 Faymoreau (Canstatt's Jahresbericht, 1860, IV, p. 74) observed inflammatory pro-
 cesses, and in three cases fatal suppuration of the spleen. 
624
HERTZ.—MALARIAL DISEASES.
   The  train of symptoms  just described is  the  same that is
encountered in malarial cachexia when it follows previous inter-
mittent fever.
   Mild grades of chronic infection and cachexia may recover
under appropriate treatment;  in  the higher  grades, however,
death generally results through exhaustion, with dropsical man-
ifestations, renal diseases,  amyloid and leucemic conditions ; or,
it may be, through  the  addition of tuberculosis,  dysentery,
pneumonia, or pleurisy.   Patients sometimes  die  of apoplexy,
which Griesinger thinks may be due to a pigment embolism of
the cerebral vessels.

                  Pathological Anatomy.

   The  fact that we  know so little of the anatomical changes
which take place  in  simple intermittent fever  is evidently in
part explained by the circumstance that hardly any such patients
ever become the subject of  a post-mortem examination, unless
their death is brought  about  by  some intercurrent disease.
When such complications exist, it is not  always easy to deter-
mine what proportion of any lesions that may be found depends
on the intermittent, and what on the other disease.
   With regard to the primary blood changes  which  take place
in primary malarial infection, we  are, thus  far,  without any
reliable  chemical or microscopical data ; for the deviations from
their normal composition which we recognize  in the serum and
the  blood-corpuscles occur  only as  the result of the disease,
that is, they depend on the consumption of tissue caused by the
fever and the high temperature, as well as  on  the changes pro-
duced in the spleen and in other important organs.  For, even in
recent cases of simple intermittent,  the spleen is, with few excep-
tions, enlarged by simple hyperemia ; in  fact,  tumors of  the
spleen have been observed in the newly born children of mothers
who suffered from  malarial  fever during pregnancy; but struc-
tural changes in this organ  occur  only when the paroxysms of
fever are very often repeated or of long  duration.  The same
thing is true of masked  fevers;  for, in spite of the manifold
localizations of the same, no one has, as yet, succeeded in demon- 
CHANGES IN THE BLOOD.
625
strating  any palpable  changes  in  the  nerves  or the organs
affected,  except in those cases  where it was a question of visi-
ble hyperemia, oedema, or inflammatory disturbances of nutri-
tion.
   The results of minute anatomical  investigation  have  been
more satisfactory in the severer forms of malarial disease, in the
pernicious, remittent, and continued fevers, as well as in the
higher grades of primary and secondary malarial cachexia.
   A very frequent condition,  in the severe forms of malarial
fever, is  that characterized by the presence  of a dark brown or
black  pigment matter,  in the form  of fine granules, or of cells
and flakes containing pigment granules, which are  found in the
blood, in the spleen, the liver, the brain, the spinal cord, the kid-
neys, especially the cortical portion,  the heart, the lungs, and the
lymphatic glands; also in the  integument, in the serous  mem-
branes, etc., showing themselves here by characteristic, usually
slate-colored discolorations in  the  course of the blood-vessels.
The spleen has long been supposed to be the point of  origin of
this pigment matter, and it has been thought to be distributed
thence after the manner of emboli.  There  seems, however, to
be some evidence to prove that the liver is not without a share
in the production of this pigment; while others believe that it is
also produced in the blood, as the frequent considerable size of
the pigment flakes in the vessels of the brain excludes the possi-
bility of a passage through the capillary system of  the liver and
lungs.  The origin  of  pigment matter in the spleen has  been
thought to be due to  the considerable  fluxionary hyperemia
occurring during the fever paroxysms, by  the escape of blood-
corpuscles through  the sound or ruptured walls of the vessels;
or, according to Duchek, by the arrest of the circulation in very
many of the venous sinuses.   In view of his observations to the
effect  that the pigment matter is not found in the  tissues of
organs, but in the walls of blood-vessels, Heschl *  believes that,
as°the hematine is retained in the  corpuscles by virtue of the
presence of a certain amount of  albumen and common salt in the
plasma,  so changes in the plasma are the cause of the escape of
• Oestr. Zeitschr. f. prakt. Heilkunde, 1862, No. 40 et seq.
VOL. II.—40 
626              HERTZ.—MALARIAL DISEASES.

the hematine, which changes  are  produced by  the malarial
poison that has penetrated the body.  The greater collection of
pigment matter in the capillaries of the spleen,  the liver, the
brain,  and the spinal cord, leads Heschl to  suppose that the
poison operates on  these organs in particular;  that it  there
causes a  disintegration of blood-corpuscles, and that the hema-
tine, which is now set free, and which  becomes a carrier of the
poison, penetrates the walls of the capillaries.
   In the bodies  of  those who have died of pernicious malarial
fever, the nervous system often gives evidence of  no change at
all, or of but very slight  changes, notwithstanding the grave
symptoms that occurred  during life.   In the comatose form, a
brownish or slate-colored discoloration of the cortical portion
of the brain, and sometimes also of the ganglia, has occasionally
been discovered,  which was due  to accumulations  of pigment
matter, as well  as numerous punctiform extravasations, which
have been thought to depend on a blocking up of the capillaries
by means of pigment, but  which Heschl says may exist  inde-
pendent  of the formation  of pigment matter,  and represent capil-
lary aneurisms.   Instead  of this, however, it is more common to
And only more or less hyperemia and oedema of the brain sub-
stance and  its membranes, together with  an  accumulation of
serum in the ventricles.   It is rare to find extravasations  of any
size in the brain or  its membranes,  or in the midst of centres of
softening.1  The  same state of things is found after the delirious
form of  the disease—indeed hyperemia and oedema are the prin-
cipal conditions present after all the disturbances of the central
nervous system connected herewith.   In the delirious form, indi-
cations of the exudation of coagulable lymph into the membranes
of the brain have been observed.  In the form characterized by
tetanic cramps, and formerly called katochus, Girard saw soft-
ening of  the brain and of the upper part of the spinal  cord, in
addition to hyperemia.   In the algid form the substance of  the
brain and cord is pale, bloodless, dry, and tough.   In cases of
icteric intermittent  the  membranes have  been  found  colored

   1 Titeca, Arch. med. beiges, 1869,  Jan., p. 5, and  Juin, p. 408. found, in two cases,
red areas of softening in the brain of from two to three centimetres in size, without
any demonstrable cause of capillary obstruction. 
              CHANCES IN THE ABDOMINAL ORGANS.          627

 yellow  with a yellowish fluid  effused into the ventricles and
 under the arachnoid.  The lungs are often  highly hypere-
 mic  and  oedematous, not seldom  showing hemorrhagic infarc-
 tions and in the pneumonic form red and gray  hepatization.
 The  heart is usually dilated, its walls flaccid, and sometimes
 pale.  In the algid form  the endocardium and pericardium are
 ecchymotic, the  muscular  substance  dark, infiltrated, tender
 and  easily torn.   In one case Rigler found  several extravasa-
 tions as large as a  pea.   The  right side of the heart and  the
 vene cave are  filled with abundant quantities of dark, half-
 clotted  blood.   In most  cases  of pernicious  intermittent,  the
 spleen is  enlarged, reaching three or four times its normal size;
 it  is hyperemic  and softened, sometimes  consisting of nothing
 but  a sac filled with  a black, bloody fluid.  Infarctions are not
 very rare, which  may result in  gangrene or the formation of
 abscess  (cases reported by Scholz,  Duchek, and myself), and
 rupture of the  spleen, with fatal hemorrhage into the cavity of
 the abdomen, may occur.   It is not uncommon to find discolora-
 tions and  thickening of the capsule of  the spleen, and adhe-
 sions to neighboring  organs.  Under some circumstances,  when
 death occurred during the first or second attack, the spleen has
 been found unchanged, this condition being particularly observed
 by Girard in the malignant fevers prevalent at Rome.   The liver
 is  often  enlarged, in acute cases hyperemic,  the  parenchyma
 swollen  and soft; sometimes, especially in the pernicious fevers
 of  the tropics, it  is studded with numerous apoplectic spots, or
 with  disseminated and confluent inflammatory and purulent col-
 lections.  In the  icteric form the  organ is very large,  the  gall-
 bladder  usually filled with thick, dark-brown bile.   The intes-
 tinal mucous membrane is either simply hyperemic, and shows
 the changes incident  to a catarrhal condition, or  it is ecchy-
 motic, as in the choleraic cases.  The solitary follicles and  Pey-
 er's patches in the small intestine are often greatly swollen, and
 colored with pigment  matter; in  the icteric form they are filled
 with  a  bile-colored  fluid;  the  colon is  swollen,  and  highly
 hyperemic, its follicles are infiltrated and  partly suppurating,
 or the mucous membrane  shows extensive  dysenteric processes.
The mucous membrane of the stomach, too,  is often hyperemic : 
628              HERTZ.—MALARIAL DISEASES.

in those cases that have had hematemesis it is highly ecchy-
motic,   The kidneys are sometimes swollen,  the mucous mem-
brane of the hilus being hyperemic.   The integument is gener-
ally of a pale yellow,  and in icteric cases of a deep yellow color.
In case of the throwing off of  pigment matter it becomes of an
ashy gray.
   The anatomical changes in  the severe  forms of remittent and
continued fever, as far as observations are collected, show a great
conformity to the picture just drawn of the conditions in perni-
cious intermittent.  The fact of the deposit of pigment matter in
various organs, in this form  too, as has  been verified by many
observers, is an argument in favor of the view that all these pro-
cesses are only modifications  of the same fundamental disease.
The other changes, too, in the  spleen and  liver, the swellings and
enlargements, the processes of softening and suppuration, the
catarrhal, hyperemic, and follicular  changes in the intestinal
canal, the relaxation and discoloration of  the muscular substance
of the heart, etc,  all these only go to confirm the above hypothe-
sis.  With regard to adynamic remittent fever, it may here be
stated  that, according to Brown, Stewardson, and  others, the
hyperemia, so commonly found  in other forms, is lacking ; on
the contrary, the brain, liver,  spleen, heart, and all the voluntary
muscles are distinguished by great relaxation and softening, the
extreme softness  and ease with  which the  tissue of the heart
would tear being  noticeable, as well as the watery quality of the
blood, and  its evident  deficiency in  fibrine.  In the autopsies
made of those who died of the fieme bilieuse hematurique, there
was  generally very  considerable hyperemia, besides  swelling
and softening of  the  spleen and  liver, the latter being  strongly
icteric and  sometimes fatty ;  the dark-colored  skin  was some-
times the seat of petechie, ecchymoses, and pustules filled with
blood (Veillard);  the brain and its membranes were rich in blood,
and icteric ; the gall-bladder contained thick, black bile ;  the mu-
cous membrane of the stomach and bowels was very vascular and
soft; the heart soft and relaxed ; the kidneys highly hyperemic ;
the bladder usually empty, injected,  and ecchymotic, the urine
always containing blood and albumen ; still the question of the
presence of biliary coloring matter in the urine  is as yet unset- 
             CHANGES IN THE ABDOMINAL ORGANS.         629

tied,  some observers accepting it as a fact, while others,  like
\ eillard, have never been able to demonstrate its presence.
   In considering the anatomical changes wliich  take place  in
.malarial cachexia, and after long-continued  and oft-repeated
attacks of intermittent fever, we  find, in addition to an anemic
color of  the  skin, to oedema of the subcutaneous  cellular tissue
and the accumulation of fluids in the serous  cavities,  to atrophy
of the muscular and adipose tissues, etc., certain alterations  in
the liver, the spleen, the kidneys,  and the heart, which claim our
further attention.  The " ague-cakes," with which every one has
long been familiar, are the results of frequent  relapses of inter-
mittent  fever, lasting for a long  time, and  of primary chronic
malarial infection of a high grade.  They consist of firm, tough,
slaty tumors, presenting a smooth surface on section, rich in pig-
ment matter, of enormous size, often fifteen or  sixteen times the
natural  size  of the organ, of the shape of a cake, usually  pro-
vided with a thickened capsule,  and attached by adhesions  to
the surrounding parts or  organs.   They represent either simple
hyperplastic conditions or amyloid degeneration.   Leucemic tu-
mors of the spleen seem  to be of more rare occurrence, inasmuch
as not a single case of the kind fell  under my observation in  Hol-
land  during six years ; and Tomasi, during four years, within
which time  he saw very many tumors of the spleen, could never
demonstrate any one of  them to be leucemic.  Occasionally the
spleen may  diminish in size again  after having been enlarged ;
in that case it  is firm, tough,  and  atrophic, with a large increase
of its trabecular tissue  and  almost entire  disappearance of its
pulp.   Similar changes are to be  found in the lioer,  producing
large, tough tumors, which, if pigment matter  is present in  con-
siderable quantity, may be of a  chocolate color.  In rare cases
the liver  is contracted,  granular, and bearing  a certain resem-
blance to the  liver  of cirrhosis.  Amyloid degeneration is  also
sometimes present, simultaneously with that of the  spleen.  In
pernicious and severe remittent fever  the kidneys  are sometimes
found in a high state of hyperemia.  According to the observa-
tions of Key,' they are more or less swollen after long-continued
1 Canstatt's Jahresber., 1862, IV, p. 50. 
 630              HERTZ. —MALARIAL DISEASES.

 intermittent  fever; and  under the microscope, in addition to
 amyloid degeneration  of the Malpighian corpuscles, and of the
 various branches of the renal artery, show a marked hypertro-
 phy of  the interstitial tissue from the new development of round
 cells, nuclei,  and branched  connective-tissue  corpuscles.   The
 basement membrane, furthermore, is greatly thickened by several
 layers of thin, spindle-shaped bodies imbedded  in  its homo-
 geneous substance.  Through the successive transformation into
 epithelium of one cell layer after another of the basement mem-
 brane lining the interior of the tubules, and through degenera-
 tion and separation of the same, wax-like cylinders or granulai
 molecular  masses  are produced, which fill   up  the  urinary
 tubules.  Diffuse  inflammation, resulting in the  enlarged  kid-
 ney, may also be  observed often enough.  I do not venture to
 say whether the contracted kidney also occurs after intermittent
 fever.   The fact that very considerable  accumulations of  pig-
 ment matter are found in the spleen,  the liver, and the kidneys,
 in chronic infection and malarial cachexia,  has  already  been
 stated.
   In one case, that of a once vigorous man, twenty-eight years
 of age,  who came from a " polder" region, and had suffered from
 intermittent fever  for years, I found, in addition to an enlarged
 liver and spleen, and dropsical  manifestations,  a high grade of
 fatty degeneration of the heart, with numerous points of hemor-
 rhage, mostly of the size of a pin-head,  scattered throughout the
 tissue of the  organ, without any pigment  accumulations in the
 blood-vessels.

           Analysis of the Individual Symptoms.

   It was demonstrated by de Haen, as early as the year 1767,
that  there was an elevation of the temperature of the body, even
during the stage of chill, a fact which has since been confirmed
on every hand.  But even some time before the chill, from three-
quarters of an hour to several hours, during the prodromal pe-
riod, the use of the thermometer in the mouth or the axilla shows
a distinct elevation of temperature.   From this  time it rises rap-
idly, and generally reaches its maximum at the end of the cold 
                 THERMOMETRY PHENOMENA.              631
stage ; sometimes, however, this point is not attained until dur-
ing the hot stage, or, according to Michael,1 until the beginning
of the stage of sweating.  As soon as the maximum is  reached,
the temperature remains stationary, with small fluctuations, for
some time (one to two hours,—in one case of Barensprung's even
four hours), and then  begins to fall, at first slowly, afterwards,
during the sweating stage, faster, without, however, quite reach-
ing the normal standard at last.  The maximum usually runs  to
a point  from 5.5° to 7° over the normal standard, scarcely ever
being under 102.2° Fahr., often over 104°, from 106.3° to  106.7°,
and in some cases has run as high as 108.5° and 109.4° (Zimmer-
mann).   The different types of the disease do not show any dif-
ference in the height of the temperature.   During the  chill, the
temperature of the peripheral  portions of the body is lowered
from 9° to 12.5°, and even more, owing to the contraction  of the
smaller arteries, the scanty blood supply thus caused, and the
consequent diminished tissue metamorphosis ;  during the hot
stage, on the contrary, the heat of  the surface of  the body is
increased.   The fall of temperature, with few exceptions,  occurs
more slowly than the rise, and, indeed, as a rule,  by a not quite
regular descent.  This is true of  simple quotidian fever,—in the
tertian form it is claimed that the fall is sometimes more rapid
than the rise.
    During an intermission  the temperature falls to  the normal
standard, or even below, which Griesinger attributes to  the ane-
mia and disturbances of nutrition resulting from the  malarial
disease ; in rare instances,  especially in  case of certain gastric
disturbances, it does not fall quite to the normal standard.  The
period of time which elapses from the beginning of the rise  of
temperature to the end of its fall usually averages from nine to
eighteen hours  in  quotidian fevers, and  from sixteen to thirty-
two hours  in  tertian,  the maximum elevation  being usually
attained in  five  or six hours  from  the beginning of  the rise,
though  it  may sometimes be earlier or later.
    Under some circumstances  the rapidity and uniformity with
which the temperature rises may be taken as a criterion of the
1 De calore corporis humani diss.  Lipsise, 1855. 
g32              HERTZ.—MALARIAL DISEASES.

severity of the attack.  In the severer forms of remittent fever,
the height to  which the mercury rises may, to some degree, be
considered as  an  indication of the amount of danger to life.  In
this form  the  temperature usually rises rapidly to its acme dur-
ing the stage of chill, remains at  that  point, with insignificant
fluctuations, for some  time, at the longest for three days, and
then, in the event of a favorable course of the disease, diminishes
gradually, with morning remissions and evening exacerbations.
Barndel *  has  observed that when the temperature remains at its
acme for several days, and the remissions are indistinct, we may
be prepared for a grave case.
   Without entering  minutely into the  theories on fever, I will
yet add a few  remarks.   The doctrine  that  the elevation of  the
body-temperature, and  the increase of the  heat supply  in  the
body, is due to the diminished loss of heat during the cold stage,
may be looked upon as exploded, for  the  temperature is high
before the subjective feeling of chill and the peripheral cooling
of the body occur; and, even where the temperature does  not
determine the  question of an increased process of oxidation and
a greater production  of heat, we conclude this to be the case
from the increased excretion of urea which often exists for some
time  before the  fever.  The production of heat  rises till  the
maximum of  temperature has been reached, as is shown  by the
thermometer,  and which usually happens at the end of the cold
stage ; then it begins to sink gradually, but not at the rate indi-
cated by the thermometer, inasmuch as the giving off of heat and
the consequent cooling of the body is increased during the hot
stage and the  stage of sweating, and, therefore, a record of tem-
perature is given wliich corresponds as little to the quantity of
heat produced as does  the record given during the cold stage,
when, on the  contrary, the excessive contraction of the smaller
vessels and anemia of peripheral parts diminish the  giving off
of caloric.
   In  the elevation of temperature that takes place during  a
paroxysm of  fever,   however,  it is not  merely  a  matter of
increased production of heat and diminished loss of heat,  but

   1 Rec. de mom. de medec. milit., 1866, Aout, p. 118.  Hirsch u. Virchow's Jahres-
bericht, 1866, p. 178. 
CHANGES IN THE BLOOD.
633
we have to do with a modification or disturbance of the power
that regulates  the heat of  the body,  by  which  disturbance,
according to Liebermeister, the average grade of  temperature is
raised to a higher point than is normal.  This has given occasion
to a belief in the existence of a special centre presiding  over the
regulation of animal heat.   Whether this is an excito-caloric or
a moderating centre, or whether  it possesses a double character,
this much seems to be certain, that in fevers,  and especially in
intermittent fever, this nerve-centre is so affected  by the specific
malarial  poison  that  it is disturbed in  its  functions, either
momentarily or for some time, whereby intermissions and remis-
sions are produced.  A certain number of the manifestations that
accompany  the fever, headache,  dizziness, malaise, violent trem-
bling and convulsions, etc., are either likewise dependent on the
direct  influence of the malarial poison on the central nervous
system, or must be regarded  as results .of  the increased supply
of  heat in the body, and as the effect of the heated  blood on
 those nerve  regions.
    In masked, malarial affections certain nerve-trunks, or at least
their roots,  seem to be directly attacked in the same way, before
 the centre that presides over the regulation of heat is  involved,
 inasmuch as  such paroxysms  are usually not accompanied by
 a high temperature.   (Sensitive, motor, vaso-motor, and trophic
 nerves are  attacked—the  two  latter in  cases  of hyperemia,
 oedema, and inflammatory disturbances of nutrition.1)   The ex-
 act determination of  the amount of  urea that is excreted during
 the attacks, which,  so far  as I know, has never been accom-
 plished, might perhaps throw a good deal of light on  this form
 of fever.  In chronic malarial infection,  whether of a primary
 or secondary nature, we meet with  still more complicated rela-
 tions, which cannot at present be entered into in full.
    As was intimated above, the changes in  the blood, at least so
 far as we  can demonstrate them, are secondary in their nature,

   > In the latter instances, the local disturbances seem to disappear during the inter-
 mission, while the paroxysms are short and  not too often repeated.  In the oPPosi e
 contingency, the vitality of the affected organs suffers,  and the changes, especially
 oedema and the inflammatory changes, remain during the  intexmission and increase in
proportion to the number of attacks. 
634              HERTZ.—MALARIAL DISEASES.

and partly the result of a defective development of blood, owing
to disease of  the stomach and bowels,  and the blood-making
organs, the spleen and lymphatic glands ; partly dependent on
the destruction of numerous red blood-corpuscles and the trans-
formation of hematine into pigment; partly owing to consump-
tion, caused by the high temperature, or by pernicious  compli-
cations, or by the loss of albumen through coincident disease  of
the  kidneys,  etc.  Careful  examinations  also demonstrate a
diminution in the number of the colored corpuscles, a lessening
of the fibrine and albumen, and an accumulation of yellowish-
red, brown, or black pigment matter.  It has not yet been possi-
ble positively  to demonstrate a multiplication  of the colorless
corpuscles of the blood.
   In a patient who is still under treatment in  my  clinic, with
primary  chronic malarial infection, and very distinctly enlarged
liver and spleen, I have been able, as I have in some other cases,
to demonstrate the extreme smallness of the colorless corpuscles,
which are no larger than the red ones.  The diminution of the
albuminoid elements  and the red corpuscles explains the pale,
anemic, and partly oedematous condition of the skin, the drop-
sies, the dyspnoea, and palpitation of  the heart,  the  fact  of
patients  being  so  easily fatigued  on the least  exertion, and a
number  of  other similar symptoms.   Frequent  epistaxis and
other hemorrhages,  the result  of the  lowered nutrition  and
tonicity  of the walls of blood-vessels,  is also remotely  attribu-
table to the same cause.
   The accumulation  of pigment in the blood (melanemia'),
often very considerable, which  can easily be shown in a drop of
blood drawn during life, occurs less frequently in  simple acute
malarial fever than in  the tedious, long-continued, or pernicious
remittent forms, and in chronic infection and malarial cachexia.
As we know very little positively with regard  to the method of
its production, it will  probably be long before we  can  explain
the circumstance that this condition exists in the  blood of one
individual, after a certain number  of attacks  of  fever, whose
number,  length,  and  intensity bear no comparison with those
   1 Compare with Vol. VII of this Cyclopaedia, and Frerichs, Klinik  der Leberkrank-
heiten, 2 Aufl. Braunschweig, 1861.  Bd. I, p. 325. 
                   CHANGES IN THE BLOOD.                635

which have been suffered by another similarly constituted per-
son,  in  whom no pigment can be found;  in fact, that in some
subjects this condition is  not developed even after prolonged
illness.   A number of serious disturbances are associated with
this condition of the blood.   Through obstruction of  the capil-
lary blood-vessels, or thickening of their walls, we  may have
ischemia, collateral hyperemia, rupture of the vessels, and ex-
travasation of blood, with consequent  functional  disturbances of
the organs in which this occurs.  In this way we may explain,
amongst other things, the  ashy gray color of the skin, an inter-
ference  with secretion in the liver by obstruction of the branches
of the portal vein, and of the flow  of bile (icterus'), secondary
atrophy of the liver  followed by ascites, hemorrhage from the
stomach or bowels after obliteration of numerous hepatic  ves-
sels ;  furthermore,  dangerous brain symptoms,  as  delirium,
coma, convulsions, and sometimes sudden death.  It  must here
be remarked, that while it is true  that in many severe affections
of the  brain immense quantities  of pigment are found in the
blood,  yet this  does not  justify  the  conclusion  that all brain
affections depend  on this cause, for in many  severe cases of
these affections, while pigment is found in the blood, the brain
is free from it.   At other times the most  profound nervous dis-
turbances exist where it is impossible to demonstrate the pre-
sence of pigment in the blood, or in any organs of the body, and
I have even found pigment in the walls of the cerebral vessels,
where no brain  symptoms whatever had appeared during life.
It is evident, from what has been said  above, that the most dan-
gerous nervous symptoms  are often accompanied by hyperemia,
oedema, and softening, which may occur without any accumula-
tion of  pigment, and which are sufficient to account for all the
symptoms.  In case of the  suppression of urine, we may, accord-
ing to Griesinger, suspect  uremic intoxication.   The algid form
of intermittent gives  unequivocal  evidence, during its course, of
gradually increasing paralysis of  the heart, which also accounts
for most of  its  symptoms,  and which  Griesinger thinks may
probably be referable to an accumulation of pigment in the mus-
  « According to Grohe (Virchow's Archiv, Bd. XX.), by the accumulation of pigment
matter in  the smaller biliary ducts. 
636              HERTZ.—MALARIAL DISEASES.

cular tissue of the heart, though the evidence of this is as yet
lacking.
   Pain in the back of the neck, including the first dorsal verte-
bra,  which is so common  in  ordinary  malarial fever, showing
itself either spontaneously  or  on pressure, probably depends on
hyperesthesia  of  the nerve-roots caused  by hyperemia,  and,
although occurring most frequently in intermittent fever, cannot
be considered as diagnostic of this form of disease.
   The changes which take place in the skin, as regards color
(pale yellow, greenish yellow, earth-colored,  or ashy gray) are
partly due to anemia, partly to the accumulation of pigment;
and  the image of malarial  cachexia often stands  out so plainly
on the countenance that he who has had  occasion to see many
such patients can often make out a probable diagnosis from the
color of  the face.  In otlier cases, with gastro-intestinal catarrh
and  closure of  the ductus choledochus, or in  pernicious, bilious
intermittents and  remittents, the  skin is more or less sallow up
to the point of being bronzed or olive-colored.  In malarial ca-
chexia the skin is  usually dry and desquamates.  After this con-
dition has lasted for some time the subcutaneous adipose tissue
is materially diminished.   In simple  malarial  fever,  copious
warm  sweats relieve the patient notably, and are, as a rule, fol-
lowed by complete apyrexia;  profuse cold sweats are an unfa-
vorable prognostic sign.
   An eruption of herpes is  of very  frequent occurrence, and
may be of value in a diagnostic point  of view, especially as
between this disease and typhus, as it is rare to meet with it
except in malarial fever and pneumonia.  The eruption appears
on the lips, the nose, and other portions of the face, as well as
the gums and  the tongue,—seldom on other  parts of the body.
It is usually an  accompaniment of simple malarial fever.   It
appears either at once, during  the cold or  hot stage, or after the
occurrence of several attacks,  or even after these have been cured
by medication.  As a rule, it appears but once, though occasion-
ally relapses are seen.   Sometimes herpes appears as  early
as the prodromal stage,  and then, according to  Ornstein,  of
Greece,' is of  prognostic significance, inasmuch as  whitish-yel-
                  1 Revue de Therap., 1861, Janv. 1. 
      DISTURBANCES OF THE CIRCULATORY APPARATUS.      637

low and amber-colored scales  and crusts  point  to a light fever:
brown ones indicate active and rapid congestion, anil therefore a
less  favorable  course; while painful crusts herald  a pernicious
attack.  The nature of the connection between herpes and inter-
mittent  fever is at present unknown.  I have sometimes seen
herpes occur with great frequency, the vast majority of patients,
at some given time, being  attacked thereby; according to my
observation  it is more likely to appear during an epidemic in the
spring  than in the autumn.   Other skin diseases,  as  roseola,
purpura,  urticaria, erysipelas,  etc.,  are often  encountered;
petechie appear chiefly in  pernicious and severe remittent and
continued fevers, as well as in children and in previously feeble
persons during  simple intermittent.  Acne,  furuncle,  and an-
thrax are sometimes observed in malarial fever, and especially
after its cessation,  so that  they  have been thought by some  to
have a critical significance ; while others endeavor to explain the
etiological relation between these skin diseases and intermittent
fever.  Poor1  believes that they owe their  origin to  pigment
embolism of the capillaries.  Noma, too, is not seldom found in
atrophic and weakly children.
    The  circulatory apparatus, too, shows abnormal manifesta-
tions in intermittent fever.  The cooling of  the surface of the
body which takes place during  the stage of chill, depends, to a
great degree,  on  a  peripheral  arterial  cramp or  contraction,
whereby the pressure on internal organs is materially increased,
even sometimes causing rupture of the spleen or heart,5 as well as
capillary  hemorrhages in  other  organs.  The  increased internal
pressure, and the simultaneous lowering of the force of  the heart
as the  result of a  lesion of innervation characteristic of the dis-
ease, leads to venous congestion (blue color of the lips and finger-
nails).  At the  same time the area of dulness  over the heart is
sometimes enlarged,  oftener  in  width than in length,  owing to
the over-distention of the right side of  the heart.  Griesinger
observed such a case, in which a very wide heart returned to  its

   1  Prager Viertefjahrschrift, 1863, Bd. I.
   -Sebastian, loc cit., p. 187, says: "I know of a  case in which a  patient, who
exposed himself to cold on the approach  of an attack, died from rapture of the right
auricle." 
638
HERTZ.—MALARIAL DISEASES.
normal  size again at the  end of the  illness.  Duchek saw a
patient in whom, during the attack, the dulness reached as high
as the second intercostal space on the left side, and during the
intermission fell to the fourth rib again,  without at any time giv-
ing evidence of an increase in width.  The impulse of  the heart
against  the wall of the chest remained  at the normal point, for-
bidding the idea that the heart might have been pushed upward
by an enlarged spleen.  During the hot stage the cramp of the
vessels  is relaxed and  the previously small  and hard  pulse
becomes fuller; its frequency is always increased in the febrile
intermittents, without the rise and fall in its  frequency  corre-
sponding to the rise and fall of temperature.
   It is not uncommon to  find systolic murmurs at all the out-
lets  of  the heart, or,  it may be, only at the  origin of  the large
vessels,  as well as in the veins of the  neck, and, according to
Griesinger, in  the region of the spleen.  They usually amount
merely to arterial murmurs ; in anemic  persons they outlast the
attack, while in others they are audible only during the parox-
ysm, and no doubt depend upon abnormal conditions of tension
in the walls of the heart and of  the blood-vessels.   Other mur-
murs again  may depend upon an endocarditis, which is perhaps
likewise developed under the influence of malarial poison.  In
the case of extreme  fatty degeneration  of  the heart already
described, I was able, during the whole course of treatment, to
perceive strong blowing sounds at both auriculo-ventricular ori-
fices.
   The  most important complications involving the respiratory
apparatus were set forth in detail when treating of the general
course of pernicious fevers.  It is therefore  only necessary here
to refer to the fact that simple  intermittent fever is sometimes
accompanied by attacks (either sporadic or to some degree epi-
demic)  of bronchitis, with dry or moist rhonchi, cough, and
dyspnoea, which arise during the cold stage,  diminish gradually
during the stage of sweating, and disappear  entirely during the
intermission.  They undoubtedly depend  on hyperemia of the
lungs, with  swelling  and excessive secretion  from the  bronchial
mucous membrane.
   Although,  as a general  rule,  it  is  true  that the  urine  is 
INCREASED EXCRETIOX OF UREA.
639
increased in amount, clear, watery, and of low specific gravity
during  the  cold stage, which is doubtless due to the  complete
inactivity of the skin caused by the contraction of peripheral
arteries ; that it is more scanty, red, and of higher specific gravity
during  the  hot stage; and during the stage of sweating is mod-
erately  abundant,  heavy,  loaded  with solid ingredients,  and
throwing down an abundant deposit of urates;  yet the excep-
tions to this rule, dependent on the constitution of the patient,
or on some cause connected with the paroxysm, are so frequent,
and at times so constant, that one is almost at a loss to determine
which is  the rule and which the exception.  Thus, I have seen
perfectly clear, light urine, free from any  sediment,  in patients
who had suffered from repeated attacks of  intermittent fever,
and whose  constitution was weakened thereby, or by other  pre-
vious illness.   The same state of the urine may be observed in
cases where the paroxysms are of short duration or irregular in
their character,  as in the absence of some of the  stages;  or  it
may even be found present where none of  the above-named  con-
ditions  exist.   The circumstance that the urine  is sometimes
paler and more abundant during the entire paroxysm than during
the intermission (Zimmermann),  is attributed by Griesinger to
the large amount of water that is drunk.
   Allusion has already been made to the fact that the increase
in the amount of urea  excreted furnishes a much  more delicate
test of  the  degree of tissue metamorphosis, and the consequent
amount of heat produced,  than does  the thermometer; for even
in the prodromal stage, before  the thermometer begins to rise,
the urine betrays the presence of an increased quantity of urea.
This increase rises rapidly in degree until it reaches its maxi-
mum, at  the end of the cold  or  the beginning of the hot stage ;
then,  during the hot stage and the stage of sweating, it falls,  fast
at first  and afterwards more  slowly.1  According to Ringer, its
   ' The determination of the amount of urea and of the chlorides excreted during a
paroxysm of intermittent fever  was made by Tranbe and by Jochmann, and the same
investigations have of late years  been pursued on a larger scale by Ringer (Lancet, 1859,
Aug. 6th), Redtenbacher (Henle  Pfeuf. Zeitschr., Ill  Reih, III, B.), Hammond (Gaz.
med. de Paris, 1859, No. 42)—who, it is true, arrives at results quite opposite to the
others—and  Ulde (Wien. Wochenschr., 1859,  p. 100). 
640
HERTZ.—MALARIAL DISEASES.
increase stands in direct ratio to the elevation of temperature, so
that every degree of heat above the normal standard represents a
definite quantity of urea.   Redtenbacher, in a series of  careful
experiments which he instituted in the Pfeufer laboratory on ten
patients,  found that, with  the  greater amount of urea excreted,
the quantity of urine was also increased during the entire parox-
ysm, and during the intermission both fell decidedly below the
normal standard.   During the cold and hot stages the  amount
of  urea  was  three and one-fifth  times greater than normal,
and during  the sweating stage one-third greater than normal ;
when compared with  the  quantity excreted  during  the inter-
mission,  it was three and one-half times greater during the cold
and hot  stages, and one-half greater during the sweating stage ;
so that during the intermission it stood about one-fifth below the
normal standard.   The quantity of urine passed was  also three
and one-fifth times  as  large as was normal, during the cold and
hot stages, and one-third larger than normal during the sweating
stage.  When the  temperature is  brought down to the  normal
standard by the use of quinine, the excretion of urea, as well
as of chloride of sodium, still remains increased for a few days,
and this  is most marked on those days when, but for the treat-
ment, the paroxysms of fever would have recurred.
   The amount of chloride of sodium excreted by the kidneys is
also increased during  the paroxysms, although it bears no rela-
tion to the  temperature, but only to the  quantity of  the urine.
Howitz found it present in normal quantity, Hammond and Uhle
found it  diminished, and Gieseler likewise found little  or no chlo-
ride of sodium in the Hannoverian marsh  fevers.
   No thoroughly satisfactory observations have been  made with
regard to the proportions  of uric acid  and phosphoric acid;
according to the scanty data which I possess, it would  appear
that both are materially diminished on the fever-days.1
   The following abnormal ingredients of the urine must also be
  1 Nicholson (Madras Quarterly Journ., July, 1863 ; Canstatt's Jahresber., 1864, IV., p.
60), could find no uric acid during the paroxysms, and found phosphoric acid reduced to
one-eighth of its former amount, whence he concludes that there is depression and
palsy of the nervous system.  Others, as Hammond and Ranke, found an increase of
uric acid during the attacks. 
                    DROPSICAL PHENOMENA.                641

 mentioned.  It is  no very uncommon thing to find albumen pre-
 sent  in  considerable quantities.  This may correspond with the
 hyperemias of  pernicious  and  remittent  fevers, and is then
 usually accompanied with an abundant admixture of blood ; but
 it appears that  even simple malarial  fevers may show a highly
 albuminous condition  of the urine, and even renal hemorrhages,
 during their course, Griesinger having reported such a case, and
 my own experience, of  late,  giving confirmation to the  same
 thing.   Albumen is to be found in the urine  either only  on
 the fever-days,  or  during  the intermission as  well (fibrinous
 tube-casts have  also been observed), and disappears on recovery.
 Still, cases do occur which  pass  into a chronic diffuse nephritis.
 Patients often complain of discomfort or  severe pain over the
 region  of the  kidneys.  As a matter of course,  disturbances of
 circulation in  the kidneys, with albuminuria and hematuria,
 may  arise from  the obstruction  of  vessels by pigment matter.
 More frequently, however, albumen is to be found  after long-
 continued attacks  of  intermittent fever, or while a person is
 laboring under the malarial cachexia, and is then constant and
 quite abundant,  depending  on the existence of an enlarged kid-
 ney,1 or on amyloid degeneration of the renal vessels.  Biliary
 coloring matter  is  found in the urine in icterus, as  a result of
 gastro-duodenal  catarrh, and in  icteric intermittent.   Blood is
 present, especially  in the above-described remittent and con-
 tinued " fievre bilieuse hematurique."   Of late years, some iso-
 lated reports by  Burdel have appeared with regard to the occur-
 rence of glycosuria  in intermittent  fever.2  In the pigment
 kidney the so-called fibrinous  casts are sometimes found covered
 with  finely granular or flaky pigment.
   Dropsy, which  constitutes so important a symptom of mala-
 rial cachexia,  running  its course either with or without ne-
 phritis, and, in the first case, according to Rosenstein,  attaining a
 higher grade  than in nephritis from  any other cause,  also shows

  1 Rosenstein (Pathologie u. Therap. der Nierenkrankheiten, 2 Aufl.  Berlin, 1870, p.
218) found the urine in nephritis, under these circumstances, highly albuminous, and
the coagula in the sediment strongly impregnated with urates and free  uric acid crys-
tals.
  a Union med., 1859, p. 139, and 1871, No.  105.
          VOL. II.—41 
642
HERTZ.—MALARIAL DISEASES.
  itself, to a greater or less degree, in the masked and in the simple
  forms of intermittent fever.   When it is confined to the lighter
  forms, and  consists only in moderate oedema of the legs and the
  face, it may be accounted for  by the disturbances of circulation
  that take place during the attacks,  the anemic condition of the
  patient probably  also contributing thereto.   Higher grades of
  the same, which,  according to Griesinger,  may develop  them-
  selves in from two to six days, with a sluggish pulse and great
  languor,  and in which the urine may contain no  albumen, or
  only traces of it, are more  difficult  to  account for.  Such cases
  are not very unfavorable, and may recover within from one to
  several weeks.  In one such case, observed by me, oedema of the
  legs and the  conjunctiva persisted for  months, the urine being
  free from albumen, dark-colored, of high specific gravity, scanty,
  but without sediment, and the patient having grown anemic.
  The heart's action was very  weak  and  the  pulse  small, and I
  believe, therefore, that we may safely attribute these cases also
  to thinning of the blood and disturbances of circulation.  Where,
  in addition to the above causes, we have obstruction to the por-
  tal circulation, due to secondary atrophy of the  liver,  ascites
  may be developed to a  high  degree,  throwing the dropsy of
  other parts into the background.
     Various disturbances may be met with  on the part of the
  intestinal canal.  The nausea and retching so frequently pres-
  ent in  the lighter forms of chronic malarial intoxication  seem
  to  be  nervous  symptoms,  inasmuch as they often disappear
  quickly, or even suddenly,  to make room for some other symp-
  tom.  The  gastric symptoms that appear during the prodromal
  stage, or the attack itself,  indicate acute gastric catarrh, which,
  according to Muhry, may result from the direct influence  of the
[  poison on  the tongue, the  mouth, and the gastric mucous mem-
:  brane.   Whether this is the  case in intermittent  attacks that
  have a longer  period of incubation, I do not pretend to say,
  but the instances of rapid  outbreak of the disease, immediately
  after infection, seem to prove that the direct influence of the poi-
  son on these  parts is  at least possible.   In  simple  intermittent,
  diarrhoea or constipation may also be present, in addition to the
  evidences of  a mild gastric catarrh.  When this gastric  catarrh 
SPLENIC SYMPTOMS.
643
is more severe, and of longer duration,  associated with jaundice
and  with a general  febrile condition,  the  intermittent  fever
assumes the form of a remittent.   More serious disturbances of
the gastro -intestinal  canal  are  to  be  found only in pernicious
fevers ;  such, for instance, as hemorrhages from the stomach or
bowels,  incessant vomiting, and choleraic or dysenteric stools.
   The  disturbances of the liver,  in simple malarial fever, are
usually confined  to catarrh of the biliary ducts, with jaundice
and acute swelling, probably as the result  of hyperemia, which
is, however, less frequent than in the spleen, and is usually ac-
companied with pain  in  the region of the liver, occurring either
spontaneously or on  pressure.  In such cases Burdel found a
pretty abundant admixture of sugar in the urine.   The jaundice
in icteric pernicious fever and in the fievre bilieuse hematurique
is, in the great majority of cases, to be looked upon as of catar-
rhal origin,  more rarely as depending on an obstruction of the
smaller biliary ducts by pigment matter.  At the  same time,
cases have been observed in which the feces were colored, and in
which the contents of the bowels were found strongly tinged with
bile, in spite of the most extreme jaundice.  Chronic tumors of
the liver and amyloid degeneration favor the cachexia ; atrophy
of this organ leads to stasis in the radicles  of the portal cir-
culation, and especially to ascites.  In the case alluded to above,
with a large tumor of the liver and the  spleen, leucine was found
in the urine.
   Tenderness and actual spontaneous pain in the spleen, or pain
on  taking a deep inspiration, or on coughing, sneezing, moving
the  body vigorously,  or producing pressure  over the  organ,
together with enlargement of the same,  are phenomena worthy of
attention in malarial fever.  Duboue l and Derblich,2 however, are
mistaken when they represent the first symptom as being seldom
absent, and regard it as of great diagnostic value, inasmuch as in
many cases it may be  sought  for in vain, especially in all those
of a chronic  character.   It  arises from the great and  rapid
stretching of the capsule of the spleen during the paroxysm, and
is to be found, above  all, in children and young persons  during
               i Moniteur de sc. med., 1861, No. 83 et seq.
               a Wien. med. Wochenschr., 1864, No. 24. 
644
HERTZ.—MALARIAL DISEASES.
acute attacks, being less noticeable in older persons, with thicker
capsules that are not so easily distended.  AVhen the spleen has,
furthermore, formed adhesions to neighboring organs, tenderness
in this region, on moving or shaking the body, may remain per-
sistent.
   Enlargement of the spleen, from the most insignificant to the
most formidable in degree, is a far more constant condition.  If
the enlargement is  not  great,  the diagnosis must be made by
means of percussion, as  the tumor does not extend below the
margin of the ribs.   In more serious enlargements, however, the
organ extends, to a greater or less degree, into the cavity of the
abdomen,  occupies  a more vertical position,  and  may fill a
great portion of the left side of this cavity.   These large tumors,
on account of  their weight, and by reason of an elongation of
the  suspensory ligament of  the spleen, often  sink  far  down
towards the pubes, and are then characterized by great mobility.
In one of my  patients,  when lying on the right  side,  the  edge
of the tumor extended  into the right lower region  of the abdo-
men.  Swelling of  the  spleen  is even  found in the new-born
infants of mothers  suffering from malarial  fever.  In  ordinary
intermittent fever, the enlargement sometimes takes  place as
early as  during the  prodromal  stage; usually, however,  not
until the  stages of chill and heat,  receding  again during the
sweat and the period of apyrexia.  The spleen may swell rapidly
or slowly, and, as a rule, attains a larger  size in children  and
young persons than in those more advanced in years, the capsule
of whose spleen is thicker and less yielding.  It is also believed
that the enlargements are more considerable after quotidian and
quartan than after  tertian fevers.  When the attacks  are often
repeated, an increase of volume remains after the paroxysm is
past; but the very largest tumors of the spleen may also be
developed without any actual paroxysms of  fever or any demon-
strable rise of  temperature.  In  such cases we have to deal with
an insidious, hidden process, a chronic infection, in which, accord-
ing to my opinion, nothing but an accurate determination of the
daily excretion of urea can give us any measure of the slow but
steady progress of the disease.   According to some  observations
made by me, in such cases, the amount of urea was increased. 
                 MODUS OPERANDI OF THE POISON.          645

   The very evident and almost constant  way in wliich the
spleen is involved in intermittent fever,  suggests the idea  that
the  two  are very nearly  related.  With  our  present  know-
ledge we can no longer attribute the swelling of the spleen to an
overfilling of the  organ with blood  during  a chill  alone, as it
may attain to the very largest size in  chronic infection without
chills.  Piorry reverses the old proposition, and designates inter-
mittent fever as a result of disease of the spleen ;  Meckel and
Duchek also declare the spleen to be  the primary seat of disease.
On the other hand, again, according  to the reports  of  Jacquot,
Saurier, and others, people  are said  to die of malarial fever, in
Africa, without  the slightest swelling of the spleen.   A  singular
case is also narrated,1 in  which  a man received an extensive
wound of the wall of the  abdomen on the  left side,  through
which the spleen escaped ;  as it could not be returned it had to
be removed.  The patient recovered from the operation, and had
malarial  fever afterwards,  just  the same as before,  although
eventually a post-mortem examination showed nothing but the
shrivelled rudiment of a spleen left.  At the same time it  should
be  remembered  that  certain  organs,  such  as the lymphatic
glands, the spinal cord, etc., have been found  capable of  acting
vicariously for the spleen ; and it might not be uninteresting, in
fatal cases of intermittent fever, with or without enlargement  of
the spleen, to direct  some  attention  to the  state of the  spinal
cord.
   The  influence of malarial poison on the spleen may, perhaps, be accounted for
on the supposition that, on the one hand, it paralyzes the vaso-motor nerves, or the
coats of the  vessels  in  this organ, thus inducing hyperaemia; on the other hand,
that it directly injures the blood in the vessels, and in the parenchyma of the gland.
By the latter means the red blood-corpuscles are disintegrated and transformed into
pigment, and the white corpuscles are  hindered in their development, which
accounts for the small, rudimentary specimens of the same found by me.  In case of
the long duration or frequent repetition of the hyperaemia, abundant proliferation
of the adenoid connective tissue and permanent enlargement result.  Perhaps the
spleen may also be regarded as a depot of deposit for the malarial poison.

   The blood is only a vehicle for the poison, which,  by hypere-
mia and destruction  of blood corpuscles in  such organs  as are
                 1 Canstatt, Jahresbericht, 1860, IV, p. 70. 
646
HERTZ.—MALARIAL DISEASES.
disposed thereto, may occasion, at such points,  the local devel-
opment  of pigment-matter.  The  nervous symptoms are merely
expressions of the  disease, which,  it is true, play a very prom-
inent role  in malarial fevers, and depend  upon  irritation of
the most  varied nerve-tracts  through  the  malarial poison, or
through the  blood altered by this poison, as may be seen most
plainly in the masked  fevers.  The effect seems to be produced
especially on the brain and spinal cord,1  perhaps also on the
roots of individual nerves.
   The question of the cause of the rhythmical recurrence of the
paroxysms remains, as yet, unsolved.   This  periodicity used to
be  attributed to  some  influence of the moon,  and was  con-
sidered as a  manifestation of  increased vitality dependent upon
that luminary.   Again, it has  been explained on the ground of a
tendency  in  the nervous  system  to  work  by rhythmical  im-
pulses,  or by supposing  that  the poisonous material  had the
power of appearing in the blood periodically, and of manifesting
itself, sometimes  in a longer,  sometimes   in  a  shorter  time.
Others have  attributed it  to a natural tendency in the healthy
subject  to daily  fluctuations  of the   pulse and  temperature.
Heschl explains the periodicity of malarial  fever  depending on
the disintegration  of red blood-corpuscles,  on the theory that
the production  of  these  corpuscles is not a constant,  uniform
process, but  takes place by starts, with a daily maximum  and
minimum.
   It is a striking fact that the attacks of fever most frequently
occur between midnight and noon, at a time, therefore, when the
   1 Griesinger  (Infectionskrankheiten, Edit. II, p. 40) narrates some cases that bear
upon this.  In one patient with complete paralysis of sensation and motion of the lower
part of the body, due to fracture of the tenth dorsal vertebra, the paralyzed portions
remained unaffected, while the rest of the body underwent a complete paroxysm of fever,
with chill, heat, and sweating.  In another patient, after the cure of malarial fever by
quinine, regular paroxysms of horripilation and cold continued in an arm which was the
seat of a suppurating wound.  In a woman sixty-two years old, observed by Griesinger
himself, who had suffered for four years from traumatic anaesthesia of the left hand,
light attacks of intermittent declared themselves by chilliness and pain in that arm.
I myself treated a tobacconist in whom malarial fever showed itself by severe, regu-
larly intermitting neuralgia of both lower extremities, with chill  and subsequent heat
in the same. 
                   COURSE AND SEQUELAE.                647

organism has gone the longest without food, and when physio-
logical waste, as well as a pathological waste  caused  by the
destruction of numerous corpuscles, call most loudly for repair.
We might, indeed, be tempted by this circumstance to suspect
some  connection between the paroxysm and the principal meal-
times. This  view  is further  sustained  by  the  fact that the
attack may be diminished in intensity, and when it is light—
especially in  the case of  masked fevers and intermittent neural-
gia—may even be prevented, by the use of means that lessen tis-
sue metamorphosis, and therefore  physiological  waste, such as
strong coffee and  rum (a popular remedy), or other spirituous
drinks.  Ritter speaks  of the admirable  results  sometimes
obtained from  black coffee, even in cases  where arsenic failed,
and quinine did not  always answer his expectations.   May not
this  hypothesis account for the popular  treatment, known in
many lands, of attempting to break up the fever by hearty eat-
ing %—whereby, in  reality,  the paroxysms  do sometimes disap-
pear.   It is true that  Griesinger and Duchek have thus far failed
in producing any effect on the'recurrence of the paroxysms by
alterations in the hours of meals and  other relations of life ;
nevertheless,  in my opinion, this  question should not be alto-
gether ignored in the  future.

             Course  and Sequela, of the Disease.

   Simple  malarial fevers  run their course  in accordance with
the types indicated above,  one type occasionally running into
another.    Recovery  may undoubtedly  take place without the
assistance of medicine, if the patient withdraws from malarial
influences by taking up his abode in some non-malarious region ;
or if, as  is the case in  some places, malaria is endemic only at
certain seasons of the year, and  then disappears.  Often, how-
ever,  this recovery is only apparent.  The paroxysms, it is true,
become more indistinct and weaker, and finally cease altogether;
the patient declares  himself free from fever, and the physician
can only recognize the remaining, almost unnoticeable exacerba-
tions of  the  same, by the  most careful use of the thermometer.
At the same time the patients grow more emaciated, weaker, and 
648
HERTZ.—MALARIAL DISEASES.
more anemic; oedema  of  the lower extremities supervenes, the
skin assumes a  cachectic hue, and the liver and spleen are more
or less enlarged.   If this condition is recognized and treated
early enough, especially if the patient is removed from the mala-
rious region, recovery  is  still  possible.   Usually, however, the
cachexia advances  in its course unimpeded, or interrupted, now
and  then, by a more decided paroxysm of fever, and the patient
eventually dies of marasmus or of one of the sequels of malarial
disease,  such as amyloid degeneration of the liver  or spleen,
cirrhosis of the liver, with its accompaniments, Bright's disease,
scurvy and tuberculosis, or chronic diarrhoea,  In rarer instances
death follows suddenly by apoplexy—perhaps the result of pig-
ment embolism  of  the  brain—or by pneumonia,  or some  other
acute disease.   The cachectic condition is especially liable to be
developed during the tender years of childhood, and then usually
carries off its victim.
   The simple  malarial fevers of our part of the world present
no special difficulty in the way of treatment, provided this is
undertaken while they are in the acute stage.  But the cessation
of the attacks for  a time is no evidence that the disease is eradi-
cated.   Relapses are very liable to occur after a variable period,
which, being overcome  by appropriate treatment, may, after a
time, again occur, and  continue to do so  three  or four times.1
The possible  doubt as to whether these are true relapses may be
answered by  the fact of the great regularity with which they are
liable to recur at the end of seven, fourteen, twenty-one, or twen-
ty-eight days from the last  paroxysm, or  on days on which, if
the fever had continued, a paroxysm  would  have fallen.  The
very brief pause, often of but a few days, between the first attack
and  the relapse, as well as the fact that in some instances the
patients have withdrawn from the malarious region immediately
after the first attack, all argue  against the  idea of a new infec-
tion, and in favor of the theory of the relapse of a disease not yet
extinguished.  Relapses are to be met with not only in  simple

  1 Griesinger (Infectionskrankheiten, II Aufl., p. 43), at the Tubingen Clinic,  saw
208 relapses in 414 cases (50 per cent.); of these 208, a second relapse a\ as observed in
113 (54 per cent.) ; 50 of the 113 had the fever a third time (40 per cent.) ; and 17 out
of the 50 (,34 per cent.) relapsed for the fourth time. 
                             SEQUELAE.                        C4Q

 malarial fevers, in the masked, pernicious, and remittent forms,
 but, even in those suffering from malarial  cachexia,  paroxysms
 of fever often show themselves, which still further undermine the
 constitution of the patient.   The  type of  the disease may also
 be changed in relapses ; indeed there seems to be a tendency to
 assume the  shorter  types.   Thus Griesinger reports 64.5 per
 cent, of  tertian and 29.2 per cent, of quotidian fevers in a cer-
 tain lot ; afterwards, during  the relapses  in  this lot, only 35.4
 per cent, of tertian and 51.6 per cent, of quotidian.  Aside' from
 certain injuries and  bad conditions that  were mentioned linden
 the head of predisposing causes,  age seems to have the greatest
 influence in determining the  occurrence of relapses.   Griesinger
 found  during the ages of from  one  to ten years 64  per cent. ;
 from ten to twenty  years 52 per cent. ; while  from  twenty  to
 ninety there were but 38  per cent, of  relapses.  The period  of
 time  within  wliich they may show themselves is very variable.
 As a rule, they occur within a few weeks, and  we do not con-
 sider the malarial influence as overcome  until some six or eight
 weeks  have  elapsed without  an attack.   Individual instances
 occur in which relapses do not appear until after some months.1
 Assertions such as those made by Todd and Guetano, and illus-
 trated by cases,  to the effect that the marsh-poison, having once
 penetrated into the system, can never be entirely driven out, have
 thus far met with very little support.8
   The sequela?, of this  disease entitled to mention, aside from
 chronic secondary malarial cachexia, are,  diffuse nephritis in the
form of  the enlarged kidney, amyloid  degeneration of the kid-
   1 Two cases by Braune, Archiv f.  Heilkunde, XI Jahr., p. 70.
   2 Ritter (Virchow's Archiv, Bd. 50, p. 164) speaks of what he calls " after epidem-
ics," as, in his experience, the year after the prevalence of an epidemic of acute mala-
rial infection there is an epidemic of chronic infection (1827 and 1869).  He explains
this, as a general rule, as follows, that in addition to an acute infection a certain num-
ber of chronic infections take place, which remain latent during the whiter and are
called into activity by various circumstances during the spring.  He thinks that the
two epidemics are proved to belong together by the fact of their occurring within the
same area and affecting the same individuals—often invading the same houses and even
attacking the same persons.  Probably the actual condition of things is this: that
some of these persons are laboring under primary chronic infection, others under secon-
dary malarial cachexia, perhaps in both cases with feeble relapses of the same. 
650               HERTZ.—MALARIAL DISEASES.

ney, the same of the liver and  spleen, contractions of the liver,
the hemorrhagic diathesis, scurvy, tuberculosis, certain nervous
affections, such as neuralgia, conditions of paresis and paralysis,
as well as various psychical  disturbances which supervene after
severe intermittent fevers, and are perhaps due, as some believe,
to pigment obstructions.  Here, according to Griesinger,1 instead
of the ordinary paroxysms of chill and heat, we find intermittent
paroxysms of  insanity, which, with the cessation of the periodi-
city, assume the remittent or continued type,  and may pass into
chronic mental diseases.   More frequently,  however,  psychical
disturbances appear  during the period  of  convalescence,  as
sequels to the disease, or not till months after it  has  been sub-
dued, particularly following long-continued,  severe  attacks of
fever, especially of the quartan type.  After  severe  epidemics,
abortions,  or premature  labors  are  frequent, as is declared by
Sebastian and others, and  confirmed by the statistics  of the
lying-in asylum at this place.  Ritter, on the other hand, found
neither abortions nor any deviations  from the ordinary course of
pregnancy and parturition.

                          Prognosis.

   The  simple,  acute intermittent  fevers of our part  of the
world, under systematic  treatment, warrant a favorable progno-
sis, as a rule.   This, at least, is true, where the epidemic is not
severe, or where the circumstances of the patient are such as not
perpetually to  expose him to the influence of intense poison, nor
constantly to renew the disease when it is nearly subdued.  The
prospect is more unfavorable in the virulent malarious regions of
warmer climates, or in the temperate regions during an especially
hot year.  Furthermore, the  individuality1 of the patient,  the
age of early childhood2  or of,advanced senility, or a previously
weakened  constitution  may, with  a moderately  severe  acute
   1 Pathologie und Therapie der psychisch. Krankheiten, 2 Aufl.  Stuttgart, 1867,
p. 188.
   s In Algiers, according to the reports of Semanas, there is great mortality among
the children of immigrants, in whom malarial fever often ends fatally at the end of
twelve to forty-eight hours, with adynamic, bronchitic, or laryngitic symptoms {Gerhardt,
Kinderkrankheiten, 1861, p. 120). 
PROGNOSIS.
651
attack, or the long  continuation of single stages, or paroxysms
with short intermissions, make the prognosis  unfavorable.  The
most  favorable  results are obtained  in the  tertian  type,  less
so in the  quotidian,  which  weakens the constitution  of  the
patient  far more, and least so in the  quartan form, which but
rarely prevails over  any considerable  extent  of country (Berlin
epidemic  of  Wolff).   The  anticipating of  the paroxysms is
looked  upon  as an  unfavorable  sign,  especially if  the later
attacks increase in  severity ; it is favorable only when they
become lighter and  shorter.   Postponing of  the paroxysms is
desirable in the quotidian form, inasmuch as it indicates transi-
tion to the more tractable tertian,  when  the attacks diminish in
length and severity ; it is unfavorable, however, when they aug-
ment  in intensity,  or when  the constitution of the patient is
evidently breaking down, as we then fear a  change to the more
malignant  quartan type.   The same thing is  true of subintrant
fever, as constituting a transition stage to the  remittent and con-
tinued fevers,  which  we  heartily deprecate.  The progressive
weakening of the paroxysms, while the spleen and liver remain
large or increase in  size, and while anemia gradually  develops
itself, is very unfavorable, as  it indicates the certain development
of malarial cachexia.  Complications affecting  any  important
organ, or the occurrence of any of the sequele of the disease,
vitiate the prognosis.
   Masked fevers give a  favorable promise,  as they generally
yield  easily to remedies,  and probably never, alone, lead to ca-
chexia.
   Pernicious fevers, in  general, are  unfavorable enough, inas-
much as, where  prompt assistance fails, they are apt to termi-
nate fatally in the second or third attack ; when recovery ensues,
they drag through a weary convalescence, or may even leave dis-
turbances of various kinds  behind them  for a time or perma-
nently.   Much depends, in these cases,  on the intensity of the
epidemic, on the question whether it is  advancing, receding, or
at its height; on the age and  constitution of  the patient;  the
question of the presence or absence of complications, the longer
or shorter rhythm of the  attack, and whether the intermissions
are complete or not, as well as on the  form and grade  of  the 
652
HERTZ. —MALARIAL DISEASES.
 disease.  Beyond doubt, the most favorable cases are those of
 the tertian type, with as complete an intermission  as possible.
 The most fatal seem to be  the algid-choleraic and  the  tetanic
 forms; the delirious and comatose varieties being less so; and
 those with localization of the disease in the lungs more favorable
 still.
    In  the lightest forms of  remittent and continued malarial
 fever, the prognosis is good ;  it is doubtful  in the medium and
 worst  forms,  especially  with a persistent low temperature and
 imperfect febrile reaction, or none at all.   According to Veillard,
 the "fievre bilieuse hematurique" belongs to the severest forms,
 and in weakly patients, or when early and effective  treatment
 has been neglected, usually ends in death.  We must always
 look with suspicion on very intense icterus,  continuous fever,  or
 very short and incomplete remissions, frequent and violent vom-
 iting, suppression  of urine,  a considerable admixture of blood
 with the urine, as well as other hemorrhages and hiccough.
    The prognosis in chronic malarial intoxication depends upon
 the grade of  the disease, that is, the severity of  its manifesta-
 tions.   The size and consistency of the tumors to be found in the
 spleen and liver give some  indication of the gravity of the con-
 dition.  When  the symptoms are moderate, the enlargements
 inconsiderable and not firm or hard, and when  neither ascites
 nor any of the more serious sequele have appeared, the prospect
 is  not  so unfavorable.  In  general, it may be  said that pri-
 mary infection or  cachexia, if moderate, offers  better chances
 for recovery than the secondary form, in which the patient  is
 usually reduced in health  and  constitution by the  previous
 paroxysms of fever.  Large tumors  of the liver and spleen can-
 not usually be reduced; still, if the liver  is healthy, and the
 patient removes from a malarious neighborhood, such tumors  of
 the spleen may often be carried for a long  time without detri-
 ment to the individual.

                         Diagnosis.

   A well-marked  attack of intermittent fever is so character-
istic that it  can hardly be confounded  with  anything  else.
When the paroxysms are not distinctly marked, however, and 
                         DIAGNOSIS.                      6" 3

symptoms of gastric disturbance are prominent, one may be led
to suspect gastric fever.  Diarrhoea and meteorism, if present,
may suggest typhoid  fever.   But the occurrence of herpes, the
absence of roseola, and above all the thermometric record, which
usually shows morning exacerbations instead of the evening rise
of typhoid fever, as well as the non-febrile intervals  present, and
the well-known  epidemic  influences under which the  patient is
laboring, are all important points in the case.   As  soon as dis-
tinctly marked paroxysms,  with their  characteristic  stages and
complete  intermissions  appear, all doubt is at  an end.  The dif-
ferential diagnosis between  intermittent fever  and pycemia is
more difficult, as the paroxysms and the high temperature are
common to both.  Besides the local troubles liable to exist in
pyemia (wounds, the puerperal state, etc.), it will be observed
that in the first pyemic attack the temperature rises much more
tardily, and generally falls more rapidly than it has risen ; at the
 same time  it  more rarely reaches the  normal  standard, but is
arrested at about 100.5° Fahr. to 101.25° Fahr., and,  as soon as the
minimum is reached,  begins to rise again, without, however, reach-
ing its former height.  It is rare to find a  complete apyrexia in
pyemia,  or  an approximatively normal  temperature  lasting
 from twelve  to twenty-four  hours;   still, cases  do  occur in
 which  the  temperature falls below the  normal standard, to 95°
 Fahr. or 93.25° Fahr., the pulse usually remaining rapid. Usually
 the attacks are irregular,  and treatment  with quinine proves
 unavailing.  We are saved from confounding malarial fever with
 the hectic of  tuberculosis,  by the absence of  those signs charac-
 teristic of the latter,  viz., local pulmonary affections, emaciation,
 night-sweats, diarrhoea, etc.
    The diagnosis of masked intermittents rests on the  prevalence
 of malaria, the  well-marked rhythm of the attacks, the sudden
 appearance and disappearance of the symptoms, with frank inter-
 missions,  the occasional febrile manifestations that supervene,
 such as chilliness, uneasiness, cold or hot sweats, and on the
 results of treatment.
    The pernicious fevers, with short intermissions or none at all,
 are often, and very unfortunately for the patients, mistaken for
 other diseases,  especially when the local symptoms  are promi- 
654
HERTZ.—MALARIAL DISEASES.
 nent.  Thus, every once in a while I have a  patient with coma-
 tose intermittent fever sent  into  hospital with  the  diagnosis of
 apoplexy.  Not only the outspoken disease,  but certain unusual
 appearances that may be seen in the paroxysms of simple mala-
 rial fever that precede the pernicious attacks,  and during the
 intermissions of such paroxysms,  are worthy of note, inasmuch
 as  they indicate the danger of a  pernicious attack.   Such are,
 severe headache, extreme prostration, an irregular, small pulse,
 unusual drowsiness, or restlessness and vigilance, apathy, a dim-
 inished secretion of urine, as well as an increase in the severity
 of successive paroxysms.  In determining whether any  given case *
 is one of  pernicious fever, we must consider  the question of the
 endemic or epidemic influences prevalent, inquire  into the exist-
 ence  of previous attacks of malarial fever,  observe  the rhythm
 of the attack,  notice the individual stages, which  are usually
 recognizable, the disappearance or diminution of the symptoms
 during the intermission and  their subsequent aggravation,  etc.,
 etc.   Where the diagnosis cannot be made with certainty, it is
 of the utmost consequence that we do not await another attack
 for the purpose of determining the question ;  but, in view of the
 imminence of the danger, that we  treat it as a pernicious attack,
 and at once institute vigorous measures.   The choleraic and algid
 forms are to be distinguished from cholera by the elevated  tem-
 perature ; the algid form is further distinguished by the fact
 that the stools, if present, are  not profuse,  and do not appear
 until late in the disease; finally, according  to Rigler, the urine
 of cholera contains albumen, while that of intermittent does not.
 The difference  between  pneumonic intermittent  and genuine
 croupous pneumonia is, that in the former each paroxysm is
 ushered in by a more or less marked chill, and that the tempera-
 ture returns to its normal standard during the intermission, while
 the objective symptoms, especially  the physical  signs, abate
 during this period, to be aggravated again during the subsequent
 attack.   The signs given by Fay moreau for a differential diagno-
 sis between icteric pernicious fever and the fievre bilieuse hematu-
rique (such as vesical tenesmus and pain in the region of the liver
in icteric fever; pain in the region of the stomach in  the other
form ; the absence of blood and hematine in the urine, of intes- 
                  PROPHYLACTIC MEASURES.               655

tinal hemorrhage, of purpura and of ecchymoses of the skin  in
the icteric form) do not appear to me to be sufficient,  I believe,
therefore, that they represent but the one form of disease, which
at one time runs a more paroxysmal, at another time a more
remittent or continued course, with less strongly marked bilious
symptoms.   This form is distinguished from yellow fever by the
fact that where it is endemic it hardly ever attacks new-comers,
as yellow fever does, but persons who have lived in the place for a
longer time, at least a year, and who are disposed to intermittent
fever.  Furthermore, the fievre bilieuse hemat. has an adynamic
character from the beginning ; yellow fever, on the contrary, an
erethetic character (redness of the face, a glistening eye, injected
conjunctiva, hot skin, and strong pulse); in the former,  jaundice
is one of the earliest symptoms, and hematuria a pathognomonic
sign, while  in yellow fever  hematuria often does not exist, and
jaundice belongs to the later stages of the disease.  Finally, in
the one case quinine shows its greatest efficacy, in  the other it is
useless.
                          TREATMENT.

    Malarial fever is one of the  diseases in which prophylactic
measures are of the greatest importance,  belonging in part  to
the domain of public hygiene,  and  in part  falling within the
scope of individual effort.  Swamps in malarious regions should
be laid dry, or, where this cannot be done, care should be taken
that the ground is always covered with a moderate sheet of water.
Ditches  of  stagnant water, in the vicinity of towns, should be
emptied and kept dry.   In marshy bottom-lands  such  drainage
should be established as will regularly and sufficiently carry off
the water, and where such lands lie in the neighborhood  of rivers,
inundations should be  guarded against by the construction  of
dykes.   Large  tracts of uncultivated land should be brought
under careful cultivation;  the streets of cities should be paved
and kept  clean.  Furthermore,  it is  the  duty of those having
charge of the public health to provide a supply of good drinking-
water1 and  to establish  poor-houses orj)laces of refuge for  the
 "^lulhTsup^ip^s^thT^s^oTwerdam may be found water that has
filtered through the sandy soil at some hours' distance from the city. 
 656              HERTZ.—MALARIAL DISEASES.

 shelterless.  The  principal prophylactic measures that  can be
 adopted by individuals are, for strangers who are about to migrate,
 to a malarious region, to select, if possible, that  season  of the
 year when malarial fever is least prevalent and severe, to avoid
 those places which are known as special hotbeds of the disease,
 and to adapt themselves, as soon as possible, to the  ways of living
 of the natives.  These precautions are particularly  important for
 those coining into the  tropics from a cooler climate.  Here, the
 winter months—from November to January, for instance, in the
 East Indies, and from January to March, in the West Indies—are
 the most favorable ones in which to arrive,  in the hope of becom-
 ing so far acclimatized during this period as to be to some degree
 steeled  against the malarial miasms of  the succeeding months.
 Even during the passage from Europe, if the sea-voyage is not so
 long as to give one a chance to become accustomed  to a warmer
 climate, certain precautions may be taken on board  ship that will
 lessen the  tendency to fevers.  These especially embrace provi-
 sions wliich  insure an abundant supply of fresh, pure air, cool
 sleeping places, cool drink, a light, digestible diet, and the avoid-
 ance of  all excesses,  especially in eating and drinking,  the use of
 alcoholics, etc.  On arriving,  a  somewhat  elevated, hilly region
 is to be  selected, or, where this is impossible, it is better to spend
 the  first few days on board  ship, on the high seas, thin  to be
 delayed on a marshy coast.  All night-work in tropical swamp
 lands is to be avoided ; and when one is obliged to travel through
 unwholesome regions, the hours of  from three to six o'clock in
 the afternoon are to be selected for this purpose, as  at that time
 the greatest heat and the most abundant exhalation  are past, and
 the miasms lie in the upper strata of air.
  ^ In our climate, too,  it is desirable to select the highest and
 driest residences, far removed from swamps, and never to have
 one's sleeping rooms on the ground floor, but upstairs, and, if
 possible, on the east or south side of the house.  Fresh air and
 cleanliness  must be  secured, but the bedroom windows should
always  be  closed during  the night.   The clothing  must be
appropriate to  the climate;  in  warm  countries cotton under-
clothing and hose are enough,  in cooler climates they should be
of wool.  One should  avoid getting wet,  and every  means of 
               PROPHYLACTIC  ACTION OF QUININE.          657

taking cold, as well as remaining long in the vicinity of swamps,
sitting out-of-doors in gardens that lie  low, or are enclosed by
high trees or walls, especially after rainy weather, and during the
damp  evenings one should be in-doors.  Sleeping  out-doors  is
very injurious, as well as bathing in rivers or lakes after sundown.
In  tropical regions strangers  must also avoid exposure to the
powerful heat of the sun, and all undue bodily or mental exertion.
   All excesses,  sexual as well as dietetic, are to  be shunned.
The food should  be simple and nourishing,  and in accordance
with the customs of the country, such as highly seasoned food;
fresh, good, and  not too fat meat; easily digestible fish; fresh
vegetables ; good, well-baked bread or rice ; and for drink, good
water which has no possible connection with the swamps.  Where
such water cannot be had, let it be boiled, or filtered through char-
coal, or let the artificial carbonic-acid water be used.   Tea and cof-
fee, good wine, and even small  quantities of brandy are desirable.
Raw salad, watery fruits in large quantities, as well as much
milk and beer, are injurious.  Every feeling of sickness,  and
especially any gastric or intestinal catarrh, should be attended to.
   The prophylactic action of quinine,  which was first observed
by Bryson in  the fevers prevalent on the coast of Africa, has of
late received  ample confirmation on the part  of various writers
(Balfour, Baikee,  Saussure, and Rogers).   The dose used  was
two and one-half to three or  four and one-half grains, two or
three times a day.  Jilek ' reports from Pola, that in a garrison
of 736 men, 500 of them were  given daily,  at  first three grains,
afterwards one and one-half grains of quinine apiece,  and a pint
of wine, while the remaining 236 men were left entirely without
treatment.  Mnety-one of the  first lot (eighteen per cent.) were
taken sick, though in a mild degree and without many relapses ;
of the last lot, or those without treatment, sixty-eight were taken
sick, being twenty-eight per  cent.  The experiments made by
Baxa, in Pola, did not yield the desired result,  and he, therefore,
recommends, instead of the daily smaller doses, to give a weekly
dose of twelve grains.  Colin s experience in Italy and Algiers also
fails to  confirm the favorable  influence  of this treatment, espe-
1 Wochenbl. der Gesellschaft der wien. Aerzte, 1870, No. 17.
 VOL. II.—42 
658              HERTZ.—MALARIAL DISEASES.

dally in preventing relapses, and he even believes that the system
becomes accustomed to the remedy, and that so it loses its effect
entirely.   My own observations on this point, made on myself and
on others, leave no doubt as to the efficacy of this daily preventive
dose.  In some instances the attacks are entirely kept off during
this  treatment, in others they occur only in the lightest forms.
I have never seen any protection afforded against relapses, and I
have noticed  that the  system established  a tolerance of the
remedy,  so that,  in order to obtain  its full effects, one  was
obliged to omit the treatment for two  or three weeks at a time.
I have no experience at all in the use of the larger weekly doses.
In  the more  serious  epidemics it may, therefore, be  recom-
mended to those who are unable to leave malarious regions (which
is unquestionably the  best prophylactic), that they make use of
daily doses of quinine.  I recommend  from four to five grains
morning and night.  In the ordinary endemic diseases it is well
to pay attention to the first signs of being  sick, and a  dose  of
nine to twelve grains of quinine on going to bed  at  night, for
three or four  days in  succession, is usually enough to break up
an intermittent \   I have never seen any special results from the
use  of the  tincture of gentian  or the tincture  of  mix  vomica,
which are also recommended as prophylactics.
   The febrile attack,  itself, if it is a simple intermittent, usually
demands no special treatment in  our part  of the world.  All
that is necessary is to keep the patient from injurious influences ;
but  in order to accomplish that, he  should, even in the lightest
cases, take to his  bed  on the first appearance of  a paroxysm,
and abstain from all  food until it is over, for fear of inducing
vomiting.   Only in case of particularly distressing or dangerous
symptoms is interference demanded.   During  the chill it is best
not  to pile on too heavy  bed-clothing, as  it only fatigues the
patient,  and to avoid the administration of copious hot drinks,
whereby it is vainly  hoped that  the  attack  may  be  cut short.
The sensation of chilliness is not removed by such means, and some
  1 The fear expressed by Neuhdld (Oester. Zeitschr. f.  prakt. Heilkunde, 1862, No.
18), that the early use of quinine might stimulate the development of dangerous sequels,
such as dropsy, etc., is entirely without foundation. 
                  TREATMENT OF THE PAROXYSM.            659
of those which have been recommended for this purpose, such as
warm or steam baths, alcoholic drinks, running or other severe
bodily exercise,'  can only do harm.   This sort of treatment is
not to be recommended, even in severe and long-continued chills ;
but we must content ourselves with friction of the skin, warming
of the bed, and, if thirst is excessive, with the administration of
a moderate amount of warm tea  or sugar-water.   In persistent
vomiting,  effervescing mixtures or  small doses of opium are indi-
cated.  Where, as is  most  likely  to occur in children and aged
persons,  the vital  powers  sink, the  pulse becomes  small  and
irregular, the respiration shallow, and collapse is threatened, the
analeptics  may be resorted to with confidence ; such as strong
wine,  ether, camphor, and black coffee internally, inhalations of
ammonia, sinapisms and frictions  with spirits and mustard, as
well as stimulating enemata.
   During the hot stage cool surroundings  and  light covering
are desirable, a  moderate indulgence in cool, refreshing drinks,
and,  in case of vomiting, broken ice by the stomach.  If severe
headache and delirium are present, giving evidence of considera-
ble congestion of the brain, cold water or ice-compresses should
be used, sponging of  the body with vinegar and water, and per-
haps vinegar clysters.   The local  abstraction of  blood from the
temples is only  to be practised in robust individuals, and even
here  venesection2 must  be resorted to with the utmost caution,
as it is often followed by alarming  collapse.   The  sweating stage
requires no particular  attention, and  above all no measures to
force  sweating.  At  the close of  tins  the patient may change
his linen, leave his bed, and, if the season of  the year is propi-
   1 Berndt (Fieberlehre, Leipzig, 1830, I, p. 629), asserts, it is true, that he has often
seen strong persons overcome the chill by hard running, and thus shorten the paroxysm.
   2 The application of wet  cups along the spine, as recommended by Mons (1836), and
by means of which Zimmermann claims to have cured forty-one patients out of fifty-
two, has met with but little support. If, as has been reported, it is possible to break up
the fever during the  stage of chill, by energetic venesection, so that the remaining
stages are not developed, still such a result is rare, and the danger of the severe brain
disturbances that may follow it, such as convulsions and coma, is not to be underesti-
mated.  Groh, of Olmiitz,  has seen the chill give way, during the cold stage, on the
inhalation of cinchonicether (3j).  The attack was reduced to a  minimum, and no
relapses occurred.  The same effect is claimed for chloroform inhalations. 
660              HERTZ.—MALARIAL DISEASES.

tious, may go out, after a few hours, observing every precaution
against taking cold.  If the apyrexia is incomplete, he should
remain in bed. As regards diet, light but supporting food should
be indulged in on the days of the intermissions ; on  the  days
when an attack is expected but little  should be eaten, as a full
stomach readily induces vomiting.
   In pernicious  intermittent fevers, the expectant plan, which
is appropriate during the  attack in the simple  form,  is utterly
out of place.  Here alarming symptoms crowd  on one another,
and  it is often only by prompt and vigorous measures, on the
part of  the physician, that the patient  can be rescued.  And it
is not only the alarming symptoms that occur during the attack,
but the disease itself that  must be combated by specific means,
the value of  which has been thoroughly established by experience.
   Where the  fevers have a  more sthenic character,  and par-
ticularly in the  pernicious icteric intermittent,  it  has  often
proved  of advantage to precede or accompany  the specific qui-
nine  treatment with vigorous purgation.  The most appropriate
article  to use  is calomel in  large doses, five  to eight grains,
repeatedly.   In the delirious form we should avoid venesection,
even in full-blooded persons.  Where the abstraction of blood is
needed,  it should be done by local means ; usually,  however,
cold water or ice-compresses to the head, derivation by enemata,
and  counter-irritation to the extremities are to be  preferred.  In
coma and apparent death, stimulating enemata, strong irritants
to the skin, and  tincture of musk subcutaneously may be used;
and in  violent vomiting,  opium, effervescing draughts, ice-pills,
camphor, and strong irritants over the region of the stomach.  In
severe chills, strong friction of the skin and warming of the bed
with hot stones ;  in the algid form, rubbing the  skin with spirits
of camphor and mustard,1 or with ice, and internally stimulants,
such as ether, champagne, and strong wine, are to be employed.
In all cerebral symptoms which are ushered  in by great excite-
ment and restlessness, opium or morphine is indicated, and may
best be combined with the quinine.  In  the diaphoretic fevers,
the  mineral acids, and drinks containing these  acids, seem to
limit the excessive sweating.
1 Oil of mustard one part, alcohol fifty parts.— German Ph. 
                ADMINISTRATION OF QUININE.             661

   As  soon as the diagnosis of intermittent fever is established
we  should not delay  therapeutic interference,  though  in  the
simple form we may await an  intermission, for the attack which
is already begun is not likely to be arrested nor shortened by
the use of the ordinary empirical means that cure malarial fever.
The former method, which was to await several  attacks, and if
there were gastric disturbances, first to remove them by  the use
of emetics, has gradually been abandoned, inasmuch as  it only
causes loss of time, and the gastric troubles usually recede any-
how under the use of  quinine.  In a very few cases, where  a fit
of  indigestion seems to have been the determining point for the
attack, an emetic may be advisable.   The same  rule holds good
with regard to laxatives.  They are not called for in  simple
fevers unless there is decided constipation.
    A  great number of  remedies have  been recommended at
various times, for regular intermittent fever, as well as  for the
pernicious fevers, the  efficacy of which  has afterwards been in
part confirmed and in part thrown into doubt,  and they have
therefore soon fallen into oblivion.
    Quinine still occupies the front rank among  these remedies,
the form ordinarily used being the simple sulpTiate, which is
given in solution, in powder,  or in pills.  The former practice of
prescribing it  in frequent small doses, two grains  every two
hours, wliich is even now often met with, ought  to be  given up,
for intermittent  fever;  because,  on the one hand, the entire
intermission is often occupied in this way without the patient's
receiving a sufficient amount of quinine, and, on the  other, the
doses given shortly before the attack have no time to act, and
an absolutely larger amount  of the drug is required to  prevent
an attack, if given  in this way.  It often happens that these
frequent, small doses  will not cure the fever, but merely make
the paroxysms shorter and  milder.  I have many times  had
occasion  to see patients who had been treated  in this way for
months without effect, and in whom a few large  doses  broke up
the fever at once.   The method of treatment recommended by
Maillot,1 and afterwards by Pfeufer, in which one or two large
doses are to be given^diyvrm^^^^^^^^ the most
               1 Traite de fievre intermit. Paris, 1836, p. 362. 
662              HERTZ.—MALARIAL DISEASES.

unqualified preference.  In simple intermittent, 9, 12, 15, or 22
grains should be given as a single dose, or 1\ to 12 grains twice
to three times, but in such manner that the last dose shall come
five or six hours before the expected  attack.  In younger per-
sons,  from sixteen to  twenty  years  old, one-third less  may be
taken ; children from ten to fifteen years of age should have one
dose of 6f grains,  or two doses of 4£ grains ; children from three
to six years of age, one dose of 4£ grains, or  two doses of If
grains.   These amounts are calculated completely to subdue the
disease,  if it is simple  intermittent fever,  especially in recent
cases.  Often, however,  particularly in cases that  are not  very
recent, the next, or perhaps even  a second  attack may occur,
although much weaker, and, as  a  rule, postponed.  If relapses
take  place,  one  dose is usually enough  for  their  removal;
where,  however, they are  frequently  repeated, and especially
where the patient's constitution is running down, it is well to
put him  on the more  prolonged use of the remedy,  combined
with iron, if he be an anemic subject.1   To adults  I usually give
4J to 6 grains morning and evening, to children  2i grains.  It
is desirable for  the  sake  of  avoiding  relapses,  in malarious
regions, to pay special attention to those days on which, in case
of the continuance of the fever, an attack would have occurred,
viz., in the  tertian type, on the third, fifth, seventh, and ninth
days, etc., and to give a dose of quinine on those days.   It is
wrong  to suppose that  attacks always recur  on the seventh,
fourteenth,  twenty-first,  and twenty-eighth  days,  and that the
patient should therefore take a dose of medicine on the day pre-
ceding those days.  Attacks are very likely to occur sooner and
to surprise the patient.   The use of  cinchona, of the wine, tinc-
ture,  and extract of cinchona are to be recommended, although
less reliable  than quinine; the tincture of quinoidine is  also a
desirable preparation,  especially on account of its cheapness.   It
is well to impress  on  patients the importance of noting the first
warnings of an attack, and as soon as such are observed, let them
take  a good-sized dose of quinine for several days in succession.
   1 van Dommelen (Aerztl. Intelligenzbl., 1864, Beil. 11) recommends pills of sulphate
of cinchonia and saccharated carbonate of iron, each, 30 grains, a day, divided into
hourly doses. After two or three days the dose is reduced to 15 grains, and finally to 9. 
                HYPODERMIC  USE OF QUININE.             663

   In  pernicious  malarial fever,  it  is usually necessary,  on
account of the more imminent danger, to increase the doses con-
siderably, and, as has  already been  stated, not to wait for  an
intermission, but to give the medicine during the attack.  I give
30 to 45 grains a day, usually in two or  three 15-grain  doses.
Maillot once ordered 180 grains during the twenty-four hours,
with a good result.   The use of quinine must here be continued
until the alarming symptoms have been relieved.  When large
doses  of  quinine in solution are vomited, or  when  there  is
extreme irritability of  the stomach, the extract  of  opium,  or
tincture of opium, with  aromatics, should  be added to the qui-
nine.  When even  this  is not borne, or when there is  severe
hemorrhage from the stomach, or if the patient is suffering from
uncontrollable vomiting, or  cannot  swallow,  quinine  must be
given by  the rectum, in which  case it is absorbed with equal
promptness.   When  used in  this way the dose is 3, 1\, 9, or  15
grains,  and in pernicious fevers  as high as 30 grains, combined
with some opium.  Under similar circumstances, where quinine
cannot be introduced into the stomach, it may be given by hypo-
dermic injection, by which method the effect of the drug  is pro-
duced much more  rapidly, and with  the use of a much smaller
amount.  Only about one-third or one-fourth of the dose is to be
used hypodermically that would be given  by the stomach, 2J to
3 grains being usually sufficient to overcome a simple  intermit-
tent attack.   Some  claim  to  have observed (Moore) that if  the
injection  is given  during  the attack, the latter will be made
milder or even cut short.  The solution ordinarily used contains
one gramme  (15 grains) of  quinine to  two  and  a half fiuid
drachms of water,  and a few drops  of sulphuric  acid.  Of this
from 5 to 15 minims are used as an injection,  containing  from i
grain to \\ grains of  quinine.  As considerable irritation  of  the
skin, with the formation of abscesses, is liable to occur, Barnatzik
recommends the following formula as being less irritating to the
tissues : Sulphate of quinia,  150 grains ;  hydrochloric acid,  50
minims ; and distilled water, 4} fluid  drachms. The indications
for  the hypodermic use of quinine, then, are gastric disturb-
ances ;  pernicious attacks-on account of the more rapid action
of the drug, and in case  the patient cannot swallow-larger doses 
664              HERTZ.—MALARIAL DISEASES.

being required in  the pernicious than in the simple form ;  as
well as  the intermittent fevers of children, particularly if asso-
ciated with eclampsia.  The applicability of this method to the
last  class is somewhat limited by the tenderness of the  skin in
children, which often  reacts severely under injections.
   Quinine has also been used externally by inunction (22 to 30
grains  in  3iv  to  3 iijss  of lard), or  as a spirituous solution,
applied on compresses or used  as a bath, and has given very
good results, especially in children.  By this method at least ten
times the amount of the drug must be used, and consequently
the item of expense has to be considered.1
   The following other salts of quinine are recommended, with-
out, however, presenting any advantages over the sulphate.
   The bisidphate of quinine is soluble in water, and is preferred
to the simple sulphate by some (Bonaventura), on account of  its
affecting the stomach  less.  Symptoms of cinchonism, however,
(roaring and  ringing in the ears, deafness, beating,  and throb-
bing in the head, etc.), supervene more quickly after its use, and
it is therefore to be given in smaller doses.   Hydrochlorale of
quinine is more soluble  than the sulphate,  contains a larger
number of effective ingredients (in the ratio of 83.6 to 74.3), and
is therefore also more  expensive.  According to Binz, it is greatly
to be preferred to the  sulphate.  Tannate of quinine,  on account
of its greater insolubility, has to be used in larger doses, as much
as two  to  four times  as large.   It is distinguished  for its less
unpleasant taste and  for producing less symptoms of intoxica-
tion, consequently it recommends itself for use with children
and nervous women, as well as in the diarrhceal and  diaphoretic
forms of intermittent.  Valerianate of quinine, a very soluble
salt, is used  in the intermittent neuralgias of  nervous  women.
The sulphotartrate of quinine is said  to be more effective than
the  sulphate, on account of its greater solubility (Mazza), and to
  1 Chevrey (Gaz. des Hopit., 1856, No. 70) cured two children, eight and ten years
old, who were seized with intermittens perniciosa hydrophobica, by enveloping them in
cloths saturated with a strong, warm decoction of cinchona, and changed every two
hours.  They were cured in seventy-two hours.  He also cured  a case of  dysenteric
intermittent, in an actress, by cinchona baths of eight  hours' duration (10 lbs. 8 ounces
to the bath). 
              VARIOUS ALKALOIDS OF CINCHONA.           665
cure obstinate fevers  and tumors of the spleen, even when given
in small doses (Barella).
   The remaining salts of quinine that have been recommended,
as the urate (Pereira, Armand), the arseniate  (Taglioni), used to
the one-fifth  or the one-fourth of a grain daily, in divided doses,
the citrate and lactate, the chino-picric acid, the iodide of qui-
nine, and the iodide of iron and quinine, are not  deserving  of
any further notice.
   Among the remaining alkaloids of cinchona that are in use,
cinchonine is worthy of mention,  the  sulphate of which is em-
ployed, and  is rendered more soluble by the addition of a few
drops of sulphuric acid. The dose is at least one-half larger than
that  of quinine, in spite of which its effect is still slower and
more uncertain,  and  it is therefore only adapted to light cases.
The intoxication observed by Moutard  and Martin, as occurring
within  one-quarter to one-half hour after the administration of
even small doses of  cinchonine, and which consisted of severe
frontal headache, a feeling of weakness, even to fainting, pain in
the stomach, and vomiting, appears,  according  to Briquet,1 to
depend on the use of the powder,  and its action on the mucous
membrane of the stomach, inasmuch as these symptoms do not
follow the use of the article in solution.   Experiments have also
been made with the  bisidphate  of cinchonine (Tourner), giving
similar results.  The sulphate of quinidia,  in the same doses as
that of quinine,  has  been given, with good  results, by Wunder-
lich.   Sufficient experience with  regard  to cinchonidia is still
wanting.   The effect of quinoidine, on account  of the variable
proportions  of quinine, cinchonine, coloring matter,  and resin
that enter into its composition,  is very uncertain, and  it has to
be given  in two or three times as large doses as quinine.  Chem-
ically pure salts of quinoidine, according to Bernatzik, give bet-
ter results, and  are  said to be but little inferior to  those of qui-
nine    The preparations used are, the tincture of quinoidine,2 m
drachm doses, solutions of the article with the addition of a
little acid, the citrate of chinoidine, or the powder with one-fifth
part of tartaric acid  (Bernatzik).____________________________
 "~^BuUetTdeT'AcacL de Med., T. 25, Nos. 11 and 12.                      _
   - Quinodine. two parts;  dissolve in alcohol seventeen  parts and pure hydrochloric
acid one part, and filter.-German Ph. 
666              HERTZ.—MALARIAL DISEASES.

   Cinchona bark in powder or in decoction, the tinctura cin-
chone, or the tinctura cinchone comp., as well as other fever
tinctures containing but little quinine, stand far behind the latter
in point of  efficacy, and are only to  be recommended as tonics
after a cure, or for the purpose of preventing relapses.
   Aside from the prophylactic action of quinine, its most fav-
orable effects  are to be seen in simple intermittent fevers, of the
quotidian or tertian type, and in certain masked forms.  Its effi-
cacy is less uniform even in the quartan form, as well as in per-
nicious fevers with serious local manifestations, and  it is least
effective and reliable in  the  remittent  and continued fevers.
Nevertheless, it remains an established fact that, even in the last-
named forms,  quinine is the most potent weapon that we pos-
sess for combating fever.
   Notwithstanding the well-known and well-established power
of quinine in intermittent fever, cases do occur where  no suffi-
cient  results follow its  use.   This sometimes  depends on  the
small  doses, given every hour  or two hours, or at all events on
its not being given in sufficient quantities, or it may be due to
the use of inappropriate or bad preparations ;* at  other times it
may be caused by a  cachectic condition  of the patient, with an
enlarged liver and spleen, these conditions also  running their
course with paroxysms of  fever. In  such cases I have overcome
the fever by the employment of iron  and quinine and the appli-
cation of the cold douche.   These conditions are often associated
with  bad habits of life and insufficient nourishment, and cannot
be overcome until the latter are removed.  At other times hidden
 diseases with febrile  movements—here in Holland generally in-
cipient  pulmonary  tuberculosis — are misinterpreted by both
patient and physician.  Occasionally quinine fails to do its work,
 without our  being able to account for this  failure, and we  are
 obliged to have recourse to other means at our command.
    The  numerous  investigations  that have been made  in the
course of time on the effects of quinine have resulted in establish-
ing its value more and more for the treatment of certain  symp-
 toms that arise in febrile diseases. Notwithstanding all this, how-
11 have often noticed that hard, old pills failed to produce any effect. 
                MODUS OPERANDI OF QUININE.             667

ever, we have thus far obtained but little insight into the method
of its producing these effects, whence it necessarily follows that
all  attempts to arrive at a reasonable theory with regard to the
way in which it acts in malarial fever have proved fruitless.
   We  need here merely allude to those  phenomena which do
not concern this part of the question, viz. : the exciting influence
on the nervous system produced during cinchonism, the diminu-
tion of  fibrine in  the blood observed after large doses (Legroux),
and the reduction in the secretion  of bile.   The features of the
greatest importance to us are the  modifications of temperature
and of  the  condition of the pulse produced by quinine.  And,
unfortunately, it is just here that our knowledge is fragmentary.
This much, however, seems to be certain, that quinine does not
increase the giving  off of heat.  How far it acts on the centre
that presides over the regulation of heat, or whether it does so at
all, is uncertain,  for Binz  and Bouvier  have observed a diminu-
tion of temperature even  after cutting off connection with  this
centre.   Neither  are we justified  on this  account  in taking
refuge in the theory of diminished production of heat and oxida-
tion within  the body (Lewizky and  Binz).  The reduction in the
rapidity of  the pulse and  in the tension within the arterial  sys-
tem are to be explained, according  to Eulenburg and Lewizky,
by  the  action  of the  drug on  the heart; but it is not known
whether this action is exerted on the  motor nerves or on  the
muscular tissue itself.  The investigations  of Binz and others on
the destructive power of quinine upon the  lower organisms, infu-
soria and fungous  growths which  are known as inducers of
fermentation and putrescence,  are worthy  of note.   Unfortu-
nately,  however,  these facts are not yet  directly applicable to
the question of malarial fever ; for,  as was  stated under the head
of etiology,  none of these  lower organisms have, as yet, been
demonstrated with certainty to constitute the malarial poison.
The fact, which is claimed by Piorry, Paget, and Kuchenmeister,
and is doubted by Griesinger, that quinine  reduces  the size of
the spleen in well persons, seems to be thoroughly estabUshed by
recent investigation.  Thus, Mosler has been able to demonstrate
it by direct measurement of the spleens of dogs,1  before  and
            i Pathologie u. Therapie der Leukamie.  Berlin, 1872. 
668
HERTZ.—MALARIAL DISEASES.
after giving hypodermic injections of quinine, and also by the
reduction produced by means of quinine in an enlarged spleen,
which had been rendered so by previous section of its nerve.  It
is thus far not known how this reduction is accomplished, whether
quinine acts on the unstriped  muscular fibres (Kuchenmeister),
or  on the nerves  of  the spleen, or whether it operates  on the
medulla oblongata, the irritation of which, as has been shown by
Tarchanoff,1 will produce marked contraction of the spleen, if the
splanchnic nerves  are intact.   According to Binz, we may imag-
ine the diminution in the size of the spleen to be  dependent on a
limitation in the development of colorless blood-corpuscles, inas-
much as  he has  observed  that  quinine hinders the  amoeboid
movements  of  the same, and their escape through  the walls of
the blood-vessels in inflammatory processes.  This  also receives
support from the investigations of Martin on inflammation of the
liver, and  the observations of Skoda to the effect that the infiltra-
tion,  in intermittent pneumonia, is held in check by quinine.
I should not like  to  deny that the action of quinine in malarial
fever may be attributed in part to its influence  in reducing the
size of the spleen,  as  other remedies, which  act in the same way
on  the  spleen,  such as eucalyptus globulus,  gentianin,  strych-
nine,  the use of cold water, etc., have  a reputation as febrifuges.
That it acts in other ways besides this, however, is evident from
the fact that  the  fever  may  disappear before  the  spleen is
reduced, and that  certain forms of fever, especially those known
as masked, which  run their  course without any  enlargement of
the spleen, are cured by quinine.  If we accept  the theory of a
specific poison  causing malarial disease, we can,  with our pres-
ent knowledge, only say this much ; that that poison can be ren-
dered inoperative  in  the  body by quinine, that is, it  can be
destroyed; for the manifold manifestations appearing in differ-
ent organs during the various  forms  of malarial disease are so
acted upon by  this agent that,  in the words of Griesinger, they
disappear  "not one after another, nor one  as the result of  the
other, but simultaneously, as though modified and destroyed by
some common central power."
1 Pfluger's Archiv f. Physiologie, Bd. VIII, Heft I, p. 97. 
EUCALYPTUS GLOBULUS.
669
   Ranking  perhaps next  to quinine  is an  article that has of
late  years been introduced  into  therapeutics,  especially as a
fever remedy, to wit,  the leaves of the eucalyptus  globulus,
a large  tree  of the  order  myrtacea,  which constitutes a  con-
siderable portion of  the woods of Australia.  Its medicinal use
was  first recommended in Spain,  and it seems, both in its physi-
ological  and in its therapeutic action, very  closely to resemble
quinine;  so that, from the experiments thus far made, which,
it is true,  are not  very numerous, eucalyptus  would appear
to furnish  us with  a most admirable  and quite  inexpensive
substitute for quinine.   The trials made on  inferior animals,
and in which the ethereal oil extracted  from the leaves, the
eucalyptol, was used, show that  the temperature of the body is
lowered thereby, and that putrescent changes and alcoholic fer-
mentation are prevented (Siegen,1  Mees).   According to  Mees,
the  amoeboid movements of  the  colorless corpuscles are arrested
on the application of one-fifteenth to  one-tenth per cent, of the
remedy" (an effect which is produced  by one-twentieth per cent.
of quinine); and in  inflammation they are prevented from escap-
ing  through  the walls of the vessels,  just as under  the use of
quinine,  especially if the frog's  mesentery be exposed directly
to the fumes of the eucalyptol. Mosler has further demonstrated
that after injection  of the tincture, or  its  introduction  by the
mouth, the spleens of dogs,  which had previously been exposed
and measured, grew harder, more consistent,  and smaller, and
assumed a steel-gray color on their surface.
    According to  the observations  of  Groos, in Hungary, in the
regions  of the Theiss and Danube rivers, as  published by Lorin-
ser, he  completely  cured  43 out of 51 patients (84  per cent.)
with this remedy, 11 of whom had previously been  treated in
vain with quinine; 5 out of 10  relapses were also overcome by
the same means.   Keller reports  432 cases, 310 of wliich (71TV per
cent.) were completely cured, and 108  of wliich were followed by
relapses; of  118 cases that were said to  have  been previously
treated with  quinine, 81  were completely restored under the use
   1 Inaugural Dissertation. Bonn, 1873.
   *Binz  (Sitzungsber. der niederrh. Gesellschaft, Bonn, Marz 17, 1873) could not
demonstrate this effect upon the blood-corpuscles. 
670              HERTZ.—MALARIAL DISEASES.

of eucalyptus.   Canstan saw 15 out of 27 cases get  well (55
per cent.);  Bertherend  had 11  recoveries  in  12 patients (91.6
per cent,).  Among 35 cases described by Mees,  13 (37 per cent.)
were completely cured;  among these were  also  quite a number
who had previously been treated with quinine  without effect;  in
10 of these  no change whatever was produced by treatment;  12
of them failed to continue the treatment, and the result was not
known.  The reports of Struve are equally favorable.  Not so,
however, are those of Papillon, who gave the bark of the  tree as
well as the  leaves, in substance, made up with honey,  to the
amount of  180  grains a day,  and who also used the alcoholic
extract to the extent of 135 to 150 grains a day, with very little
effect.   Out of 17 cases, 6 got well without any  treatment what-
ever,  2 under the  use  of eucalyptus, and  in  9  quinine had  to
be resorted to.   Similar results were  obtained by Burdel,1  in
Sologne, among 123 patients with fevers of the  quotidian, tertian,
and quartan types: only 11 were cured without relapses,  22 for
five days, 33 for nine days,  and in 57 the treatment was without
avail.   The observations made in the  clinic at  Basle, and pub-
lished  by Fichter,"  were likewise negative,  inasmuch  as the
remedy, used in the form of tincture, was either entirely without
effect  or very uncertain in  its action; whereas, in those same
cases the fever was promptly subdued by quinine.
   It appears, then, from what has already been said, that euca-
lyptus globulus possesses virtues  as  a remedy in fevers,  and,
indeed, in all types of simple  intermittent  fever,  being  most
effective, according to Keller, in the tertian t}rpe (75.57per cent.),
less so in  the quartan, and still less in the quotidian ; serving a
good purpose in obstinate relapses, especially when quinine has
failed, and in acute and chronic tumors of the  spleen.  It is dis-
tinguished by the rapidity of its action (usually preventing the
third attack), has no disagreeable after-effects, tastes better than
quinine, and is far  cheaper.
   The great lack of uniformity in the results arrived  at under
this treatment  doubtless depends, to  a certain degree,  on the
   1 Bullet, gen. de therap., 1872, p. 402.  Ref. in Medic. Centralblatt, 1872, p. 688.
   s Deutsches Archiv f. klin. Med.,  Bd. XII, p. 508.  I,  too,  as the result of my own
experience, cannot at present join in singing the praises of this remedy. 
                   TREATMENT WITH ARSENIC.                071

employment of too small doses.   The quality of the preparations
used has also a good deal to do with it, as the trees that grow in
their native soil yield more valuable leaves than those cultivated
in Europe ; the fresh, young leaves, too, are more effective than the
old, dry ones.   It also seems to me to make a difference whether
the cases treated are new or old.  It would appear, according to
my rather limited experience, that the remedy is more applicable
in old, protracted cases than in recent ones, therein resembling
arsenic.  This would be confirmed  by the negative results in the
recent cases of Fichter's,  and  the  positive  results in  the  older
Theiss-fever patients of Groos ;  those reported by Mees were also
almost exclusively cases  that had lasted for months and years.
    Probably the most desirable of  the preparations of eucalyp-
tus  is the alcoholic  extract, made from the fresh leaves, simply
cut up fine, as in  this way none of the  ethereal  oil  is  lost.
Lorinser prepares the tincture by digesting one  part of  fresh
leaves with three parts of  alcohol  for fourteen days,1 and  gives
two to three teaspoonfuls in  light cases, and in severer  ones
larger doses.   The leaves have also been used in the form  of an
electuary, or as an infusion,  in  doses of half an ounce to an ounce
a day.
    An important place in the list of remedies for malarial  fever
has long been accorded to arsenic.   At the same time its efficacy
is undoubtedly less than that of quinine, especially in fresh attacks
of  fever, where its  effects are  either  uncertain or entirely nega-
tive.1   On the other  hand, it is of value in cases where quinine
fails,  in  old, inveterate,  and frequently relapsing intermittents
   » The tincture which was used by Mees in Groningen and Leiden is prepared by
digesting one part of the dry, young leaves with eight parts of alcohol at 25 per cent.
   2 This inefficacy is ascribed by Boudin, the great advocate of arsenic, to the fact
that physicians do not sufficiently regard the circumstances that modify the effect of the
drug; thus, for instance, the doses should be larger in summer than in winter, etc.
The most recent periods have again developed warm advocates of this remedy ; Sistach,
(Gaz. med. de Paris, 1861), Turner (Med. Times, 1861, Sept. 28), Legrand and Pichaud
(Virchow and Hirsch's Jahresber., 1866, II, p. 177).  Some of them recommend Bou-
din's formula: Boil fifteen grains of arsenious acid in thirty-four ounces of water until
it is all dissolved;  then add, besides the water  that has been lost, thirty-four fluid
ounces of white wine, and give a tablespoonful four times a day (viz., one-ninth of a
grain of arsenic at a dose). 
672
HERTZ.—MALARIAL DISEASES.
and in malarial cachexia, as well as in neuralgias, which often
yield to arsenic alone when all other remedies have proved una-
vailing.  Of course, the individual circumstances of the patient
must be especially regarded when prescribing  this drug.   It is
contraindicated  during  the existence of disturbances of  diges-
tion, in extreme old age,  or in pernicious fevers ;  long-continued
use of the  article is  also to  be avoided.   A cure is  sometimes
accomplished in a few days ; oftener, however,  after it has been
used for two or three weeks.   During its use a supporting diet
should be taken, and in case of cachexia, iron should be com-
bined with  it.   The most desirable preparation  is Fowlef s solu-
tion, of which eight  to thirteen drops should  be given two or
three times a day (one-sixteenth to one-eleventh of a grain at a
dose,  one-ninth  to  one-third  of a grain during the  day);  the
acidum arseniosum1  is not as good a form to use.
   The recommendations made of late years by Barrant, Loren-
zutti, Tessier, Calvert, Declat, and Treulich in favor of the  use of
carbolic acid,* internally,  in  doses of  from £ to £  of a  grain
each, and amounting to 2J, 4|, or 9 grains a day, during the inter-
mission ; or subcutaneously (according to Tessier, If grains to a
fluid drachm of  water,  of which  20  to 40 drops are to be used
shortly before the attack), have not been sufficiently confirmed
by more recent observers, such as Paluel de Marmon, Caisne, Mar-
ken, Curschmann, and Eisenlohr. This article, which was lauded
by  the first-named observers  as most admirable in   its effects,
has been  found  by the  last  two named to be utterly inopera-
tive, as it  neither  controlled the duration  or the intensity of
the fever, nor produced the slightest effect on the swelling of the
   1 Clemens (Gaz. des hopit., 1860, No. 11) recommends a preparation,  which, it is
claimed, can be used for years without detriment, viz. :  R. Acidi arseniosi, potassas car-
bonat., 3a gr. lx ; solve in  aquae dest.  f.  § ix.  Adde brominii puri gr.  cxx.   At
first it must be  frequently shaken, and is fit for use after four weeks, though it must
always be kept from the light.  Three or four drops are to be taken, in water, once or
twice a day.
  2  White (Med. Times and Gazette, 1868, Oct. 3d, p. 105) recently reports that  the
laborers in the  petroleum works at Makum, in Upper Assam (India) enjoy marked
immunity from the malarial fever, which is very prevalent there ; this has been thought
to be due to the neutralizing  influence of the carbolic acid contained in the gaseous
petroleum exhalations on the malarial poison. 
                    COLD-WATER TREATMENT.               673

spleen,  although given in large doses.  Is it not  possible that
here, too,  recent cases respond to the remedy differently from
old and inveterate  ones ?  The good results from the use of com-
mon salt,  or sea-salt, which  are claimed  by Piorry, Thomas,
Maroschkin, and Pioch as following doses of  3 ij to § ss, or even
 3 vij twice a day, especially in lymphatic persons,  have not been
confirmed  by Grisolle, Mucarin, and others.   A  considerable
number of observations have  been made,  of late years,  on the
value of the sulphites of soda  and magnesia, which were  first
introduced into the treatment of malarial fever by Polli.  These
articles are  particularly reported on  by  American  and Italian
physicians (Mazollini,1 Ranzoni, Turner,  Baxter,  Leavit, Hamp-
ton), some of whom estimate their value as being equal to that of
quinine.  Griesinger and others  have not been able to obtain any
results  from  their  use.  Every  one  admits that their action is
slower,  and therefore they are  not to be used instead of quinine in
pernicious fevers.  The sulphite of magnesia is given in doses to
amount to 3iij, or  3iij,  3ij to  3 v, in solution, during the day :
the soda salt to amount to 3 ss.  to § j  a day.
   The treatment  instituted by Currie, in 1805,  of subjecting
the patients to affusions of cold water  during the attack, was
afterwards further amplified by Priessnitz and Fleury.  The for-
mer of  the two had  his  patients rubbed off with cold, wet cloths
during  the attack, and during the intermission had them packed,
rubbed, and given  the half-bath.   Fleury  only applied cold
douches of 54° to  57° Fahr. one or two hours before the attack,
using a general shower-bath and a local douche directed against
the region of the spleen,  throwing a shower-jet  of one inch and a
quarter in  diameter.  By  means of experiments on  animals,
using the cold douche or  ice-compresses over the region of  the
spleen,  the spleen  being  exposed  to  direct  observation and
measurement, as well as by  the use of both methods in acute and
chronic intermittent fevers,  Mosler has confirmed Fleury's asser-
  1 In Canstatt's Jahresbericht, 1863, IV, p. 82, and 1864, IV, p. 67, this writer compares
the effects of the sulphites and of quinine.  Under the former there were 83 per cent, of
recoveries,  under the latter 59. Relapses took place, under the former, in 5 per cent.
of the cases, under the latter in 44.5 per cent.  Sequel*, under sulphites 3.2 per cent.,
under quinine 19 per cent.  Gastric irritability does not forbid their use.
           VOL. II.—43 
674
HERTZ.—MALARIAL DISEASES.
tion with regard to the effect of cold water, especially in the form
of a douche, in reducing the size of the spleen.  But he can find
no  support for the further statements of Fleury, viz.,  that qui-
nine can be entirely replaced  by the use  of cold water,  and that
the latter is even more effective than the former in old,  obstinate
cases  with ansemia and with tumors  of the liver  and spleen,
especially as  it guards  against relapses.  According to Mosler,
the power of cold douches in reducing the size of the spleen, as
well as their influence on the intermittent processes and in pre-
venting relapses, is inferior  to  that of  quinine, and they  can
therefore  not be considered  as  a substitute  for  this drug,  but
merely as  admirable  adjuvants  thereto.   Cold baths and affu-
sions, for the purpose of shortening the attack, need not be used
in simple  intermittent fever,  as they are disagreeable to  the
patient  and  of doubtful utility.  In the pernicious forms, when
danger threatens, they are  sometimes of good effect, in addition
to quinine treatment.  For  several years I have used the local
cold douche  in enlargements  of the liver and spleen after inter-
mittent, and  it has done admirable service, in  combination with
quinine treatment, even in old cases.   I use  baths of 72° to 75°
Fahr., seldom warmer, and of fifteen or twenty minutes' duration,
with a local douche of from one minute to a minute and a half.
   The  alcoholics, such as rum,  brandy, etc., are  of  doubtful
value as direct febrifuge agents,  and it is only in the  lighter
forms of fever that they seem to do any good.   Chloroform  has
been recommended by various writers (Serrano, Delioux, Alienza,
Clellan, and others), to be used during the chill, in  doses of one
drachm, either given  but once or repeated several times at inter-
vals of one quarter to  one-half hour apart.  This is administered
less with a view to breaking  up the fever, than for  the purpose
of shortening the attack, as refreshing  sleep is very likely to fol-
low the first  or second dose.  Where chloroform cannot  be ad-
ministered internally,  it may be used as an enema, with olive oil
or glycerine.
   The most effective  of the remaining vegetable substances seem
to be, piper ine, of which nine to fifteen grains  are to be given
during the intermission, and from  which Griesinger  has seen
good  results in the recent attacks of young  persons; and the 
              TREATMENT OF SPECIAL SYMPTOMS.           675

sulphate  of Bebeeria,  in  doses of four and a half to fifteen
grains during the intermission.  The roots and young shoots of
the box-tree, long since known as a febrifuge, have also been
used again of late.  Mazzolini  claims to have treated 308 eases,
with  235  recoveries,  by means of  the sulphate of buxine  (the
alkaloid obtained from the leaves and seeds), in  doses of from
fifteen to twenty-two grains, in pills, during the intermission.
Casati reports a rapid cure in thirty-seven cases out of forty-five.
This article  is decidedly cheaper thaii quinine, and is said to be
without its  disagreeable after-effects.  The remaining vegetable
substances that have been recommended are of inferior or doubt-
ful efficacy,  such as salicine, apiol (a liquid  obtained by the diges-
tion of parsley-seed with ether), cnicine, veratrine, strychnine,
santonine, gentianine, capsicum seeds, etc.   The external appli-
cation of  spirits of camphor or peppermint, oil of turpentine, and
laudanum along the spine are of no use in combating the fever.
    In the light grades of remittent  and continued fever,  with
gastro-bilious disturbances, it may be well, in addition to a strict
regimen,  to give some of the vegetable tonics, as quassia or gen-
 tian, with  the alkaline carbonates ;  and  under  some  circum-
 stances, emetics or purgatives,  such as calomel, jalap, and  rhu-
 barb.   But here, too, quinine, in daily allowances of fifteen,
 twenty-two, or thirt}^  grains and over, is our main reliance, and
 must continue to be given until the end  of the fever.  This is
 still more the case in the severer forms, where the doses must be
 increased ;  the local morbid conditions that may here arise,  such
 as bronchitis,  diarrhoea,  dysentery,  etc.,  require special  treat-
 ment.  In great irritability of the stomach, quinine is best given
 in combination with morphine or opium, or in extreme cases it
 may be  administered by enema  or hypodermically.   In case
 of severe vomiting we may, in addition to ice and effervescing
 mixtures, employ cold and counter-irritants over the region of
 the stomach.  In cerebral symptoms, great restlessness and exci-
 tability,  quinine  and  opium,  combined with constant  bathing
 of the head with cold water, or ice-compresses  to the head, are
 advised.   In adynamic conditions,  blisters to  the back of the
 neck  with other irritants to the  skin,  and internally,  wine,
 bran.lv,  ammoniacal  preparations,  warming of  the  bed, fric- 
676              nERTZ.— MALARIAL DISEASES.

tions, etc., must be employed.   Brown recommends nitric acid,
three drops  every hour,  largely diluted.   In all remittent and
continued fevers,  even  with severe cerebral manifestations, we
must abstain from  general  or  copious local  blood-letting,  as
even without this the  disease will soon assume an  adynamic
character.  In the fievre  bilieuse hematurique, Veillard recom-
mends,  at the beginning of the disease, an emetic of ipecac,
and purgative doses of calomel followed by neutral salts.  Here,
too, quinine constitutes the main item of treatment, and must be
given in doses of thirty to forty-five grains, and in case of severe
vomiting be  introduced by the rectum ; in addition, acids and
tonics, and in case of severe pain or great excitability, opiates
and antispasmodics.  If it is possible, the patients, in  all these
forms of fever,  should  be removed from the malarious region,
even during their illness.
    In the masked fevers quinine is to be used in the intermissions,
and where this  fails, arsenic.  In facial neuralgia I have often
seen good results, especially in  nervous women, from the use of
the valerianate of  quinine  and from the  citrate of caffeine.
Sometimes these may be  advantageously combined with opium
or morphine, and the veratrine ointment applied  externally.   In
ansemic persons we give iron ; in robust subjects, with  torpor of
the bowels, a course at the mineral springs of Carlsbad or Marien-
bad is  of admirable  service.  In intermittent  cardialgia, where
quinine alone fails and numerous  relapses occur,  I order it in
combination  with bismuth and'nux vomica as follows :  Sulphate
of  quinine, 75 grains ; subnitrate of bismuth, 45 grains; extract
of  mix vomica,  2^ grains ; made into 50 pills.   Give 5 pills
twice a day.  In anamrie subjects, we give iron with quinine,  and
in very severe cases, apply a few leeches, and warm, narcotic com-
presses over  the region of the stomach.  In intermittent diarrhoea
the tannate of quinine is used, with opium; in cases of  colic, qui-
nine with opium or morphine, and, if there  is constipation,  a
cathartic of  sulphate of  magnesia or sulphate or phosphate of
soda ; in spasmodic cough or sneezing, valerianate of quinine, with
large doses of valerian root, best given in the form of a tea, sev-
eral cups of which, cooled, may be drunk in the evening ; in epilep-
tiform attacks, valerianate of quinine with bromide of potassium. 
                   TREATMENT OF SEQUELAE.               077

   During convalescence, and for the  purpose of avoiding re-
lapses, it is of the greatest consequence that all excesses in eating
and drinking, and  all chances of getting wet  or taking cold be
avoided, and this is particularly true in convalescence from the
severer forms of fever.   The continued use of quinine, as well
as of bitter and aromatic tonics, such as quinoidine,  the  tinc-
tura cinchonse composita, the extract of cinchona, is to be recom-
mended.   In severe forms, iron should also be given,  and if
associated with  enfeebled digestion, bismuth, as well as small
doses of rhubarb.  The very best treatment, beyond  all doubt,
is removal to some elevated non-malarious  region.  Those who,
after suffering  from fever,  return from  a southern  (tropical)
climate  to colder  latitudes,  should dress  warm,  wear  flannel
next to the skin,  and  keep their feet well clad, for the purpose
of avoiding colds.  It is also well that such a return should take
place during the summer months, from July  to September.  After
arriving at home, special attention will have to be given  to the
tumors of the liver and spleen that still remain.
   In primary chronic malarial infection, it is of great importance
to avoid all  predisposing causes, especially getting wet, taking
cold, and a prolonged  stay in marshy and  unwholesome places.
It is also of the utmost  consequence that  one should occupy a
good,  dry house, and,  above all, such a bedroom.  In addition
to  this,  quinine,  quinoidine,  and compound tincture of  cin-
chona, or the wine of chinchona—and in ansemic cases kon—
should be continued for some time.  Frequent cool baths, with
douches to the region of the spleen;  a good, strong, somewhat
highly seasoned diet; good Bordeaux wine,  or, for those in more
moderate circumstances, small quantities of brandy, aid the cure
materially.  If the symptoms are more marked, we should give,
daily, one larger dose  of quinine (nine to twelve grains),  wliich
may best be given  at evening.
   In the treatment of  enlarged spleen and liver, quinine is to be
given as long as the thermometer shows even slight febrile move-
ment,  and on account of the ansemia that is  often  present, it had
better  be combined with iron^Jn addition to  this, I  have
 "»«ffirecomm^he^loride of bebeerine for the treatment of malarial
enlargement of the spleen, to be given to the amount of 3 i to 15 grains daily, m alco- 
678
HERTZ.—MALARIAL DISEASES.
learned to regard cool baths, with the jet douche over the region
of the spleen and liver, as the most effective treatment ; river,
sea, and surf bathing are also of benefit.  After all febrile move-
ment has subsided,  alterative  remedies are  most  applicable;
iodide of potassium, or, better yet, the syrup of  the  iodide  of
iron, or Blancard's iodide of iron pills, which are very popular in
France and Holland ; muriate of ammonia, or muriate of iron and
ammonia; when the bowels are confined, aloes, or rhubarb with
the alterative vegetable extracts (ext. of chelidonium,  of tarax-
acum,  etc.),  and various mineral waters.  Sometimes the simple
chloride of sodium waters are sufficient (Homburg or Kissingen);
the alkaline saline springs,  however, are better (Karlsbad, Mari-
enbad);  and in disturbances of digestion and ansemia, the saline
iron  springs (Elster,  Franzensbad, Rippoldsau, etc.),  combined
with mud baths, where  these are  to be  had.   Where pecuniary
considerations forbid a journey to  the baths, I  order the artificial
Karlsbad salts (one to two teaspoonfuls in half a winebottleful
of hot water,  of the  temperature  of 122° to 126.5° Fahr.) to be
taken in the morning before eating.  I fully agree with Griesinger
in the opinion that  this treatment is of more avail in swelling
of the spleen  only, than  in those cases where the liver is like-
wise tumefied, inasmuch as the latter implies  a higher grade of
disease and  our means of combating it are less  effective.  Pain in
the region of the liver or spleen may call for local blood-letting,
anodyne poultices, or the Priessnitz compress.
   Acute dropsy, as well as albuminuria  of  recent date, may
often be promptly suppressed by the use of  quinine and iron, and
a good nourishing diet, to which,  in the former case, mild vege-
table diuretics may be added.
   Advanced  cachexia demands, in addition to careful  dietetic
treatment, a removal of the patient from the  malarious district
to a high, warm, mountainous region, exercise in the  open air,
light, nutritive diet,  and warm clothing.   The medicinal treat-
ment consists in the use of quinine and iron, or arsenic, and,
holic or watery solution, or hypodermically.  He saw, without any disagreeable results
from its long-continued use, 26 complete cures among 41 cases;  several others were
materially improved, and only one died. 
                  TREATMENT OF SEQUEL.E.               679

according to Keller, of the tinctura eucalypti  globuli,  in small
doses, morning and evening, in addition to cool baths, with the
jet douche over the liver and spleen, and general shower-baths.
   All further complications and sequelae demand special treat-
ment. 
 
        EPIDEMIC
CEEEBRO-SPINAL  MENINGITIS.
ZIEMSSEN. 
 
EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.
General works.
Hirsch, Handbuch der historisch-geographischen Pathologie, Bd. II, p. 624 et seq.—
     Wunderlich, Handbuch  der Pathologie und  Therapie, II Aufl.,  Bd. Ill, Abth.
    1, p. 505  et seq.—Hdser,  Geschichte der epidemischen Krankheiten, II Aufl.,
    1865, p. 684 et seq.—Leyden, Klinik der Ruckenmarkskrankheiten, Bd. I, 1874,
    p.  410 et seq.
Special works.
France.   1805.   Vieusseux (Geneva),  Journ.  gen6r.  de med.,  XXIV, p.  163
    (Hufeland's Journal, XXI, p. 181).—1814.  Comte (Grenoble), Journal gener.
    de  med.  de  S6dillot,  1816.—1822.  Pratbernon  (Vesoul),  Journ.  gener. de
    med.  de Corvisart, Tom.  82, p.  74.—1837-1851.   C. Broussais, Histoire des
    uigningitek cerebro-spinales, qui  ont  regne  epidemiquement dans  differ-
    entes garnisons en  France depuis  1837-42. Paris,  1843  (Schmidt's Jahrb.,
    XLIV, p.  254).— J. Ch. M. Boudin, Histoire du typhus cSrSbro-spinal ou de
    la  maladie improprement appellee  Meningite cgrebro-spinale  epidemique.
    Paris, 1854.   (Complete history of the disease from  1837 to 1851).—18:57-42.
    Faure- Villars, Histoire de 1'epidemie de meningite cerebro-spinale (a Versailles,
    1839).  Paris,  1844.—Gazette med. de Paris, VI,  441, VII,  465.—Chauffard,
    Revue  m6dic, 1842,  p.  190.—Gaste,  Resume" clinique sur les  meningites
    cSrgbro-rhach., etc.   Metz, 1841.—Simonin, Recherches  topogr. et med.  sur
    Nancy, 1854,  p. 206.—Rollet, De  la meningite,  etc.   Nancy, 1842.—Memoires
    de  l'academie de  m6d., X, Paris, 1843,  cf. Gaz. meU de Paris, 1844, Nr. 3s,
    and Canstatt's Jahresbericht,  1846, IV, p. 107.—Lefevre (Rochefort), Annales
    maritimes,  1840,   Avril.—Barnouin (Avignon), Memoire  sur  la  meningite
    cerebro-spinale, etc.  Avigncn, 1842.—Tourdes (Strasbourg), Histoire de l'epi-
    demie dc meningite, etc., a Strasbourg en  1840 et  1841.  Strasbourg et Paris,
    1843.  (Schmidt's  Jahrb., Supplem., IV, 101.)—France, Die Epidemie zu Stras-
    bourg.   Wien, 1845.— Wunschendorf, Essai  sur la  meningite, etc., S Stras-
    bourg en 1841.  Strasbourg, 1841.   (Schmidt's Jahrbucher, Suppl., I, 111, 117).
    —Sehilizzi (Aigucs-Mortes), Relation  historique de  la meningite cerebro-spi-
    nale, etc.  Montpellier,  1842.—Mahot (Nantes), Epidemie  de meningite, etc.
    Nantes,  1842.—Gaultier de CI embay, Memoires del'acad. de meU, XIV,  p. 155.
    —1846-47.  Artigues (Montpellier), Clinique de Montpellier, 1847, Nr. 194 and
    195. Canstatt's Jahresb., 1847, IV, 74.— Mmichet  (Lyon), Gaz. med de Paris,
    1847,  Nr.  15.—Chapuy (Lyon), De la meningite encephalo-rhachid.  These. 
G84     ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MEXIXGITIS.

    Paris,  1847.— Corbin  (Orleans), Gaz.  med.  de Paris,  1849, Nr.  24.—Fallot
    (Nismes), Gaz. med. de  Montpellier, 1848, Mai.—Maillot  (Lille), Gaz. med. de
    Paris,  C.  Ill,' 845.—Levy (Paris), Gaz. m6d. de Paris,  C.  IV,  830.—Giraud
    (Toulon), Lettre pathologique sur la meningite, pphL  These de  Montpellier.
    Juin, 1851.—Lariviere  (Bordeaux), Journ. de med. de Bordeaux, 1868, Aofit.
    —Bertrand (Strasbourg), Relation de quelques cas de meningite,  c. sp. Stras-
    bourg, 1868.
Italy.  S. de  Renzi, Sul tifo apoplettico-tetanico,  pphl.  Napoli,  1850.— The same,
    Rivista di varii lavori, pphl.  Napoli, 1841.—67. Spada (Cervaro), Sul tifo apo-
    plettico-tetanico,  pphl.   Napoli, 1840.-^1. J. du Maida,  Sul tifo  apoplettico-
    tetanico  di Calabria.   Filiatre  Sebezio,  1842.—67.  Pagano,  Qualche  parole
    intorno alia febbre  soporosa  convulsiva detta  cominunamente  Torticollo.
    Napoli, 1842.
Africa.   Magail, Rec. des mem. m6d.,  LIX, 1845.  (Schmidt's Jahrb., LIII, 31).—
    Besseron (Algier), Comptes rendus de  l'acad.  des  sciences,  1847,  Mai.  (Can-
    statt's  Jahresb.,  1847, IV, 74).—Sourier et Jacquot (Tlemcen),  Gaz. mgd.  de
    Paris, 1848, XIX, 4.— Chayron, Relation d'une epidemie de  meningite cerebro-
    spinale en Afrique.  Montpellier, 1850, 8.
Spain.  Thompson (Gibraltar), Med.  Times,  1845,  April.—Gillhrest,  Lon. Med.
    Gazette, July,  1844, p. 455.
Denmark.  Sundhetscollegiums Forhandlinger, 1846-49.
Great Britain.   Mayne (Dublin), Dublin Quarterly Journal, m, 95.  (Schmidt's
    Jahrb., LV, 28, LVI, 46).— Whittle (Liverpool), London Med.  Gazette, 1847,
    IV, 807.—McDowell (Dublin), London Journ. of Med., 1851, Sept.— Charles
    Murchison (London), Lancet, I, 16, 1865, April 22.— Wills,  Brit. Med. Journ.,
    I,  p.  427.—Grimshaw,  Thermometric Observations on  Epid.  Cerebro-spinal
    Mening., Med. Times and Gaz., 1868, Octbr. 24, p. 438.—Johnson, ibidem, 1868,
    Octbr. 31, p. 469.— Collins, Report upon Epidemic Cerebro-spinal  Meningitis,
    Dublin Quart.  Joura., 1868, Aug., p. 170.
Sweden  and Norway.   Beriittelse  om  Medicinalverket  i Sverige or  1856-1860.—
    Lindstrdm, Om meningitis cerebro-spinalis epid., etc.   Lund., 1857.— Wistrand,
    Hygiea, XVIII and XIX.—Ofversigt of helso och  sjukvarden i Sverige, 1851-
    60.   Stockholm, 1863.—Arentz, Norsk  Magazin for Laegevidenskaben, 1860,
    XIV, 401.—Beretning om Sundhetsstilstanden in Norge i  aaret, 1860. Chris-
    tiania, 1863.
Netherlands.  Nederlandsch  Tijdschrift voor Genceskunde, V, 15.
Russia, Turlcey, Greece, and the East.  Kuttner (Petersburg), Petersb. med. Zeitschrift,
    1869, XVI, p.  53.—Hbrschelmann (Krimm), ibidem,  XV, p. 265.—Diamanto-
    pulos (Smyrna), Wiener med.  Presse, 1870,  Nr.  34-36.—Kotsonopulos (Nauplia,
    1869), Virchow's Archiv, Bd. 52, p. 65.—Sandreczky (Jerusalem), Berliner klin.
    Wochenschrift, 1872, Nr. 20.
North America.  White, New Orleans Med. Journ., 1847, Nr. 49.— Chester, ibid.,
    1847, p. 314.—Boiling, ibid.,  1847, p. 732.— Ames,  ibid.,  1848, p. 295.—Drake,
    Treatise on the Principal Diseases of the Interior Valley of North  America.
\ 
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 686     ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

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Affections of the Organs of Hearing,  Erhard.    Berliner klin. Wochenschrift, 1865,
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     York Med. Record,  1867, Aug. 15, p. 341.
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     I,  p. 58.—Jacobi  (Danzig),  Graefe's Archiv f.  Ophthalmologic, XI,  p.  156,
     1865.—Schirmer  (Greifswald),  Klin. Monatsblatter  f.   Augenheilkunde,  v.
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HISTORY.
687
   Nr. 33.—Kreitmair (Niimberg), Bayr. arztl. Intelligenzblatt, 1865, Nr. 21, and
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   Socin, Beitrag zur Lehre von den Sehstorungen bei Meningitis, Deutsch. Archiv
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   Treatment of Diseases of the Eye in Cerebro-spinal Meningitis, Philadelph. Med.
   and Surg. Reporter, 1868, March 7.—Knapp (New York), Blindness and Deaf-
   ness in consequence of Epidemic Cerebro-spinal Meningitis, New York Med.
   Record, 1872, Aug. 15, p. 341.

                        INTRODUCTION.

   We use the term epidemic cerebro-spinal meningitis to define
an acute diffuse inflammation of the pia mater of the brain and
spinal cord  with deposit of a  fibrino-pnrulent  exudation;  the
infectious character of the disease  being  shown by its epidemic
occurrence, the nature and mode of its propagation, and  by its
course and lesions.
   It follows, therefore,  that this affection is to be  separated
from the diseases of  the spinal cord,  and classed among  the
infectious diseases.  It is naturally allied, as Hirsch has shown,
to those infectious diseases which, like dysentery, are character-
ized  by a marked localization in some  tissue  or organ of the
body.
   Its synonymes  are very numerous:  cerebro-spinal typhus,
typhus cerebralis apoplecticus; fievre  cerebrate, phrenesie, cep-
halalgie epidemique, meningite cerebro-rhachidienne, meningite
purulente epidemique (France);  spotted fever,  congestive fever,
(North America); febbre  soporoso-convulsiva,  tifo  apoplettico
tetanico,   torticollo  (Italy); nacksjucka, dragsjucka  (Sweden);
Genickkrampf, Genickstarre, Hirnseuche.
    This multiplicity  of  terms  may be  explained partly by the
protean variety of  forms which the disease assumes in different
epidemics, and partly by the fact that  careful attention has been
directed to the lesions only within the last ten years.

                          HISTORY.

    For an exact  knowledge of  this disease we  are indebted to the
 last  few  decades,  during which a severe  and  wide-spread ep- 
6S8    ZIEMSSEN.— EPIDEMIC CEREBRO-SPINAL MENINGITIS.

demic has appeared, affording an opportunity for careful clinical,
anatomical, and etiological study.
   We have reliable accounts of the affection as far back as the
beginning of the  present  century.   It is very probable that  it
occurred during previous centuries, but the fact cannot be ascer-
tained with certainty, as Hirsch has clearly shown in his His-
torico-geographic Pathology.  We may  dismiss,  therefore, the
opinion of many writers, the French in particular,  that the
disease  prevailed in  earlier, indeed even in ancient times, and
will begin with the small circumscribed epidemics which occurred
in Europe at the commencement of the present century.
   The  first  epidemic prevailed in  Geneva, from February to
April, 1805.'  Then followed epidemics in  Grenoble (1814), Vesoul
(1822), and one in Dorsten, on the Lippe  (1833).  In Grenoble  it
was almost  exclusively confined to the garrison; in Vesoul, to
the civil population.   The disease which  prevailed  in Dorsten in
the winter of 1822-23  was described by Sibergundi as a  "mye-
litis, sometimes complicated with encephalitis ;" but  the symp-
toms described correspond to those of cerebro-spinal meningitis,
as has  recently been shown by Haser,2  and other trustworthy
writers.
   After a long interval the disease again appeared in  France, in
1837,  and spread as  an  epidemic in Bayonne, Bordeaux, La
Rochelle, and other places.  In the following years it occurred
in Versailles,  then in north-western and north-eastern France,
everywhere spreading with increasing violence.   In many locali-
ties it  remained confined in  a  remarkable manner for many
years to the barracks, and was  transferred to otlier places by the
inarches of  the troops.   Paris received  only a  transient visita-
tion.  In 1849 it  disappeared temporarily from France.  About
the same time with the more formidable  developments in France,
the malady entered Italy, and prevailed  there  from 1839 to the
spring of 1845 ; afterwards it appeared in Algiers, where it con-
tinued from 1839 to  1847, especially in  the  central and eastern
districts.
   In 1844 a transient epidemic occurred in  Spain, at Gibraltar.
            1 Vieusseux, 1. c.
            2 Geschichte der epidem. Krankheiten, 2 Auflage, p. 691. 
                            HISTORY.                        689

In  Denmark in 1845-48;  in  Great Britain in 1846, especially in
Ireland—m England there were only traces of the disease (Liver-
pool).  After an interval of several years the disease appeared in
the south and south-west of Sweden in 1854.

   Nowhere did the epidemic meningitis show such malignancy, regularity, and
persistence in its progress as in Sweden.  In the course of seven years eighteen out of
the twenty-four Swedish stadtholderships were invaded by the disease, and 4,138
persons died.  From this excessive mortality we may approximately infer the whole
number of  the sick, which  could not be accurately ascertained by the board of
health.  The proportion of  fatal cases in many neighborhoods was stated to have
been as high  as 66.6 per cent., but  the grand total could not have been so large.
The most northern point which the  disease reached in Sweden was in Sundewall,
situated near the sixty-third degree of north latitude.

    In Norway there was  an epidemic  in 1859 and in 1860; in
Holland a transient one in the winter of 1860-61.
    In the United States of  North America the  disease  made
active progress from the year 1842, visited most of  the States at
long intervals, and prevailed with the  greatest intensity during
the civil war.
   During the last few years  it has  appeared in Canada (1870\
and in the United States has shown itself,  either in sporadic
cases or in small epidemics, up to the present time.
    As previously mentioned,  Germany saw the new guest first in
Westphalia in the winter of 1822-23  (Sibergundi\ afterwards in
1851 in Wurzburg (v. Rinecker).   Otlier small epidemics of malig-
nant  " inflammation of the brain," wliich were observed between
1830-50, in  southern and central Germany,  probably also belong-
to this disease.
   An invasion of more severity and longer duration began in
1863.   It appeared first  in Silesia, Posen, and Pomerania,
reached  the Mark in   1864,   and about  the same time entered
Hannover and Brunswick,  also  Saxony  (Leipzig),  and Thuringia
(Eisenach).   At no place, with  perhaps the exception of Brom-
berg, did the disease prevail as a severe  epidemic.
   In southern Germany, however, where it was first observed by
me  in Erlangen,  in the beginning of July, 1864,  the epidemic
became  much  more alarming.   Its first appearance  probably
dates somewhat further back, since in  the winter of 1862-3, as
          VOL.  II.—44 
690    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

appears from  the reports of Immermann  and Heller, autopsies
were made of five cases of suppurative cerebral meningitis at the
Erlangen Poliklinik.
   Almost simultaneously the disease appeared in Nuremberg,
and in 1865 it spread extensively  in  central,  upper,  and lower ,
Franconia.
   Further south there were unimportant offshoots of the epi-
demic as far as Munich, Landshut,  and Augsburg.
   In 1864-65 Baden and Hesse were visited.
   In Austria there were only small and isolated epidemics ; in
Vienna in 1865, in Pola in 1866, in Lissa and Trieste in 1867.
   In Russia also the disease appeared in small epidemics, which
attacked especially St. Petersburg in 1864-68.  In the beginning
of the year 1868 it was also observed in the Crimea.
   We have reports  of small and mild  epidemics in Turkey,
Greece, and Asia Minor during the years 1868-72 ; also in Nau-
plia (1868-69), Smyrna (1870), and Jerusalem (1872).
   In Germany there have been traces  of the disease here and
there  during the last few years  ; in  1871 in Berlin, Bonn, Nurem-
berg1, Furth, Munich, and Baden ;  in 1872 in Vienna; in  1873
traces in central Franconia again, some of which I investigated;
also in upper Bavaria (Munich).   The disease appears to  have
become naturalized with us.


                          ETIOLOGY.

   Although the past twenty  years have furnished  very abun-
dant material for the study of epidemic meningitis, and although
all the data of value in regard to  the origin and spread of the
disease have been  investigated in  the most diverse places, and
generally with  great care, we still  find  ourselves in entire igno-
rance of the original source  of the  affection.  The  expression
of Chauffard,2 in  his  account  of the  epidemic  at Avignon,
from  the  year 1840,  "L'etiologie  de cette affection  est restee

  1 In Nuremberg, according to Maurer (1. a), a small epidemic prevailed from  March
to September (inclusive),  with the numbers 1, 3, 13,  9, 3, 1, and 3 for  the respective
months.
  2 Revue medic, 1842, Mai, cit. by Hirsch, Monographic, p. 127. 
         RELATIONS WITH OTHER INFECTIOUS DISEASES.      691
 enveloppee  d'ombres  impenetrable^" has  even to-day  much
 significance^  It  is true that in some points we have recentlv
 reached positive  results, but  in regard  to  the most important
 etiological questions, we are still far from certainty.
    It will  not readily be denied at the present time, by any one
 conversant with the subject, that the meningitis is an infectious
 disease.   Although it  is the inflammation and exudation which
 first strike the eye and tempt us to  regard the whole process as
 a simple inflammation, yet a more careful examination shows us
 that this opinion  cannot be maintained.
    The infectious nature of the affection may be inferred from
 the following considerations:—Occurring only very rarely and
 sporadically, until within  the last  few  decades,  the disease
 has since  spread  as an epidemic over whole populations—wide
 districts—in fact  over a large part of two continents, progressing
 either uniformly or by leaps ; the symptoms  and  lesions are siim
 ilar in the mildest, the moderate, and the severest cases; derange-
 ments such  as eruptions, enlargement of the spleen, alterations
 in the blood, and muscular degeneration, which  are found more
 or less well-marked in most infectious maladies, are of almost
 constant occurrence in  the  meningitis ; finally, the course of  the
 disease is rapid from its beginning to its fatal termination, wliich
 often occurs within a few hours in the height of malignant epi-
 demics—a fact for which no satisfactory explanation is found in
 the lesions, nor any parallel  except in what  occurs  in the most
 severe infectious diseases.
    The question here naturally arises,  Whether a comparison  of
 all the facts positively shows the identity or relationship of the
 meningitis with other infectious diseases ?  It is maintained  b}7
 English, American, Italian, and many French physicians, that
 the illness is a typhous disease, identical with or allied to exan-
 thematous typhus, or the so-called cerebral  typhus.1 But the
 critical investigation of  this question by German physicians, espe-
 cially by Hirsch,2  has shown the untenableness of this opinion.
Hirsch has properly called attention  to the fact that  the connec-
tion which unites  the " typhous" diseases in a common class is
          1 Hence the synonymes spotted fever, tifo apoplettico, etc.
          2 L. c, p.  145 et seq. 
692    ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MENINGITIS.
 really a very loose one, and that there  is still less reason  for
 admitting epidemic meningitis into this group when we consider
 that this affection, independently of its still  obscure pathogen-
 esis, presents no symptomatological or anatomical facts  which
 can entitle it to be included under that broad  and elastic generic
 term "typhus."
    In epidemic meningitis the lymphatics, the spleen, and the
 bronchial  mucous  membrane are not affected in  a  marked or
 constant manner; nor in their heterogeneousness and capricious-
 ness do the eruptions of the disease present a complete similarity
 to those of  typhoid  fever  or  exanthematous typhus.  Careful
 clinical investigations during the last few decades have shown
 that the behavior of the fever and  cerebral symptoms, and the
 absence  of a typical course,  etc., indicate  a wide difference
 between the general character of the meningitis and that of the
 individual typhous diseases.
    So also it can be readily shown that epidemic meningitis has
 no connection with malarial diseases, or, in other words, that
 there is no identity or relationship between the infecting prin-
 ciple of meningitis and malaria.
    The frequently well-marked  intermitting character of  the
 fever, the fitful progress of the inflammation and exudation, give
 to  many cases a superficial  similarity to intermittent fever and
 intermitting inflammations, such as pneumonia intermittens.   It
 is chiefly for this reason that some have admitted a relationship
 between the two infections, or at least a modification of  the men-
 ingitic process by malaria.
    That this  opinion cannot be maintained, is  readily seen upon
 careful examination.   In the first place, the meningitis by no
 means selects malarious neighborhoods, but  rather sandy, dry
 plateaus—the high plateaus of  central  Franconia,  with  their
 sandy soil, afford a suitable illustration; secondly, it  does not
 prefer the  seasons  of  the  year and conditions of temperature
 which are  favorable to the  development of malarious epidemics,
 but  rather the  winter;  thirdly, when occurring  in malarious
regions it shows neither a greater malignancy of; the cases, nor
more frequently  an intermitting type than it does in other places
which are free from malaria; nor, finally, is there any  other simi- 
                    PREDISPOSING CAUSES.                 693

larity to intermittent fever.  The spleen is generally only slightly
enlarged, more frequently of a normal size, even in the so-called
intermitting cases (v. Ziemssen  and Hess); enlargement of  the
liver, melanamiia, and other sequelae of malarial fever do  not
occur in this disease, and quinine  is always useless in the inter-
mitting cases.   Finally, the preference of the disease for the age
of childhood is opposed to the idea of malarial influence.
   Quite recently (1867) the dependence of the meningitis upon
malaria was  disproved by Bonsaing (1. a), who noticed that the
Pola epidemic did not seek out the notoriously malarious parts
of the city;  that during the epidemic, and after its disappear-
ance, malarial  fevers were almost entirely absent, and that qui-
nine was without effect in the intermitting form.
   If now we consider the influence of the other important causes
of infectious diseases, we find that climate and conditions of soil
are wholly irrelevant;  since,  as Hirsch has shown, the  disease
arises and subsides in the same form, with nearly the same mor-
tality and independence of fixed season or weather, whether in
the eastern hemisphere from the northern coast of Africa to sixty
degrees north  latitude, or in the  western hemisphere  from  the
coast of the gulf to  the New England  States.  The tropical
regions proper have hitherto escaped the disease.
   The season of the year and the weather seem nevertheless to
have an important  influence.   The  disease generally occurs in
winter and spring,  yet the effect of  temperature, moisture, and
direction of  the wind  has not been accurately ascertained in
detail.  The  cold of winter appears to have less influence than
great variations of temperature and the moisture of the air.
   Hirsch gives  a very instructive tabular statement of those
French and  Swedish epidemics in regard to which the time of
their prevalence has  been accurately given  according  to  the
respective months.   (See following page.)
   As  regards  individual predisposition,  age  and the external
conditions of life are of much, sex of little importance.
   With respect  to classifications  of age,   childhood suffers
severely both in susceptibility to  the disease and in mortality.
No ao-e is wholly spared-we have examined after death persons
as old as seventy to seventy-seven years-cases beyond the  age 
694    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.
of forty are very rare, somewhat more  common between twenty
and  forty years, but in the first two decades of life excessively
frequent.   In many epidemics only children under fifteen years
were attacked
Epidemics prevailed.
In December.
" January...
" February..
" March___
" April.....
" May......
" June......
" July......
" August. ..
" September
" October...
" November.
France.	Sweden.
26 times	19 times
32 "	45 "
39 "	55 "
30 "	65 "
23 "	68 "
16 "	59 "
16 "	37 "
7 "	16 "
7 "	11 "
8 "	8 "
10 "	6 "
12 "	8 "
In Winter

In Spring

In Summer

In Autumn
France.
97 times

69 "

30 "

30 "
Sweden.
119 times

192  "

 64  "

 22  "
   In Sweden, out of 1,267 fatal cases of meningitis occurring
during 1855-60, where the  age  has been stated, 889 were  under
15 years, 328 from 16-40 years, 50 above 40 years (Hirsch).
   For the districts of Carthaus and Berent (circuit of Dantzig)
Hirsch has prepared the following report of the mortality at dif-
ferent ages:  Out of 779 fatal cases, 208 occurred in the first year
of life, 337 from 1-5 years, 151  from  5-10 years, 41 from  10-15
years, 16 from 15-20 years, and  26 over 20 years.  As Hirsch
remarks: the relative susceptibility to the disease at different
ages is not correctly shown by the tables of mortality, since the
fatality is much greater  during the first years of life than  later,
and  therefore the numbers during the first ten years  of life are
much too high.
   In the circuit  of central  Franconia, according  to the official
report (Aerztl. Intell.-BL, 1865,  No. 30),  from June, 1864, to date
of report in 1865, 456 persons were attacked, of whom
               257 were from  0- 9 years of age
               126  "    "  10-19   "     "
                41  "    "  20-29   "     "
                32  "   over 30      "     " 
              ERRORS OF HYGIENE AS A CAUSE.           695

   Of the 42 cases occurring under our own observation
               14 were from  0- 9 years of age
               13  "   "   10-19   "    "
                9  "   "   20-29   "    "
                6  "  over 30     "    "
   The external circumstances of life which favor the outbreak
of epidemic meningitis are those bad hygienic conditions which
furnish the  soil for the deposit and  further development of the
morbific germ, viz., poverty, insufficient nourishment, and damp,
overcrowded,  badly  ventilated,  unclean  ground floors.   The
better class  suffer little from  the disease.  The overcrowding of
dwelling and sleeping rooms, and the consequent loading of the
air with animal emanations,  perhaps also the saturation of the
soil with garbage and the products of its decomposition, appear
to be as powerful agents in the germination of the contagium as
they are in that of cholera.
    In no other way can be  explained  the frequency  of local
epidemics in workhouses and other densely populated localities.
The numerous epidemics during the years succeeding 1830 and
1840  in France, which were confined to the military in  the bar-
racks, entirely or  almost entirely without extension to  the civil
population ; the  epidemics in the workhouses in Ireland during
1846; in the French  brothels and prisons ; the accumulation of
the sick in certain streets, in rows  of houses, and in detached
dwellings, as is observed in  every epidemic, compel  us to look
for the  collateral  causes of the development  of  the  morbific
germ in the same direction where they are found on an extensive
scale in the case of cholera.
    To the  same hygienic errors may also be  attributed the
repeated severe  epidemics among  the  negro slaves in  North
America   In these cases the fault lies rather with improper
vital conditions than with a difference in race.  The influence of
the latter upon susceptibility to meningitis  is still very doubt-
ful, and  cannot be traced in  the course of the epidemics in the
western hemisphere.                         .  -,   .       .,
    We must not conclude, however, that errors in hygiene are the
 only source of the  disease and of  its epidemic development.
 Such an idea is opposed by the permanence  of these conditions 
696    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

without the continuance of the meningitis, and by the presence
of the same conditions in other places without the development
of the disease ; finally also by the repeatedly observed transmis-
sion of the affection, a point to which we shall return hereafter.
   The influence of sex is  shown by the fact that almost always
men are attacked in larger proportion than women.
   Bodily conditions do not appear  to play an important part.
Those who are attacked are generally healthy and strong chil-
dren or young persons.   Nevertheless, chronic invalids and  suf-
ferers from acute affections, particularly of the air-passages, are
frequently the subjects of the disease.   The details upon  this
point will be given hereafter under the head of complications.
   Whether the poisonous material is a miasm or a contagium, or
whether the epidemic meningitis is to be regarded as a miasmatic-
contagious disease, are questions at present far from settled.
   The majority of writers very properly reject the  idea of con-
tagiousness in the strict  sense   of  the  word.   If the disease
generally spread  by transmission from one person to  another,
there would be as little doubt  of the fact as there is of  the con-
tagiousness of small-pox,  measles, scarlet fever, exanthematous
typhus, etc.   On the contrary, it appears very probable,  from the
course of the epidemics and from some very trustworthy observa-
tions  of the transmission of the  disease, that we have to deal
with a morbific germ, which primarily arises in the human body,
and infects healthy  neighbors only when it has undergone a
certain, still unknown, modification  by means of cultivation in
suitable intermediate individuals [Zwischentragern].
   This, in the main,  is the view expressed by French physicians,
who have traced the transmission of the disease from one garrison
to others.  Hirsch has collected  convincing facts * in regard  to
this point, and has added reliable observations from Berlin and
western Prussia.  I will briefly give the most important  of them.
   According to Frentzel, the first case of the disease among the troops in Berlin was
in one  of the reserve of the Alexander regiment, who a few days before had come
from Liegnitz, where the meningitis was then prevailing as an  epidemic.  In the
second company of this regiment, to which he  belonged, five more cases afterwards
occurred ; in the two companies lying on either side there were three cases in one,
1 L. a, p. 150. 
GENERAL DESCRIPTION.
697
two in the other;  in the four companies beyond these only one, and that the mildest
case, while there was no illness at all in the second battalion, which occupied the
same barracks, and was separated from the first by only a small court ; the two bat-
talions, as is generally the case, associating  but little with each other, but sharing
completely the same labors  and mode of  life, and eventually the evils of over-
crowding.

    The observation cited by Hirsch is still more striking.

   On the  8th of February, in the township of Sczakau, K., aged 20 years, was
taken ill, and was nursed by a young woman, W., who had hastened to  him from
the village of Sullenczyn.  After the death of K. his  nurse returned home, and
there died, Feb. 26, of meningitis.  This was the first fatal case  of the  disease in
Sullenczyn, with the exception of a previous one on January 15.  To the burial of
this maid at Sullenczyn came the family of the farm-steward K., from the township
of Potgass, accompanied by a servant, D., and the four-year-old daughter O., of
the teacher R., in Potgass.  After their return from the funeral, a little child of K.
sickened and died within twenty-four hours, then the servant D., who died March
4, and, finally, the girl K., on March 7.

    Such observations, and  others like  them, made by the phy-
 sicians  of upper Franconia, in  regard to the transmission of the
 disease,  confirm the supposition of a poisonous  material convey-
 able by intercourse, just as has  been  proved  to  be the case in
 cholera.
    Whether it  be,  as in  diphtheria and  relapsing  fever, a para-
 sitic agent, which in some way gains access  to the  soft investing
 membranes of the central nervous system, and there excites exu-
 dative inflammation, as the diphtheritic  germ probably does in
 the  throat, is  a question which  must  for  the present remain
 unsettled.  At all  events, more searching study must be devoted
 to these points in future epidemics.

                            PATHOLOGY.

               General Description of the Disease.

     The  meningitis almost  always  begins  abruptly  without a
 definite  prodromal stage.   In the epidemic observed by us we
 looked carefully for prodromata,  but found  them in only five out
 of  forty-three  cases.   In these five cases there were headache,
 exhaustion, nausea, anorexia, and flying pains.  Previous  to the 
698    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.
 sudden outbreak of the disease there was generally an interval
 of several hours, during which the patient felt perfectly well.
    The initial symptoms almost  always present a furious char-
 acter : a violent chill or chilliness, extreme malaise, wliich drives
 the patient at once to bed, raging headache, and free vomiting,
 wliich recurs whenever he rises.   In severe cases there  occur at
 the start loss of consciousness, coma or delirium, convulsions, and
 the characteristic stiffness of the neck, which in a few hours may
 develop into a tonic contraction of all the extensors of the spinal
 column.  In moderate cases there is only the stiffness of the neck,
 the patient is not completely unconscious, but somnolent, tossing
 on the bed  in continual  restlessness;  on being  spoken to or
 questioned, he immediately awakens from his stupor and  gives
 answers which are generally correct but  not very intelligible.
 His most constant and loudest complaint is of the headache, and
 even when quite unconscious he shows the intensity of the pain
 by groans and by pressing his head with his  hands.  The face is
 more frequently pale than  congested, and  the expression of the
 countenance is that of profound suffering.
   The disease develops  rapidly to its full intensity.   The fever
 is generally moderate, very irregular, and without  typical char-
 acter.  The pulse is either quite normal or moderately quickened,
 but undergoes  great and rapid changes in frequency.  During
 the active delirium, which alternates  with  unconsciousness, and
 while the restlessness still continues, the skin becomes generally
 hyperaesthetic, and afterwards the other soft parts and the joints,
 so that every movement of a limb, even the  raising of a fold
 of the skin, causes loud expressions of pain.  Then follow cuta-
 neous  eruptions;  first herpes on  the face, not infrequently  on
 the extremities, sometimes symmetrically arranged on both sides
 of the body;  then erythema, roseola, urticaria, and  petechia?
 From  the  third to  the fifth day the tongue becomes dry and
 cracked, the appetite fails,  the  bowels are  constipated, more
rarely  there is  diarrhoea, and often the  discharges are involun-
tary.
   If  the attack is to terminate fatally,  the symptoms of irrita-
tion of the nervous  system subside, and those of  depression
increase; the patient lies in complete unconsciousness,  there is 
                       FULMINANT CASES.                   699
little or  no reaction, the urine and stools are passed involunta-
rily, the pulse becomes very rapid—towards the end too rapid to
count—small,  and scarcely perceptible, the  temperature  shows
high elevations, there are convulsive muscular  movements, par-
alysis of the cranial nerves, paresis of one-half of the body, gen-
eral  convulsions ending in profound  coma, and finally death
closes the scene.
    If the disease run  a favorable course, the symptoms  of depres-
sion are  not marked,  or if they are, it  is only for a short time.
The patient complains continually of pains in the head, spinal
column, and extremities,  even on the  slightest movement, and
generally  lies motionless  in one position;  the eyes  are intol-
erant of light, the ears of  noise ;  the vomiting subsides after five
or six days ;  the headache and stiffness of the neck  gradually
diminish, and convalescence begins generally in from one to two
weeks, sometimes later,  but may be protracted for a long  time by
pains in the spinal column and extremities, and by disturbances
in the organs of sight and hearing.
    So different from this general  outline of the severe and mild
cases of the disease is that of  the most  severe and mildest types,
as well  as that of the intermitting form, that it is necessary to
devote separate attention to these latter varieties.
    1.  Meningitis cerebro-spinalis siderans (Hirsch)—the menin-
gite f oudroyante of the French.   The disease begins in the midst
of perfect health, with a shaking chill, quickly followed by loss
of consciousness,  convulsions,  and contraction of  the  neck.
Death ensues  in a few hours.   According to the descriptions of
the French writers,  the patients in rare  instances fall in the
street, are struck down,  as it were, in a  moment, and are brought
dying to the hospital.1
    As an illustration of  this form, take a case which occurred in
the epidemic at Erlangen.       ^________________________
   1 "Tout a coup, au  milieu de la sante la plus parfaite, des homines  pleins de
jeunesse et de force etaient atteints des accidents les plus graves ; ils succombaient en
pen d'heures sans qu'aucun  trouble fonctionel eut precede cette subite invasion.  Des
militaires ont ete frappes dans la rue, a l'exercise, dans les casernes, pendant leur repas,
ils tombaient comme foudroyes, et l'on  transports  a l'hopital dans un etat desespere
deshommes, qui pen auparavant faisaient tear service sans se  plaindre.»-2™nto, L
c, cit. by  Hirsch, p. 44. 
700     ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MENINGITIS.

   Margaret Eckart, aged 8 years, was a feeble child from birth.  Later in life she
was noticed  to be deficient in intelligence and memory.  Frequently without any
external cause she fell into fits of weeping.  For some years she had suffered from
attacks of severe headache. The mother of the child died of pulmonary tubercu-
losis.
   On the afternoon of April 22 the child was suddenly taken ill with severe head-
ache while playing out of  doors, and came home complaining and weeping.  After
being put to bed she suffered also from nausea, active vomiting, and vertigo.   The
headache increased, the eyes became distorted, and the fingers of both hands firmly
clenched.  This condition  is said to have lasted about two hours, during which the
patient remained apparently conscious, and often screamed loudly.  Evening, six
o'clock. —Present condition.  Patient is gracefully formed, skin pale, muscles flabby
and poorly developed.   She lies quietly in bed, perfectly conscious, complaining of
headache and intense thirst; cheeks considerably reddened; neck not stiff.  Tem-
perature 103.3° F. (rect.); pulse  100.
   23, Maiming.—Last  evening several attacks of vomiting.   Slept poorly, but the
headache was slight, and  is now entirely gone.  The skin, especially that of the
face, is very pale ; moderately warm.  Temperature 100.7° F.  (rect.) ; pulse 100.
   Towards  noon patient left her bed feeling quite well; went out, and  brought
beer from a neighboring public-house.
   About two o'clock, after having for some time amused herself with  her sisters, she
suddenly became quiet, lay down upon the floor of the  room, and  complained of
severe headache.  She was put to bed.  After some time the " eyes became drawn,"
and marked contractions of the hands and feet ensued, which soon passed into vio-
lent general convulsions, with continual groaning and screaming.  Consciousness is
said to have been lost for only a short time.
   About six o'clock in the  evening the convulsions gradually ceased,  and after ask-
ing for a drink the child sank into stupor, and died half an hour afterwards.
   Sectio cadaveris:  A small amount of sero-purulent infiltration of  the arachnoid
and subarachnoid space in the  brain and spinal  cord, anaemia  and  oedema of the
brain and spinal cord, bronchial catarrh and partial collapse of  the lungs, swelling
of the solitary follicles in the small and large intestines.


   These cases occur in all epidemics, and most frequently at their
commencement.   As a rule, they are fatal.    Among  forty-three
cases we  have ourselves  observed four, the  duration of  which
amounted to twelve, twenty-four, twenty-eight, and thirty hours.
All four terminated fatally.
   2. Meningitis cerebro-spinalis abortiva.    This abortive form
of meningitis has for a long  time  been  observed wherever epi-
demics  have  prevailed; a fact which furnishes additional  proof
of the  infectious nature of the disease.   Like other  writers,  we 
THE ABORTIVE FORM.
701
have noticed, during the height of an epidemic, the lightest form
in ambulant patients, who complained only of headache, stiffness
and pain in the neck,  and  malaise, without being compelled  to
desist from their work.  Such cases are naturally to be explained
as  rudimentary forms  occurring on  the  outskirts  of the epi-
demic.
    As incidental complications of inflammatory affections of the
lungs, pleura, and  tonsils, we have observed  symptoms wliich,
though of a mild nature, were characteristic of meningitis, such
 as headache,  with nausea  and vomiting,  sometimes preceded  by
 chill, slight stiffness of the neck and of the whole spinal column,
 vertigo, unconsciousness, and  slight elevations of temperature.
 Below are two such cases observed by us.

    I. Johann Scholl, aged 19 years, journeyman cabinet-maker, was taken ill on May
 12, 1865, at half-past six o'clock in the evening, in the midst of perfect health, with
 a shaking chill and severe headache.   During the following sleepless night there
 were alternate chills, fever, and perspiration, and, in addition, stiffness of the neck.
 Towards morning the patient vomited a yellow, watery fluid, and had a consistent
 passage from the bowels.  In the afternoon he was admitted into the University Hos-
 pital.
   Men, 13, iM^.-Temperature 103.1° (rect.); pulse 80, full  and  hard;  face
 sliohtly congested; pupils widely dilated, but reacting promptly; tongue moist,
 and somewhat coated.  Forward movements of the head were difficult and painful.
 The dorsal portion of the spine was bent out of its natural curve, so as to be abnor-
 mally straight,  and not easily flexible forwards.   The lower vertebra,  (from the
 seventh dorsal downwards)  were of normal position and  flexibility.   No chest
 symptoms.  Abdomen retracted, not painful.  No eruption, no enlargement of spleen.
 Ordered twelve wet cups to the neck.  Calomel gr. v, pulv. rad. jalap gr  x
     May 14 Morning.-^ quietly without dreams.  Temperature 100.4  (rect.);
  pulse 80; less headache; neck still stiff and painful in forward movements; tongue
  miirh coated: some appetite.                                          .
     ^.-Temperature  100- pulse 72; uo headaehe.  Stiffness of  corneal
  vertebra: somewhat less.  Vertigo. Two loose stools.
     L,15 JmW^.-Patieut slept during the whole night.  Temperature M! ,
  nnlse 1 s «   About the chin and the corners of the mouth are some eczema yes-
  fete   Pa«ent can raise himself in bed, and remain in tins posi.mn for some  fme
  ^  hontdfflcnlty  Cervical vertebr* still somewhat stiff.  Cerv,eal glands aymmet-
  rilCbutelghtyswoncn.  Vertigo.  Constipation.  Improved appet, e
  neatly but sn^i  v                                 ^ nQw eRsi]y be bent
     ^.^.-Temperature  99.9  , pute.72.                 General condition
  forward, and the neck is no longer painful.  Veitio0 com
  good.  Constipation.  Ordered ol. ricini. 
702     ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MENINGITIS.
   May 16,  Morning.— Temperature  97.2°;  pulse 60.  No vertigo.  Subjective
and objective condition normal.  Discharged.
   II.  Jacob Nobenberger, eight years of age, son of a farmer in Hessdorf, a slen-
der boy and small for his age, was taken ill on the morning of May 25, with active
vomiting, headache, severe tearing pains in the neck, and immobility of the same.
He was obliged to go to bed.
   In the evening  he was more cheerful, although the headache, according to his
statement, is undiminished.  On the following day (May 26) patient left his bed.
Herpes on the lips, loss of appetite.  Headache still present, especially towards
evening.  On the following days, during the period of headache, which recurred
every evening, the hearing was so much affected that patient understood only when
loudly addressed.
   On May 31, the  seventh day of the disease, he presented himself at the clinic,
after having travelled on foot an hour without much fatigue.  The evening head-
ache still continues.  Pupils and pulse normal, herpes crusts on the lips.  The tick-
ing of a watch was not heard  on the left side at 2", on the right at 1".  Nothing
abnormal was found in the external auditory canal, nor in the membrana tympani.

   3. Meningitis epidemica intermittens.  This form of  menin-
gitis  has  also  been observed in epidemics  of the most  diverse
character  in  France, Italy,  Sweden, and Germany.  It is distin-
guished by febrile attacks, recurring sometimes regularly  in quo-
tidian or  tertian form, with exacerbation of all the other symp-
toms, and by intervals of complete  or< almost  complete freedom
from fever and other indications of disease.   The  similarity of
severe  cases of this  kind  to pernicious intermittent fever  was
noticed by Vieusseux.   As has been already  mentioned in the
chapter on  Etiology, page 692, recent observations,  especially
those  made  in Germany,  clearly  show that this variety has
nothing in  common  with  malarial diseases, except the objec-
tive sign  of  an intermission of  fever.  I have myself, moreover,
demonstrated by systematic measurements of temperature, in the
Erlangen  epidemic,  the fact' that the  alternation of intermission
and exacerbation is not  always uniform, and that in this respect
the resemblance to intermittent fever is more apparent than real.
These  intermissions  appear either  in the beginning  of  the dis-
ease, both in the short  and protracted cases,  or  in the  stage of
defervescence and convalescence.
   1 L. c, p. 401 ; see also the graphic representation of the course of the fever on
page 714. 
PATHOLOGICAL ANATOMY.
703
   In the first case the short prodromal stage may consist of
several attacks, as is shown by the case of Eckart, quoted at page
7<)0 ; generally the  intermitting character of the fever lasts for
several weeks, and then changes to the continuous form,  or ter-
minates immediately in death or recovery.
   In the second case the stage of defervescence  is interrupted
by more or less  regular febrile exacerbations, which  are often
very severe, and are introduced by shaking chills, the thermome-
ter rising to 10-1° Fahr. and upwards.  The resemblance  to the
febrile attacks of pysemia is very striking.
   The significance of this behavior of the fever will be again dis-
cussed when I come to treat of the fever.
   4.  Typhoid epidemic meningitis is  regarded  by Hirsch,
Tourdes, and others, as that modification of  the disease in  which,
after the meningitis has lasted  for some time, a so-called typhoid
condition is developed, the patient  lying  soporose or with mut-
tering delirium, with a dry, cracked tongue, sordes on  the teeth,
lips, and alee  of the nose, cold extremities, small, very rapid
pulse, involuntary  diarrhoeal  discharges, decubitus, and otlier
similar symptoms.
    Although  it cannot be  denied  that there is  a  resemblance
between the  course of severe typhus and this variety  of epi-
demic meningitis, yet to designate the latter as "typhoid" tends
to identify it with the typhoid diseases, and to increase the con-
fusion which  it requires  so much effort to remove.  It is better
to regard such cases as prolonged meningeal inflammations, in
which the  infection has been severe. Nowadays  the typhoid
forms of severe scarlet fever and measles are no longer regarded
as scarlatinal or morbillous typhus, but rather as cases of  violent
infection.

                    Pathological Anatomy.

    The lesions of epidemic meningitis are quite constant.  The
most important changes are found  almost without  exception at
every autopsy, and vary only in the degree of their development.
    The emaciation in  the protracted  cases is very great.  The
rio-or mortis continues for a long time,  Numerous hypostases of 
704    ZIEMSSEN.— EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.

considerable size appear early, and sometimes  elsewhere than on
dependent parts.
   The skin shows the remains of the different eruptions, especi-
ally herpes and petechiae.   The muscles, especially those extend-
ing along the spinal column,  are reddish-brown or pale, and are
found  to have undergone granular degeneration  (Zenker); the
fat molecules being of such fineness that the fibres appear cov-
ered with a fine dust (Klebs).
    In some cases multiple abscesses are found in both the sub-
cutaneous and the intra-muscular connective tissue (Faure-Vil-
lars, Klebs).
    The calvarium is frequently congested (in a punctate or linear
manner), especially along the sutures.
    The dura mater of the brain is often tense, smooth on its
exterior  surface,  here and there united  to the vitreous table,
sometimes specked with blood, the inner surface hypersemic and
adherent to the arachnoid.
    In the sinuses thin  fluid blood, loose or  firm post-mortem
clots, rarely older decolorized thrombi are found.
    The arachnoid is sometimes quite normal, sometimes hyper-
aemic or opaque, dry or viscous ; after a protracted illness occa-
sionally roughly thickened.
    The pia mater is almost  always hyperaemic, with capillary
apoplexies, opaque and thickened  by exudative infiltration.   It
can with difficulty  be separated from  the surface of the brain,
and often only by tearing the latter.
    The more acute the course of the disease, the less free exuda-
tion is found between the pia mater and the arachnoid.   In  the
fulminant cases the free  exudation is entirely absent, and only
microscopic changes are  found in the pia mater, in the form
of a dense infiltration of  cells, especially in the neighborhood of
the vessels.  Where free  exudation is present in the subarach-
noid space, it appears after  an illness of from one to two days,
as a slightly cloudy mucous  serum, or as a yellowish, whey-like
exudation.
    If the disease have lasted from two to three days, the exuda-
tion is distinctly purulent, of a greasy, gelatinous, or firmer con-
sistence, sometimes of a bloody tinge, and several lines in thick- 
                   LESIONS OF  THE BRAIN.                70.1

ness.   It is deposited both on the convexity and  at  the  base,
especially along the course of the great vessels, in the folds and
depressions of the surface of the brain, in the fissure of Sylvius,
along the sulci, between the  pons varolii and chiasma, and on
the pons and cerebellum.  In rare cases the whole surface of the
brain is quite uniformly  covered.   The exudation consists of pus
cells, free granules, fibrine, and mucine.
   The membranes of  the spinal cord are in much the same con-
dition as those  of the brain.   The dura mater  is often found
separated from  the vertebrae by  extravasated blood, the aracli-
noid cloudy, and the pia mater thickened, and very adherent to
the cord.  The exudation appears here also at an early period as
cloudy serum, but soon afterwards as a more or less thick fibrino-
pus deposited in lines or as a layer, still later as a thick uni-
form stratum of pus, chiefly in the lumbar, less in the cervical re-
gion, and almost exclusively on the posterior surface of the cord.
The roots of the spinal nerves are frequently bathed in pus.  The
anterior surface is much less frequently covered by the exuda-
tion ; and when this is  the case the whole cord is surrounded.
The exudation is  found posteriorly, principally because it flows
to the dependent parts while it is still fluid (decubitus); and in
the  rare cases, where the cord is wholly imbedded—we have ob-
served one exquisite case of this kind after the disease had lasted
eleven days—the  variation from the rule depends mainly upon
the solidity of the exudation.
    The brain substance appears sometimes congested, with punc-
tiform hemorrhage and secondary development of small spots of
softening ; at other times, particularly when the disease has been
hyperacute or very long-continued, it is juicy  or oedematous,
with a  smooth, level surface, and  of a  watery appearance on
section,  whether  in  the cortex,  medulla, or central ganglia.
More rarely the substance is of a tough consistence.
    In the majority  of  cases, especially  those which are  pro-
tracted,  the ventricles contain considerable serum  or  a turbid,
perhaps purely purulent exudation ; the plexus and the  epen-
dvma are much injected, even ecchymosed, and  covered with a
layer of fibrino-pus.  These conditions are found also in the third
and fourth ventricles, though less frequently than in the lateral
           VOL. II.—45 
706    ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MENINGITIS.

ventricles.   The neighborhood of the ventricles is found to have
undergone Irydrocephalic softening.
   After a very long-continued illness the serous effusion may
reach an enormous amount;  resulting in eccentric  atrophy  of
the brain substance,  flattening of the convolutions, and great
oedema of  the brain  and spinal cord.  We also find shrinking
and caseous degeneration of  the exudation between the arach-
noid and pia mater, with opacity and callous thickening of these
membranes.'
   In  the  substance of the spinal cord the  same  changes  are
found as in the brain (injection or anaemia,  serous infiltration or
pulpy softening), but they are generally less marked, and less
uniformly  distributed through the organ.

   As characteristic of the myelitic softening, Mannkopf found an abundant infil-
tration of cells, which lay along the course of the vessels and extended with them
through the anterior and posterior fissures into the substance of the cord.

   In a patient of Fronmuller, a servant girl  aged fourteen years,
who died  after  four days'  illness,  the autopsy made  by us
revealed a  large  serous effusion, purulent  exudation in the ven-
tricles (including the fourth) and dilatation of the central canal
of the cord, which was filled with pure pus.
   Of the other organs, the lungs alone exhibit frequent changes,
such as simple hyperaemia and oedema, especially bronchiolitis
in the lower lobes at  their posterior surface, with a tough catar-
rhal secretion, secondary atelectases, and  often lobular, more
rarely lobar, pneumonic infiltrations.   The pleurae and the peri-
cardium are sometimes inflamed, covered with purulent  exuda-
tion, or ecchymosed.  The heart is  often flabby, and  contains
dark, thin  fluid blood, with loose post-mortem coagula, less fre-
quently firm fibrinous clots.   Recent endocarditis  is not often
seen.  The liver and  spleen are generally congested, and of very
variable consistence.  The liver cells often show an albuminous or
fatty cloudiness.  The spleen is sometimes moderately enlarged.
The stomach frequently exhibits well-marked cadaverous  soften-
ing, even in adults.  In the small intestine the mucous mem-
   1 See Ziemssen and Hess, I.e., Cases XVI-XIX, and the section " Complications and
Sequelae " in the present article. 
             ANALYSIS OF INDIVIDUAL SYMPTOMS.          707

brane is normal or injected, even ecchymosed ;  the solitary folli-
cles and Peyers patches are swollen, and in rare instances ulcer-
ated.  In the large intestine we once saw marked lesions of dys-
entery.  The kidneys are generally flabby and congested.   The
renal tubules are sometimes filled with fat granules and fibrinous
casts.   The mucous membrane  of  the  bladder is here and there
injected or  ecchymosed.  Purulent exudations are sometimes
found in the joints.
    The auditory apparatus is often affected, more rarely the eye,
most rarely the organs of smell and taste.  The disturbance in
the functions of the latter senses is  doubtless due to the pressure
of  the  exudation upon  the  respective  nerves at the base of the
skull.   The  lesions in the eye are choroiditis, with consecutive
detachment of the retina (Knapp); in  the ear, if we may trust
the few autopsies made hitherto, purulent inflammation of  the
labyrinth and tympanum (Heller, Lucae).

             ANALYSIS OF INDIVIDUAL SYMPTOMS.

    Headache may be regarded as an almost constant symptom,
since it is rarely absent.   It is generally very severe, extorting,
even during  coma, loud groans and sighs of pain. It causes also
great restlessness ; the patient frantically strikes out with  his
arms, and  stamps with his legs, presses his head automatically,
and moves it to and fro;  finally, in some instances he becomes
furiously  delirious, springs out of  bed, fights those about him,
and requires  forcible restraint.
    The pain  is situated sometimes  in the forehead, sometimes at
the back of the head or temples, occasionally it extends over the
whole  head,  and is of a beating, boring,  stabbing character; or
the  head feels  as if compressed by  a  band.  The seat of the
headache  does not always correspond  to the  situation of the
inflammatory products found after death, nor is the  violence
of  the  pain  in  direct ratio to the intensity or danger of the
disease.  In many cases there are not merely marked remissions
of the headache, but distinct intermissions,  although generally
the pain continues of uniform intensity, with slight daily varia-
tions.  Its cessation during the attack is one  of the most favora- 
708    ZIEMSSEN.— EPIDEMIC CEREBRO-SPINAL MENINGITIS.

ble symptoms, yet we must expect several exacerbations,  with
elevation of temperature, during convalescence.
   According to  our observations, the  headache  in  many in-
stances continues for years after recovery from the meningitis.  It
returns upon exertion of the body or mind, stooping, etc., and is
accompanied by pain in the back  and  weakness  of  the  lower
limbs.   These  symptoms perhaps depend upon the rough thick-
ening of the pia mater, wliich we have repeatedly  found in sub-
sequent autopsies, and also upon the tendency to congestive and
inflammatory disturbances which is left  behind in  the pia mater
from the previous inflammation and its results.  We shall return
to these points when we come to consider the sequelae.
    Vertigo is  frequently associated with the headache.  During
the convalescence  the return of the vertigo and headache, which
had entirely disappeared, especially if associated with vomiting
and convulsions, is a very bad sign, because it often indicates the
development of hydrocephalus.
    Vomiting is rarely absent.   It is an initial symptom, con-
tinues generally not more than two days, and is excited by move-
ments, especially by rising.  In some cases it frequently recurs
during the whole course of the disease, is each time accompanied
by increased headache, and prostrates  the patient very much,
because it interferes seriously with the  assimilation of nourish-
ment.  It appears to me probable that this return of the head-
ache and vomiting is owing to a renewal of inflammation or con-
gestion.
   It is scarcely necessary to mention that the vomiting is to be
regarded as only a symptomatic expression of the irritation of
the meninges and brain, and not as an indication of simple gas-
tric derangement.
   Stiffness or contraction of the neck is the third constant
symptom, and gives such a characteristic expression  to the dis-
ease that, as has  been already mentioned, the affection is popu-
larly known' as "der Genickkrampf."
   The stiffness of  the  neck is due to a more or less  developed
contraction of  the deep  cervical muscles—the trapezii are almost
always  unaffected.   There are  great variations in  the degree of
                    1 In Germany.—Translator. 
THE  MUSCULAR CONTRACTIONS.
709
contraction—from a slight stiffness, felt only when the patient
attempts to bend the head forward, to so great a retraction that
the back of the head presents nearly a right angle with the spinal
column.   In the latter case the patient swallows with much dif-
ficulty, probably because the larynx is firmly pressed against the
spinal column by the extreme tension of the anterior muscles of
the neck (sterno-thyroid, thyro-hyoid  and sterno-hyoid).   This
marked contraction generally occurs between the second and fifth
days.  The stiffness is rarely seen on  the first day, and then only
to a slight extent.
   In almost half the cases there is also more or less contraction
of the other erector muscles of the spine—from a mere stiffness
and straightening of  some parts of the column, with disappear-
ance  of the spinous processes, and with the presence of pad-like
projections of the hardened muscles on both sides, to complete
opisthotonos.  The latter condition, as far as we have observed, is
rare,  but complete orthotonos is frequent.  The spine then be-
comes a straight shaft, and the convexity of the dorsal and con-
cavity of the lumbar curves disappear.  If we attempt to raise the
patient,  the body remains stiff, and the  patient, in his violent
efforts to bend  himself, slips to  the  foot of the bed ; or we may
succeed  in getting him into a half-sitting position  by means of
some still remaining flexibility of the lumbar vertebrae,  or  by
bending him  at the  hip-joints.  The severe pains in the spine,
induced by the strain, prevent him  from long maintaining this
posture.
    Pleurothotonos, or unilateral contraction of the spinal erector
muscles, has  been observed (Levy, Hirsch), but is certainly very
rare.
   The contraction lasts a very variable time.  In favorable cases
it disappears in from two to three weeks, but not unfrequently
continues much longer (four to six weeks); indeed we have sev-
eral times seen convalescents going about with a rigid spine.
   In rare instances the stiffness of the neck is entirely absent.
I have myself seen some  cases of this kind in which, at the
autopsies, the anatomical changes, and particularly the extent of
the inflammation in the spinal meninges, were not found  to  be
at all different from those of other cases where the symptom 
710   ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MENINGITIS.

was well marked.  The absence of this symptom cannot be ex-
plained.
   Pathogenetically, the stiffness of the neck is to be regarded as
a reflex contraction, due to inflammation of  the pia mater of the
medulla  oblongata, and probably also of  the  posterior columns
and posterior roots of the cervical portion of the cord.
   Trismus and  contraction or  rigidity of other muscles, par-
ticularly those  of  the extremities, are rarely seen.  Trismus  is
usually  observed  only in those  who are dangerously ill  and
comatose, and is an unfavorable prognostic symptom.
   Rachialgia,  or pain in the spine, especially in the neck,
varies  considerably in  intensity and duration.  Many patients
with rigid spines are wholly free from  this pain as long as they
lie immovable  on their  sides, yet make loud complaints when
any attempt is made to bend the head or trunk.
   In other cases the pain continues severe in whatever position
the patient lies.
   Exacerbations and  remissions of  the  rachialgia occur,  al-
though less frequently perhaps than is the case with the cepha-
lalgia,  and sometimes the stiffness of the neck increases or remits
synchronously with the pain.
   Besides its situation in the neck,  the pain affects  most fre-
quently the loins, and more rarely extends along the whole spine.
   Pains in the extremities, especially the legs,  are a frequent
symptom,  and are  caused  or increased  by  concussion of the
spinal column.  They are described as darting with the rapidity of
lightning.  Other parts of the body are also affected, the funda-
ment and the  sterno-cleido-mastoid muscles,  for instance,  and
sometimes the pains shoot quickly from one place to another.
   Patients also frequently complain of a persistent pressure in
the epigastrium, pain in the chest, and difficulty of breathing ; in
one case, in fact,  we observed repeated severe asthmatic attacks.
   A universal, or at least a widespread, hyperesthesia of the
skin, the other soft parts, and the joints is one of the  more im-
portant symptoms  of the spinal  meningitis, but is by no means
a constant one.  Hirsch,  Frantzel, and myself failed  to find it
in many cases.   When  it is present,  it occurs most frequently
in the lower extremities, occasionally at the same  time in the 
                     CUTANEOUS ERUPTIONS.                7ll

 trunk and upper extremities.  It is so severe that every move-
 ment of the legs, every pressure on the surface of  the body even
 shaking the bed while the patient is profoundly comatose, excites
 loud expressions of pain, and even reflex convulsions   Asso-
 ciated with this condition is often found great sensibility of the
 senses to light, odors, etc.   As  Hirsch has  correctlv observed
 this general hyperaesthesia interferes very much with the exam-
 ination of the patient.
    Partial anasthesia of different parts of the skin has hitherto
 been noticed with much less frequency.
    Cutaneous lesions  are very common.  Copious eruptions are
 a marked symptom in some epidemics, while in others they are
 less frequent.   It would  be difficult from  our own observations
 to  understand why the American physicians called the disease
 "spotted fever," ' were it not that roseola and petechiae are more
 frequent symptoms of epidemic meningitis in  America than in
 Germany.
    Of all the different eruptions, herpes facialis is  the  most
 frequent.  It begins generally in the neighborhood of the mouth,
 upon  the upper  or lower lip, sometimes on both sides,  and
 extends  to the cheeks, nose, ear, and eyelids.  I have never seen
 herpes in other diseases spread  so widely  as  in meningitis.
 It is by no means rare to see one or both  sides of the  face cov-
 ered with vesicles  or crusts.  Irregular extensions of the erup-
 tion often take place very late in the disease, even in  convales-
 cence (in the sixth or eighth week, Hirsch).  Tourdes and myself
 have observed that it generally begins from the third to the sixth
 day.   With our present information no prognostic significance
 can be ascribed to the eruption.
    Petechial are the next most frequent eruption; then follow
 roseola, erythema, urticaria, erysipelas, and sudamina.  Some-
 times a  patient presents  three or four varieties.  Vieusseux,
 Faure-Villars,  Upham, and others have called attention to the
 ominous  significance of the ecchymoses appearing in the latter

  1 Exanthematous typhus was formerly known by its other name, spotted fever (fleck -
fieber), and hence this designation of the meningitis has led to an unfortunate miscon-
ception on the part of American and English physicians as to the nature of the new
disease. 
 712    ZIEMSSEX.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

 part Of the  disease, and the extensive hemorrhagic suffusions of
 the skin, which resemble the livid spots of the cadaver.
    It is interesting to notice the frequent symmetry of the erup-
 tion on both sides of the body.   Not only on the face and trunk,
 but also on the extremities, the herpes is often found developed
 bilaterally in  exactly corresponding situations.   Thus, we have
 seen herpes present at the same time on the joints of both hands,
 urticaria on both legs, and petechiae on both shoulders, etc.
    The symmetrical appearance, variety, and frequency of  the
 eruptions, as well as the hyperaesthesia, point very strongly to a
 trophic disturbance of innervation in the brain and spinal cord, an
 explanation similar to the one  now accepted as probable,  if  not
 certain, in regard to the lesion present in non-meningitic zoster.
    Besides the  symptoms above mentioned, fever is also a con-
 stant accompaniment of the  disease.
    The behavior of the bodily temperature,  as shown especially
 by Wunderlich and myself,  is irregular.
    Generally the temperature is quite high, not always at the be-
 ginning, but first on the second or third day ;  sometimes, however,
 it rises rapidly after the initial chill.   In severe cases, especially
 towards the end, it is  sometimes as high as 107° F., and higher.
    Generally the medium temperatures are from  100.4° to 101°,
 with very irregular variations above  and  below these points,
 often interrupted  by long-continued normal  temperatures,  while
 the other symptoms continue unabated.  Moreover, if  we com-
 pare the temperature tables of numerous cases, we find that only
 a few of the curves resemble  each other.
   Below are found some of the curves, together with brief abstracts of the cases,
 illustrating the course of the temperature and pulse in severe and mild cases.

                       I.—Severe  Form.
   L. W., aged 15 years, a plasterer's apprentice.  Access abrupt, with  chills,
cephalalgia, vomiting, trismus, tetanus of cervical and spinal muscles.  Conjuncti-
vitis, hyperaesthesia of skin.  After the fourth day, herpes facialis, roseola, erythema,
urticaria, and petechiae on the extremities.  Moderate fever, with retardation of
pulse.  Furious delirium followed by sopor.  With rapid elevation of temperature
and pulse, death ensued on the seventh day of the disease.
   Autopsy.—Purulent  cerebro-spinal meningitis.  Remains of  old pleurisy  and 
                      THE BODILY TEMPERATURE.                   713

perihepatitis.   Partial atelectasis  of lungs, and lobular pneumonia.  Cadaverous
softening of the stomach and  diaphragm (five hours after death).  Suppurative
                 Temperature.                             PnlBe
       MEMEMEMEMBM            MEMEMEMEMEME
        I    II   III   IV   V   VI            I    II   III   IV   V   VI Diseas*.
tendo-synovitis in the left hand.   Areas of degeneration  in  the  spinal and recti
abdominis muscles.  Ulceration of cornea.
      EMEMEMEMEMEMEMBMEMEMEMEMEMEMEMEM
III   IV   V   VI  VII  VIII   IX  X   XI  XII  XIII  XIV  XV  XVI
                  II.—Moderately Severe  Form.
M. V., ao-ed 12 years, daughter of a stocking-weaver. Access abrupt, with chill, 
714    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

and vomiting lasting during the first four days.  Frontal headache.  Stiffness and
pain in the spine, jactitation, urgent thirst.  Mind at first clear, afterwards delirium
and somnolence.   Petechiae on the second day, herpes  on the face on the seventh,
on the thumb on the tenth day. Effusion into the right wrist-joint.  Conjuncti-
vitis and keratitis.  Aphthae.  Temperature at first high, but gradually diminish-
ing, while the pulse becomes very rapid.  Tedious convalescence.  Duration of the
disease about six weeks.

                         III.—Mild  Form.

   C. St., aged 16 years, daughter of an umbrella-maker.  After a prodromal stage
of two days' duration, patient was taken ill with pains in the head, extremities, and
epigastrium, nausea, vomiting, stiffness of neck, delirium, premature menstruation;
herpes on the fourth day, conjunctivitis, and transient fever.  Improvement  at the
end of the first week.  Duration of the disease three weeks.
          Temperature.                           Pulse.
EMEMEMEMBMEMEM    EMEM EMEMEMEME
ii   in  iv   v   vi vn  vni     ii  in   rv  v,   vi  vn  vm
                         Intermittent  Form.

    In these cases the accurate use of  the thermometer  by no
means shows that regularity in the alternation of fever and apy-
rexia  wliich a superficial  observation seems  to  indicate.   The
remissions  and intermissions often  extend over several days,  so
that the graphic representation of the  course  of the temperature
presents the appearance of great irregularity,  sometimes even of
a mere recurrence.

   Below are curves of intermittent cases :
   1. Catharine F., aged 8 years, daughter of a laborer.  Access abrupt, with vom-
iting and  cephalalgia.  Chill, pains in the neck,  difficulty in swallowing, stiffness
and tenderness in the neck and dorsal region of the spine.   Sensorium clear, occa- 
Kath. V., 8 years old.                                                    Temperature.                                      I  Quinine.
EMEMEMEMEMEMEMEMEMEMRMEMEMEMEMEMEMEMEME MEMBMEMEMEMEMEMEMBMEMEMEMB
M   R .                 '""    M    ^         M   M
Kath. P., 8 years old.
 E
Pnlie.
ME MeTeM EUEMEMEMEMEMEMEMEMEMEMEMEMEM EMEMEMEMEMEMEMEMEMEMEMEMEMEME     C
«                     M   ™             P   ,_
P    P   q       Oi 
716     ZIEMSSEN. t—EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.

sionally mild delirium.  Epigastric  pains.  Herpes  labialis  on  the fourth  day.
Temporary polyuria and slight albuminuria.  Pulse at first  retarded, afterwards of
variable frequency.  Temperature very high at the beginning, later in the disease
elevations apparently intermittent, preceded by chill, vomiting,  and cephalalgia.
Cessation of these attacks in the fifth  week.   Recovery  in the seventh week.
(Temp, curve, p. 715.)
   2. Th. M., aged 19 years, student.  Prodromata for eight days.  Access abrupt,
with cephalalgia, vomiting, slight convulsions, unconsciousness.  Neck somewhat
stiff.  No fever during the first few days.  Exacerbation on  the fourth day,  with
fever of short duration, followed by apyrexia and disappearance of the  malaise.
On the fifth, seventh, and eighth days the exacerbations recurred with marked spinal
symptoms.  Then followed daily exacerbations,  but of less intensity and shorter
duration.  No eruption.  Complete cessation of febrile attacks after the eighteenth
day.  Recovery.  Duration of disease six weeks ;  of convalescence four weeks.
   Th. M., 19 years.     J Quinine.
EMEMEMBMEMEMEMEMEMEMEMEMBMEMBMBMEMEMB
II  III IV V  VI VII VIII IX  X XI XII X1IIXIV XV XVIXVII XVIU XIX
    I  have  already shown that in  these cases  there is no true
intermittence.   In many of them the febrile attacks in the begin-
ning and in the subsequent course of the disease are probably,
as  it seems to  me, due to the irregular progress of the inflamma-
tion,  and thus  resemble what occurs in migratory erysipelas and
pneumonia ambulans.
    In the  retrogressive  stage  these attacks often  present the
character of the absorption fever, so frequently seen during the
retrograde  metamorphosis of  purulent  exudations  on  other
serous  membranes  (pleura, peritoneum).   When  the  attacks
occur during convalescence they are more probably due to slight
returns of the inflammation.
    The pulse is generally as irregular as  the temperature.   Its
frequency does not always correspond to the height  of the tem-
perature and the intensity of the other symptoms.  Attention is
particularly called to the pulse curve on page 715, lest  the diver- 
                CONVULSIONS AND PARALYSES.             717

gence from the temperature curve there shown may be over-
looked.  When the inflammatory and febrile symptoms are of
equal intensity, the pulse is sometimes normal, sometimes mode-
rately, at other times considerably increased in frequency, but
rarely retarded.  Occasionally it varies thirty to forty beats or
more within  the course of a few hours; indeed, even within a
few minutes, as Tourdes has observed, differences of as much as
thirty beats may occur.
   Abnormal slowness of the pulse is much less frequent  than in
tuberculous basilar meningitis.  It rarely occurs except at the
outset, and then in connection with  lowered temperature, soon
changes  to increased  frequency,  and in fatal cases usually the
pulse rises so  high that it cannot be counted.  Irregularity in
rhythm  is not  uncommon.  Continued rapidity is generally to
be regarded as an unfavorable symptom.
   In quality the pulse is either quite normal or of increased ful-
ness and tension.   When the symptoms  of  depression occur it
becomes small and weak, and when at the same time extremely
rapid, very difficult to count.

   We now come to the consideration of certain disturbances
which, though less frequent, are still  not without significance.
   Of those affecting the central nervous system, the following
may be mentioned :—
   General or partial convulsions are most often seen in the ful-
minant and  comatose forms occurring  in children,  sometimes
on one half of  the body with paresis  of the opposite  side, some-
times alternating with tonic contractions.   If long  continued,
they are generally an  unfavorable symptom.   Taking place in
the   retrogressive  stage, they  indicate the  commencement of
hydrocephalus (see Complications and Sequela?).
    Clonic convidsions  also occur in certain nerve districts, for
instance, in the distribution of the facial (unilateral or bilateral
mimetic facial convulsions), or in the muscles of the eye (nystag-
mus)   Unlike the convulsions, the paralyses are developed usu-
ally  in  the  retrogressive stage,  and are of  long, even life-long
duration  The cranial nerves, particularly the  abducens, oculo-
motorius, and facial, may be thus affected, the paralysis, per- 
  718    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

  haps,  depending mostly upon lesions  of  the  respective nerve-
  trunks in their course to the base of the skull, as a result either
  of  the surrounding exudation (purulent infiltration of the neu-
  rilemma), or of  the contraction of the hyperplastic connective
  tissue of the nerve sheath.  This explanation is the more plau-
  sible from  the fact that, in the cases which have been carefully
  examined,  the paralyses showed all the characteristics of peri-
 pheric lesion, and that the nerves mentioned were found at the
  autopsies so frequently and  markedly enveloped by the puru-
  lent exudation that it is remarkable that paralysis of the cra-
  nial nerves is not more common.
     Central paralyses originating from the  brain or spinal cord
 are not often found (hemiplegia, hemiparesis, paralysis  of one
 or both lower extremities), yet it must be borne in  mind that in
 severe cases,  particularly where  there is loss of consciousness,
 these  symptoms are with  difficulty discovered and easily over-
 looked.
    Aphasia and anarthria likewise occur (Leyden).
    The  eye and ear have  been found to  be more frequently
 affected than the other organs of special sense.
    Disturbances of hearing usually begin in the first few days.
 The patient complains of pain, humming, and ringing in the ear,
 then deafness rapidly ensues, usually in both ears.  After some
 time hearing is  partially or wholly restored, or complete deaf-
 ness results, which, as a rule, is incurable.  I have observed these
 symptoms eight times in forty-eight  cases.
    In a few cases examined  by A. Heller, Klebs, and Lucae, the
 lesions were found to consist sometimes of suppurative inflamma-
 tion of  the labyrinth, with destruction of the membranous laby-
 rinth, sometimes of catarrhal or purulent  inflammation  of the
 middle  ear.  The latter condition is evidently less dangerous,
 because, as  I  myself have observed  in one case, the perforation
 of the membrana tympani results in only a moderate deafness.
 The investigations of Heller render it very probable  that the
 inflammation makes its way within  the sheath of the auditory
 nerve
   The ocular lesions consist partly of mild  or severe conjuncti-
vitis, and opacity and ulceration of  the cornea—the latter, as I 
         DERANGEMENTS OF THE ABDOMINAL ORGANS.      719

have shown, frequently depending upon incomplete closure of
the lid from paresis of the orbicularis  palpebrarum muscle, in
consequence of the  cornea  being exposed, in the region of the
opening, to injury  from the  air—partly of  severe  suppurative
irido-choroiditis, resulting  in detachment of the retina, cloudi-
ness of the lens, and atrophy of the bulb ; partly of  optic neuri-
tis terminating in  atrophy of the nerve.  These inflammations,
like  the auditory lesions, probably depend upon the extension
of the inflammatory exudative process to the base of the skull,
along the sheath of the optic nerve (Schwalbe).
   The marked chemosis which sometimes surrounds the cornea
like a wall, results, according to Leyden,1 either from suppurative
infiltration of the fatty tissue of the orbit, or  from  severe pan-
ophthalmitis.  The  paralysis of the ocular  muscles, especially
the abducens and oculo-motorius, has already been considered.
The pupil is often  normal during the whole course of the dis-
ease,  and becomes  dilated only towards the  end ; but is fre-
quently contracted at the  outset, and dilates first after two or
three weeks.
   The digestive  organs  early exhibit various derangements.
In addition to the vomiting, which has been mentioned as a
leading symptom, there are nausea, anorexia,  and retraction of
the abdomen ; less  frequently  meteorism and  constipation ; in
some cases diarrhoea, and a moist, heavily coated—but only in
comatose cases dry—tongue.
   The nutrition suffers seriously, especially in the severe forms
of the disease, on account  of  the obstinate vomiting, anorexia,
sleeplessness, fever,  and severe affections of the nervous system.
Hence the  great emaciation wliich the  corpse  presents after a
long illness.
   Besides  icterus, wliich occurs in a few cases, the liver pre-
sents no evidences of derangement.
   The spleen is sometimes moderately enlarged.   It is only
rarely  that the increased size can be discovered either during
life or after death, nor are the intermittent  cases characterized
by this symptom.   We have  not observed tumors of the spleen
so frequently as Wunderlich and Mannkopf have.     _____
                    1 Virchow's Arch., Bd. 29, p. 199. 
720    ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL  MENINGITIS.

   Inflammation  of  the  parotid  gland  likewise  occurs  but
rarely.
   As regards the urinary organs, the quantity of the secretion
is often much increased even during high fever.
   In one case, a girl eight years of age, we noticed polyuria
for some six or seven days,  in  connection with  slight albumi-
nuria and moderately high fever.  Mannkopf1 likewise observed
marked polyuria in a case similar to ours,  and afterwards sugar,
but no albumen.  Mosler has described  one case  of hydruria
lasting for years in a boy seven years old, as a sequel of cerebro-
spinal meningitis from wliich he had recovered in his third year.
   It is probable that both the polyuria and the melituria are
neurotic  derangements; at least this is the explanation which
was formerly given by Mosler and myself, and yet the relative
frequency of the deposits of exudation which we  have found in
the fourth ventricle  would seem to  demand a more frequent
occurrence of these symptoms.
   The reaction of the urine is  generally acid.  Exceptionally
we find deposits of urates and phosphates, and a  small amount
of albumen.  In comatose cases  retention   of  urine readily
occurs, and,  if the  catheter  be not  used at the proper time,
cystitis.
   Organs  of Circulation.—The  characters of the pulse  have
already been considered.   Pericarditis and endocarditis are rare
complications.
   The respiratory organs very generally show catarrhal affec-
tions of the  bronchial mucous membrane (rarely of  the upper
air-passages), with secondary atelectasis and  broncho-pneumo-
nia.  I have already2 called attention to the fact  that these
lesions in the inferior and posterior  portions of the lungs are
found particularly in those patients who  for  a long  time have
had  orthotonos,  and I believe  that this connection  may  be
explained by the strong contraction of  the spinal-erector mus-
cles, which renders the proper inspiratory expansion  and the
forcibly-expiratory compression of these parts of the lungs im-
possible.  On the other hand, it is supposable, although not very
1L. c, p. 166.
2L. c, p. 373 and 444 
INTERCURRENT  AFFECTIONS.
721
probable, that the broncho-pneumonic areas may sometimes be
produced by the gravitation of the fluids used as food into the
parts, in consequence of the difficulty of swallowing caused by
retraction of the head.  Against this view we have the fact that
the pneumonic infiltration was absent in those of  our cases in
which  there was merely stiffness of  the neck but none of the
spinal  column, while in ten  cases of marked  contraction of the
whole  spine the  consolidations were present  nine  times (bron-
cho-pneumonia eight times, collapse of the lungs on both  sides
once).
   I can say, from  my own observations,  that the longer the
marked orthotonos continues during  life, the  more certainly we
find at the autopsy inspissated  secretion in  the bronchi of the
lower lobes, lobular collapse, and lobular pneumonic infiltration.
   In  the  fulminant cases  the bronchi  and lungs are  entirely
 unaffected.
   The frequency of respiration is rarely much altered at first,
being generally normal.  The absence of the well-known loss of
rhythm  of tuberculous basilar meningitis  is quite noticeable.
Towards the end, the breathing usually becomes very rapid, and
then arythmic. the respirations regularly alternating with respi-
ratory pauses, as is the case  in  the Cheyne-Stokes symptom.
Leyden supposes that this irregularity is due to pressure on the
medulla oblongata, or to oedema of the same.

                 Complications and Sequeloz.

   The most frequent complications, those occurring in the lungs,
ear, and eye, have been already considered in  the analysis of the
individual symptoms.  It may here be added, that pleurisy,
endocarditis, pericarditis, diphtheria of the intestines, parotitis,
and purulent effusions  into  the  joints occur as complications of
some cases in every epidemic.
   The inflammatory processes in the lungs are by far the most
serious of these intercurrent affections, yet according to our obser-
vations they very readily undergo resolution  if they are devel-
oped as secondary broncho-pneumonias.
   Much more serious, however, is the  occurrence of croupous
          VOL. II.—46 
722    ZIEMSSEN.— EPIDEMIC CEREBRO-SPINAL MENINGITIS.

pneumonia  during epidemic meningitis, or, on the other hand,
the development of the latter in the course  of croupous pneu-
monia.
   The  latter coincidence, viz., the occurrence  of cerebro-spinal
meningitis,  during an epidemic, as a complication of otlier acute
diseases, particularly  of the  true croupous  pneumonia, is the
more remarkable from the rarity with which this complication is
observed in  ordinary times.
   The  older literature in regard to epidemic meningitis gives us
little information on this subject.  All the more valuable, there-
fore, are the special  investigations on this point by Immermann
and Heller,1 in the Erlangen epidemic, and by Maurer.2  It ap-
pears from their reports that the combination of croupous pneu-
monia and cerebro-spinal meningitis was most frequent after the
termination  of the epidemic;  as if the  infectious poison had
then lost its violence, and was able to resume its activity only
when aided by the force of otlier diseases.
   The cases collected by Immermann and Heller,  and the obser-
vations at Erlangen,  published by Maurer and myself, show the
following results for 1866-72 :
   Meningitis as complic. croup, pneumonia,         14 times.
        "         "           scarlatinal nephritis  1 time.

                                                  15 times.
Of these cases, six were children in their first year, while in the
epidemics of 1864-66 no nursing infants were attacked.
   The symptoms of this form of cerebro-spinal  meningitis are
of  so  slightly marked a character that, in many of  the  cases
observed by us (see Immermann  and Heller), the diagnosis was
uncertain, or could  not be made at all.   Generally,  after the
pneumonia  had lasted for  one or more days, the headache be-
came worse, and  other severe  characteristic cerebral  symptoms
appeared:  delirium, convulsions,  coma,  vomiting, stiffness of
the neck and spine, and contraction of the pupils. It must be
borne in mind, however, that the contraction of the neck is often
  1 Pneumonie und Meningitis, Deutsches Arch, f. klin. Med., 1869, Bd. V, p 1 et seq.
  2 Pneumonie und Meningitis bei Kindern, Deutsches Arch. f. klin. Med., 1874, Bd.
XIV, p. 47. 
PNEUMONIA AS A COMPLICATION.
723
absent, even in severe meningitis.  The difficulty of diagnosis is
greatest in children under one year of age, in whom convulsions,
especially when occurring during the first few days, slight stiff-
ness of the neck,  somnolence, and coma are  not characteristic
indications, and in whom  also the  existence of headache can-
not be ascertained  with certainty.
   Maurer calls attention to the great importance of examining
in young infants  the great fontanelle, which is found arched
and tense, as a result of the increased intracranial pressure from
the meningeal exudation and oedema.1   This symptom in young
children is very significant when  it occurs  in  the course of a
pneumonia and  in connection with  convulsions, coma, retarda-
tion of the respiration, and stiffness of the neck.
   The prognostic indication of this complication is very serious,
since almost all the cases terminate fatally.

   I give briefly, with the temperature curve, an example of this complication.
   A. Wiinsch, aged thirty-six years, a Prussian militiaman of delicate constitution,
was taken  sick with  a chill, while at work, on the evening of August 22, 1806, at
Erlangen,  and was received into  the  medical clinic on the 23d.  On the 24th a
pneumonia of the upper lobe, with high fever, was discovered. Unusually severe
headache, also vertigo.  On the 25th, headache more intense, great restlessness, deli-
MEMEMEMB MEM  EMBMBM BMBM BMBM BM
XI  XII  XIII XIV
  _ and hallucinations.  Mind clearer after the application of ice-bladders.  On
the 27th and 28th the pneumonia extended to the inferior and midde lobes.  Mod-
num
  " In one of Maurer>s cases the arching and tension were  so great, that neither the
idges of the bones nor the pulsation of the brain could be felt. 
724    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

erate headache, somnolence, slight delirium. During the night of the 28th and 29th,
active delirium ; somnolence in the morning. Fever still high (see diagram). After-
noon, August 30, continued delirium ; at night great restlessness, wanders about the
room, hallucination.  Evening, August  31, conscious, vomiting of milk, complains
of headache.  Evening, September 1, active delirium, loud expressions of pain when
patient rises, spine somewhat stiff, meteorism.  During the night of September 2-3,
actively delirious, wanders about the room.  Evening, September 3, muttering deli-
rium ; on rising, complains much of pain in the loins and back.  September 4,
extreme collapse, coma. Death at noon, September 5.
   Autopsy (twenty-four hours after death).—Croupous pneumonia on the right
side, suppurative cerebro-spinal meningitis, oedema of the lungs, bronchial catarrh,
enlargement of the spleen and kidneys.
   The more important  of the sequela? are  deafness,  derange-
ments of vision, chronic hydrocephalus, and chronic meningitis,
with  the consequent impairment of intelligence,  and lesions of
motility in the form of paralyses and pareses.
   1.  The aitditory lesions may occur either in the middle ear
or in the labyrinth.   The true inflammations of the  middle ear
usually lead to perforation of  the membrana tympani, and pro-
duce more or  less deafness.  In one case * which came under our
observation, the otitis began with severe pain on the twenty-fifth
day.   On  the thirty-sixth  day the pus discharged through the
membrana tympani, cicatrization of the perforation took place,
and slight deafness in the right ear resulted.
   Suppuration in the  labyrinth is far more serious,  affects
generally both ears, and usually ends in complete deafness.
   In regard  to the anatomical conditions wliich cause these
frequently occurring sequelse, it may easily be conceived that
the suppurative exudation produces some effect upon the striae
of the auditory nerve at  its origin in the fourth ventricle, or upon
the trunk  of the nerve.   And yet I have often found the  floor of
the  fourth ventricle macerated by pus, and  the auditory nerve,
together with the facial nerves, completely surrounded  by the
purulent exudation, without  the occurrence of deafness during
life ; and  on the other hand, in cases of  marked deafness during
life, several observers have found very important changes in the
middle and internal ear, such  as purulent and adhesive  inflam-
mation in the  tympanum, and suppurative inflammation in the
1 L. c, page 390. 
                   DEAFNESS  AS A SEQUELA.               725

labyrinth with ecchymoses (Heller,  Merkel, Klebs).  The audi-
tory nerve was found surrounded and much infiltrated by pus in
the meatus  auditorius internus.   We must, consequently, sup-
pose, either that the inflammation creeps along the sheath of the
auditory nerve, and enters the labyrinth, or that the lesions in
the tympanum and labyrinth  are developed simultaneously with
the  inflammation of the pia  mater, as co-effects of one and the
same destructive cause.  The  former supposition is regarded by
Heller as the more probable.  At the same time, it is remarkable
that the facial nerve is so resistent to the purulent infiltration,
as has been noticed by Heller  in two cases.  This is undoubtedly
the  explanation of the fact  that the  function  of the facial
always remains intact;  at least, I have  observed this to be the
case in all the patients I have seen with complete deafness.
    The frequency of impairment of  hearing is much greater,
according to my observations, than one would suppose from the
statements of writers.  I was much surprised  at  the large num-
ber of completely deaf children who were brought to me for
examination from the rural districts of central and upper Fran-
conia, during the first few years after the termination of the epi-
demic.
    In children under one year of age complete  deafness results
in deaf-muteism, if they have not previously learned to talk ;  in
the second, third, and subsequent years, in the loss of articulate
speech, even if the child had  fully acquired the  power.  In the
latter case,  several months after the occurrence of deafness, the
speech can be understood with difficulty, and  after a year  or
more, becomes quite inarticulate and unintelligible.  Such  chil-
dren'should be placed under the instruction for deaf-mutes, if
their speech is to be of any  use to them in later  life.   Forget,
Lindstrom,  and others, have  noticed that deaf-muteism is a rare
result of the meningitis, even in those cases in which hearing is
completely lost.  Hirsch  has called  attention to  the fact that
impairment of articulation, and even aphasia may occur at the
same time  with the deafness.  In those cases of which Hirsch
arLeyden have  observed examples, the  loss of  speech is no
the result of the deafness, but is a co-effect of the meningitis   I
cannTreniember any such cases; but I am wiling to grant the 
  726     ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

  possibility of such an acute origin of impaired articulation from
  the meningitis, perhaps by means of oedema or  hemorrhages in
  the  spinal  cord.   In  the numerous instances which I have
  observed, the articulation was good for a  short time after  the
  meningitis, and became worse gradually.
     I am indebted to Dr. Roth for some very interesting statements in regard to the
  pupils of the deaf-mute institution in Bamberg.  This charity is intended only for
  the deaf-mutes from the district of upper Franconia.  The number of pupils in
  April, 1874, was 42 (20 boys, 22 girls).  All the pupils had become deaf-mutes from
  epidemic  meningitis.  Thirty-eight of them came from the rural districts, and only
  four from Bamberg, although the epidemic in Bamberg had been very severe.
     I am also indebted to Dr. Merkel for similar accounts of the deaf-mute institu-
  tion in Nuremberg.  The number of deaf-mutes from meningitis was 22 (10 boys,
.  12 girls), out of a total of 32 pupils.

     2. The more important and frequent sequelae of the affections
  of the eye are opacities of the cornea, posterior synechia, etc., as
  results of iritis ; amaurosis from choroiditis  with detachment of
  the  retina, and finally optic neuritis with secondary atrophy of
  the  nerve.   These severe lesions depend either upon an exten-
  sion of the inflammation along the sheath of the optic  nerve, or
  upon a localization of the suppurative inflammation in the eye
  and brain at the same time (Rudnew).
     3. Permanent affections of the brain, the spinal cord, and
  their membranes are by no means rare. In my opinion, by far the
  most frequent of these  sequelae is chronic  hydrocephalus.   At
  least I  have seen a very large number of hydrocephalic  patients,
  and  have made  autopsies  on some of them, both during the
  course  of  the epidemic and in subsequent years.  These exami-
  nations show that the successive  changes in the  central organs
  take place in  very nearly  the following  order:  During the
  second week the meningeal exudation, which has hitherto been
  little changed, or perhaps somewhat thickened, undergoes fatty
  degeneration of the cells and fibrine, and is thus slowly or rapidly
  absorbed,  or  ultimately shrinks into caseous matter, if absorp-
  tion does not occur ; the connective tissue of the arachnoid  and
  pia  mater proliferates,  the hyperaemia of the substance of  the
  brain disappears, and  the purulent  effusion in  the ventricles
  increases.   From the twenty-seventh to the thirtieth week  the 
SECONDARY  HYDROCEPHALUS.
727
arachnoid and pia mater exhibit a pulpy hyperplasia or already
a cicatricial thickening; the caseous remains of the meningeal
exudation are still more shrunken;  the ventricular effusion has
become more moderate  in amount, but quite clear, owing to the
inspissation of the cellular elements into small caseous flakes on
the dependent parts of  the ventricle.   The earlier hyperaemia of
the brain is completely  gone, the brain  is anaemic, even oede-
matous, the ependyma of the ventricles thickened and  distinctly
granulated, and the choroid plexus bloodless. Unless the hydro-
cephalic effusion be moderate, the brain substance is atrophied
sometimes to a very considerable degree.  In a boy two years of
age we found the medullary and cortical layers  of the cerebrum
together only seven to nine  and a half lines in thickness, while
the central ganglia were much flattened.
   It almost appears as if the increase of the ventricular effu-
sion were due to the shrinking and thickening of the pia mater;
at least this supposition is rendered  probable  by the interval
of  apparently progressive convalescence which usually occurs
between the acute stage of the meningitis and the appearance
of the hydrocephalic symptoms.
    The symptoms of secondary hydrocephalus  consist of parox-
ysms of severe headache, pains in the neck and  extremities, with
vomiting, loss of consciousness, convulsions, and involuntary dis-
charges of faeces  and urine.  These attacks recur either in rapid
succession  and tolerably regular type, or  with intervals which
sometimes last for weeks, and  during which the activity of the
mind and senses may be unimpaired,  the appetite excellent, the
sleep quiet, and the patient in good spirits and  gaining strength.
If  the intermissions be long continued, we easily fall  into the
error of supposing that the disease has taken a favorable turn;
but a  new attack dispels the illusion.  Moreover, the condition
of  the patient during the intermissions is generally not so favor-
able as to lead to such a mistake in prognosis ;  there are still to
be found the general hyperaesthesia and increased reflex excit-
ability, the slight contractions or pareses in the extremities, psy-
chical disturbances, and other symptoms.
    Of  far greater importance  is the  question,  whether and to
what extent these hydrocephalic  effusions are  capable of retro- 
728     ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MENINGITIS.

gressive changes; in other words, whether recovery from second-
ary hydrocephalus is ever possible.
    The prognosis  of this  condition is certainly  in the highest
degree hopeless ; yet I have seen  some cases in wliich a complete,
and others in which an incomplete, recovery took place.   Of  the
first class of cases  I have already  published one instance (Arch, f.
klin.  Med., Bd. 1, page 389); of the  latter,  the  following is  a
very instructive  case, in which the autopsy was made seven years
after the attack  of meningitis.'

   Joseph Klaussner, aged 19 years, son of a farmer at Rockenhof, near Erlangen,
passed through an attack of epidemic meningitis in his twelfth  year (1865), at the
same time with several  of his sisters (one of whom died).  He was confined to his
bed twenty-eight weeks.  The most prominent symptoms were stiffness of the neck,
trismus, very  severe  pain  in the extremities, especially in the  fingers, so that he
wished to pull them off, and  impairment of hearing.   In consequence  of his exces-
sive weakness  and emaciation, the convalescence was very tedious ; yet he recovered
completely.   There  was left, however, great  feebleness of memory.  He  forgot
everything which he had learned before his illness.  Headache, especially on stoop-
ing ; afterwards he suffered from weakness of the eyes, and remained  stationary in
his growth.
   In January, 1872, he had a discharge from the ears, a weeping eruption on the
head, and enlarged glands in various parts of the body.   The left side of the body
was numb; yet the patient regularly walked the long distance to Erlangen in  two
hours.
   Patient states that at the beginning of February he had for fourteen days pains
in the neck and difficulty in swallowing (diphtheria ?), yet  he was not confined to
bed.
   At the end of March the right side of the body was numb (with the exception of
the leg), and  his  speech had been of a nasal character for four  wTeeks.  On eating
and drinking, the food passes into the larynx  and naso-pharyngeal space.   Gait
staggering, now  and then vertigo, enormous  salivation,  near  and distant vision
defective.
    Present State.—A small  man, of  stupid  appearance,  deficient  intelligence,
childish frame and voice, yet with well-developed pubic hairs.  Paralysis of left
half  of the soft  palate, which  presents  no reaction to the farado-electric, but
increased sensibility to the galvanic current.
   After  several  local  applications of electricity to the  paralyzed  muscles, the
nasal character of the  voice and the difficulty of swallowing  disappeared.   Gait
improved; right arm still numb.

   1 For the notes  of this case, and for the opportunity of attending the autopsy, I am
indebted to the kindness of Dr. Maurer,  of Erlangen. 
                    SECONDARY HYDROCEPHALUS.               729

   On April 1 patient  returned from  a visit to the country  apparently well-
was taken ill early in the day, on April 2, with high fever, and died suddenly aboui
one o clock in the afternoon.
   ^wtopsy—Marked hydrocephalus, with thickening of the ependyma  The cen
tral canal of the  spinal cord was dilated.  Remains of cerebro-spinal menino-itis
in the form of opacity and callous thickening of the pia mater indifferent places.'
   Double pleuropneumonia, emphysema, and oedema of the lungs.   Old bron-
chiectases.  Moderate hypertrophy of the heart.  Hyperemia of the liver and kid-
neys.

    The chronic hydrocephalus, with thickening of the ependyma
and  hyperplasia of the arachnoid  and  pia mater, must properly
be regarded as a sequel of the meningitis.  At the  same time it
is questionable whether the impairment of  intelligence and  of
bodily development is likewise and exclusively due to the reac-
tion  of the  hydrocephalus  and meningeal  shrinking upon the
central organs of intelligence and upon  the trophic functions.
    So many cases  of secondary hydrocephalus similar to mine
have been observed within the last few years, that the disease can
no longer be regarded as a  rare sequel of meningitis.   Reports
of such cases  have been  made by Merkel,  Bohmer, Bonsaing,
Pimser, and others,   v. Lindwurm observed  a very  instructive
case  of this kind at the beginning  of  the year 1874, in his clinic
in Munich.

   A  baker, 18 years old, previously always healthy, was taken sick Jan. 12, 1874,
with repeated vomiting and severe headache ; on the next day, lumbar pains, double
vision, contracted pupils, stiffness of the neck, herpes; temperature between 102.2°
and 104°; pulse 100-120;  urine abundant, without albumen or sugar.
   After January 18, gradual decrease of all the symptoms.  Towards the end of the
month, returns of the headache,  involuntary stools, imbecility.  On the 29th, two
attacks of vomiting, some diarrhoea,  pupils dilated, temperature about  normal.
After  this time, intermissions of one  to three days' duration alternated with periods
of exacerbation, during  which there were vomiting, headache, dilatation of the
pupils, somnolence, and general malaise with  pain.  On the favorable days the appe-
tite was good, and there  was no fever.   On March 4 patient felt so well that he re-
quested to be discharged;  in the evening facial  paralysis was noticed, and the
bowels moved involuntarily.  Abscess in the glutei muscles.  At the end of March,
after long-continued alternation between improvement and  symptoms  of pressure
upon the brain, the patient was extremely emaciated, exhibited marked decubitus
and slight dulness over the right apex anteriorly. Pulse varied between  75 and 100.
   After the beginning of April the pulse continued constantly above 120.  Abscess 
730    ZIEMSSEN.— EPIDEMIC CEREBRO-SPINAL MENINGITIS.
in the nipples.  Dulness over right apex increased, without bronchial breathing;
pneumonic sputa.  Decubitus very marked, emaciation and extreme prostration.
  Death on April 20.
  Autopsy.—Convolutions of the brain much flattened. A large quantity of serum
in the subarachnoid space, particularly at the base.  Ventricles enormously dilated
and filled with turbid serum.   Substance of brain ansemic.  Recent desquamative
pneumonia of the upper lobe of the right lung.
   Feebleness of mind and memory, aphasia, and anarthria are
often observed as  sequelae, but generally the prognosis is favor-
able, as they usually disappear within a few months.
   Paralysis of single extremities or nerves,  especially of the
cranial nerves, or general motor weakness, are not very infrequent
complications or sequelae, and seem to depend upon lesions either
in the brain  or in the spinal cord.   Hitherto there have  been
found in some cases only disseminated encephalitis  (Klebs),  or •
punctate hemorrhages in the spinal  cord,  and an extension of
the  inflammation to the  cord (Mannkopf).   Ley den1 saw, in a
boy five years of age, a myelitis which  had resulted from cere-
bro-spinal meningitis,  and which  was much improved by tonic
treatment.  (The final  result is unknown,  as the patient left the
hospital too soon.)
   Tourdes, de Renzi, Leyden, and others state that the prognosis
in these paralyses is not unfavorable,  as recovery takes place in
most of the cases within a few months.

                           Diagnosis.

   The diagnosis  of  epidemic meningitis usually presents  no
difficulties, if the disease occur primarily and during the -preva-
lence of an epidemic.   The acute onset,  with or without prodro-
mata,  the  symptoms of violent disturbance of the cerebro-spinal
system,  especially the furious  headache,  the rachialgia, the
vomiting, the contraction of the cervical muscles,  afterwards the
orthotonos, the general hyperaesthesia,  the alternation  of som-
nolence and  delirium,  the eruptions, especially herpes facialis—
all  these are  sufficiently  characteristic  symptoms, even for one
who had never before seen the disease.  The occurrence, after a
' L. c, p. 430. 
                   DIFFERENTIAL DIAGNOSIS.               731

few days, of irregularity of temperature and pulse, of exacerba-
tions, etc., renders the diagnosis certain.
   The diagnosis is difficult when,
   1st, It  concerns  isolated cases occurring either beyond the
limits or at the  beginning of an epidemic,  particularly cases of
little children; or,
   2d, When  the epidemic meningitis  occurs as a complication
of other acute diseases, especially croupous  pneumonia.
   In the  first case,  the distinction  of sporadic  cerebrospinal
meningitis from the epidemic form is rendered easy by the great
rarity of the former, as well as by the fact that the spinal symp-
toms are not well marked, nor does it seem to  run a hyperacute
course.  Moreover, the spinal symptoms, hyperaesthesia, stiffness
of the spine,  with rachialgia, and the pains in the extremities, are
often entirely absent, and the contraction of the neck is less than
it is in epidemic meningitis.
   In tuberculous basilar meningitis there may be considerable
stiffness of the neck, and similar headache, loss of consciousness,
restlessness, with irregularity and moderate height of the fever ;
but  the tuberculous nature of the affection may be distinguished
by the long-continued prodromal period—wliich  is very seldom
absent—the less violent onset, the more  protracted course, the
marked  remissions, the very slow  pulse, the irregularity of the
respiration, the  absence of  eruptions; finally, by the  evident
hereditary tendency  to tuberculosis, as well as the history of
scrofulous and phthisical affections.  In some cases, especially in
children, the differential diagnosis may present great difficulties.
   So also under some circumstances, and at  the  outset of the
disease,  it may be simply impossible  to distinguish the  affec-
tion from typhoid fever.  Leyden has called special attention
to the fact that the  severe headache, vomiting,  lumbar pains,
sleeplessness,  roseola,  petechiae,  enlargements of the  spleen,
indeed, even the lowered temperature, stiffness of  the neck, and
hyperesthesia of the extremities may occur in  typhus, and men-
tions in  this connection the doubts  which were for some time
entertained on account of the presence  of these symptoms  in a
number  of cases at the outbreak of typhus fever in the army
besieging Paris (autumn of 1870). 
732    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

   A  positive diagnosis  of meningitis may be made, if, after
repeated observations, we find the characteristic  course of  the
fever, a contracted condition of the spleen or absence of enlarge-
ment, and the occurrence of herpes facialis—a very rare symp-
tom in typhus.
   The  recognition of epidemic meningitis—when it arises as  a
complication of croupous pneumonia and other acute diseases—
we have seen it in acute nephritis,  pleuritis,  tonsillitis,  etc.—pre-
sents much greater difficulties, especially during the first years of
life, when this complication is most apt to  happen.   It  appears
from  the observations of Maurer that the  diagnosis may be
made from the occurrence of coma towards  the middle or end of
the normal course of pneumonia, with convulsions which follow
immediately, and recur frequently until death ensues; from the
retardation  of the respiration during the pneumonia, and from
the arching of  the great fontanelle.  In adults, so far as I have
observed, more  importance is to be ascribed to the apparently
causeless occurrence of headache,  or to its sudden increase when
it is  already present,  to the painful stiffness of  the  cervical
vertebrae, the hyperaesthesia, restlessness,  active  delirium,  and
coma.   I am convinced,  from the observation of  cases in  the
Erlangen clinic and polyclinic,1 that the high temperatures  and
frequent respiration of  pneumonia  may continue  unchanged,
notwithstanding the meningitis, and moreover, that the alterations
of the pupil, the vomiting, the eruptions, and even  the stiffness
of the neck  may be absent.  So also the majority of the cardinal
symptoms of meningitis may be wanting,  and the  diagnosis may
thus be made doubtful for some time.

            Course, Duration, and Terminations.

   As we have seen in the description of the general symptoms,
the course of the disease is very variable.   The hyperacute  and
the abortive cases run the most rapid course (one and a half to
five days), while those of moderate severity begin to convalesce
after  one or two weeks, but sometimes last for months.  When
1 See Immermann and Heller, 1. c. 
                         TREATMENT.                      733

complications or sequelae arise, the whole duration may be six
months or more.
   In the fulminant cases death is the rule; in the  moderately
severe attacks it is still  comparatively  frequent, and  even in
the mild cases it sometimes occurs as a  result of the complica-
tions or sequelae.  The rate of mortality varies very much accord-
ing to the intensity of the epidemic; in the mildest epidemics,
30 per cent., in the most severe, over 70 per cent.  It appears at
least very probable that the excessive percentage (70 to 80 per
cent.) which occurred during the French  epidemics of the decade
following 1840, was due to immoderately antiphlogistic treatment.
   The mortality will average about 40 per cent.

                         Prognosis.

   In individual cases the prognosis can  never be made with cer-
tainty.   To be sure, we may say  in a general way that  in the
fulminant cases the patients die, while in the mild and abortive
ones  they recover; but the exceptions are  so  numerous  that
we can be guided in our prognosis only by probabilities.   In the
majority  of severe and moderately severe cases,  any prediction
of the result  must  be withheld for the first few days, and we
must wait for further developments.
   The following conditions are generally to be regarded as of
unfavorable import: infancy and  old age,  unusual severity of
the symptoms of excitement, and  the early appearance of those
of depression,  return of  the vomiting, intense cephalalgia, and
loss of consciousness after apparent improvement,  continuous
coma, convulsions,  and irregularity of the respiration.
   A favorable prognosis may be made in the moderately severe
and mild cases,  when all the symptoms uniformly decline in the
first and second weeks, and convalescence takes place during the
third or  fourth  weeks without the development of important
complications or sequelae.

                         TREATMENT.

   In our ignorance of the etiological conditions of  the disease
prophylactic  measures can be recommended only in a general 
734    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

way. In consequence of the evidence we possess that the specific
contagion may spread among the different occupants of a house,
whether from  the individual  first attacked or  by means  of
unknown noxious  conditions in the soil, water, building, or other
situation, it seems advisable that after the appearance of the
disease  in  one family the  dwelling  should be abandoned  by
others until after the disappearance of  the epidemic.  This will,
of course, be possible only in exceptional cases, and under very
favorable circumstances.  Moreover, it  should be  recommended
that all  the linen and other articles used by the patients should
be carefully disinfected, or perhaps burned.
   Persons who are  much  alarmed may be advised to leave the
infected district immediately on the outbreak of the epidemic  as
the surest protection.
   In regard to the  treatment  of the disease,  we  know of  no
abortive method of cure.  At the same time, we are not obliged,
as some  have supposed, to assume a purely expectant attitude
towards  our patient.  We are  certainly able, by rational treat-
ment of the symptoms, to  favorably influence the course of the
disease in many respects, at least so far as the immediate result
is concerned. Whether by such treatment we can  affect the sta-
tistics of mortality, and lower the death-rate, is a question which
we  are at present unable  to decide.   To be of value, scientific
statistics in regard to the  success of a particular mode of treat-
ment must  extend  over  a  proper length of time  and  must
embrace  a sufficient number of cases which are observed under
as similar conditions as  possible.   When  thus compiled, such
statistics furnish results of  great importance, even  in such infec-
tious diseases as typhoid fever, as is shown by the undoubted
difference in the mortality tables under  the expectant and under
properly regulated antipyretic modes  of treatment; but even
with large  collections of facts little can be expected in a disease
which presents all the peculiarities of an  epidemic migratory
infectious malady, especially its variableness  in morbility and
mortality.  We have already seen that in the different epidemics
the mortality ranged between thirty and seventy per cent.
   In estimating the results of different modes of treatment  in
epidemic meningitis, we  should also be careful to confine our- 
ANTIPHLOGISTIC.                    735
selves to the study of the immediate effect upon the subjective
and  objective condition of the patients, and to the duration of
that effect.  Then let conclusions be drawn from the largest pos-
sible number of similar cases.
   Antiphlogistic treatment,  by means of local abstractions of
blood, leeches behind the ears, and ice-bags, is very efficacious.
We have found but few patients who did not praise the applica-
tion of  ice to the head.   That many patients repeatedly pull off
the ice-bags while they are comatose or delirious, is no evidence
that the cold is not well borne.  The ice-bags are to be left upon
the neck and  back so long as the patient is comfortable,  and
this is often a long time. One old woman bore the application
uninterruptedly for twenty days and nights, and afterwards, at
intervals, for three weeks longer, for the relief of recurrent head-
aches.
    The cold almost  always relieves the severity of  the headache,
and secures rest and sleep.  It  is best applied by means of large
rubber bags.  Every time ice is introduced, all the air should be
pressed out before the cork is inserted,  in order that the bag
may fit the scalp smoothly.
    Cold should also be applied to the neck and back.  For the
 spine,  Chapman's long ice-bags  are  most suitable,  wliich are
 divided into three adjacent compartments for the ice, and  can be
 fastened around the body by means of tapes.   I have had  rubber
 bags made twenty-three and a half to twenty-seven and  a half
 inches in length, for the purpose of covering the whole length of
 the spine.1
    Abstraction of'blood is best made by leeches to  the temples or
 mastoid processes, and. by the application  of wet cups to the neck
 or along the spine.   General  blood-letting  has nowadays few
 advocates  among  those who have seen most of the disease.  Tne
 effect of this measure in subduing the cerebral symptoms is com-
 paratively slight and transitory,  while a large venesection  pro-
 duces  those evil results which are  found to occur in all infec-
 tious diseases, such as collapse, weakneasofth^

 "^^^^
 of ice to the thorax in double pneumonia, to the abdomen, or
 Unfortunately they are very expensive. 
736    ZIEMSSEN.—EPIDEMIC  CEREBRO-SPINAL MENINGITIS.

still  to be considered, however, whether in hyperacute cases, in
which all treatment has hitherto been unavailing, a rapid and
copious withdrawal  of blood from a vein may not avert  or at
least postpone the  fatal  termination.  The  acute congestion of
the brain and its  membranes,  if  not  the only, is at  least an
important  cause of the  unfavorable  course  of  these cases.
Leyden,  who favors venesection  in  such attacks,  maintains,
moreover, that under proper circumstances general blood-letting
is  indicated by the excessive restlessness of the patient, which
renders the application of leeches almost impossible.
   Local abstractions of  blood, even when frequently repeated,
produce  almost  always and immediately a very beneficial effect.
They are most suitable at the beginning of the exacerbations of
inflammation and fever.  The diminution of the intra-cephalic
hyperaemia is shown by the  relief of the headache, jactitation,
and delirium, and by the return of consciousness.
   Mercury, in the  form of mercurial ointment or calomel, was
formerly and  is still much used for  the purpose of prevent-
ing the  extension of the meningeal inflammation and exudation.
I have used it in most of the cases from the beginning of the dis-
ease. In adults about thirty grains, in children fifteen to twenty-
two grains of mercurial ointment were rubbed into the skin twice
daily (the place  being  regularly changed).   Calomel was almost
always given in large doses with jalap, for the purpose of acting
freely upon the bowels, and thus producing an active determina-
tion to the intestinal mucous membrane.
   For the purpose of preventing stomatitis,  the mouth was
washed  every half  hour, after the commencement of  the  mer-
curial treatment, with pure water and with a solution of chlorate
of potassa,  twenty-five grains to the  ounce.   Although  one
drachm of mercurial ointment, and on  an average  about twelve
grains of calomel were daily used in the adult cases, the local treat-
ment of  the mouth prevented the occurrence of salivation in all
except a  few instances, and in these the symptom gave  but  little
trouble.
   When mercury is employed in connection with other reme-
dies, it is difficult to ascertain its share in the common effect; but
even when  used  alone its efficacy is  by no means  clearly estab- 
                    NARCOTTIC  TREATMENT.                737

lished.  Still, Leyden believes that it does check the inflamma-
tion and the exudative process.  Its employment may be the more
recommended as we possess no remedy wliich is more effectual.
   The opinion of the older writers, that the occurrence of mer-
curial stomatitis is a favorable indication, has not been confirmed
by my experience ; indeed, in most of the protracted cases death
was preceded by a mild stomatitis.
   The antipyretic treatment by cold baths and large doses of
quinine is indicated in but  few cases, as there is generally only
a moderate fever, and  it is very rare that the fatal result is
due to a high temperature.   Besides,  as Leyden has insisted,
patients with meningitis usually bear the baths badly, on account
of the resulting depression and  the pains caused by the unavoid-
able movements of the spine, etc.   Cold affusions are also not
 well tolerated, and should be used only in the very acute cases,
 and when the patient is soporose.
    Quinine may be employed  as an antipyretic in doses of  fif-
 teen to thirty grains, in those rare cases in which the tempera-
 ture ranges very high.  It is entirely useless against  the  exacer-
 bations of the intermittent form.
    Narcotics  play an important part in the whole course of the
 treatment.  The  majority of recent writers confirm the happy
 effects which Chauffard has noticed and praised so highly.
    The violent headache, restlessness, and  sleeplessness are suf-
 ficient indications for the administration of opium and its alka-
 loids, of  which morphine, and  particularly by hypodermic injec-
 tion, acts the most promptly.  If we wish to secure a quick and
 certain effect, we may use quite large doses  (one-third to one-
 half grain in adults) without fearing any injurious consequences.
 Smaller  doses administered every one or two hours, when toler-
 ated by the stomach, appear to be  of great service in relieving
  the incessant jactitation.  For  the exacerbations of the cephalal-
 gia it is better to give a larger  dose of morphine by injection.  If
 the latter  be used immediately after  a local blood-letting, the
 most restless delirium gives place to quiet and sleep, which often
 last for  seven or eight hours.  Morphine may be  regarded as
 one of the most indispensable remedies in the treatment of  epi-
  demic meningitis.
            VOL. II.—47 
 738    ZIEMSSEN.—EPIDEMIC CEREBRO-SPINAL MENINGITIS.

   As useful palliative measures, we may use ether dropped or
 sprayed  upon the back of the head and neck, and friction with
 chloroform  liniment.  Inhalations of chloroform  or ether, and
 large doses of chloral are recommended by many writers, and
 are,  at all events, worth the trial.
   In the later period of the disease, especially when the course
 has been protracted,  iodide of potassium is of service in  produ-
 cing absorption of the exudation.  Traube, Leyden,  and myself
 have seen good results from this treatment, convalescence  taking
 place with  unusual rapidity.   In chronic hydrocephalus I have
 found it to be entirely useless.
   The hydrocephalus unfortunately withstands all other treat-
 ment, whether  external or internal.  Applications of cold water
 give relief in many cases, but the improvement is always  only
 temporary.  Counter-irritants  to the neck and  scalp, setons,
 etc., are without apparent effect.
   Derangements of hearing and vision are, of course, the objects
 of special therapeutic attention.  In severe cases, either of deaf-
ness or amaurosis, but  little success can be expected.  The gal-
vanic treatment of deafness following meningitis is illusive, and
I herewith  record my warning.   In cases of complete deafness
this  treatment  is absolutely  useless,  and  no one has ever yet
produced electric auditory sensations.
   The diet must  naturally be regulated according to the con-
dition of the fever,  etc.   After the disappearance of the fever,
a nutritious, but fluid,  diet should be adopted early, in view of
the fact, which experience has  shown, that a disproportionately
great emaciation and prostration commonly occur in meningitis
after the  patient has been confined to bed for but a short time.
   The other sequelae, such as  general motor weakness, various
pareses, etc., may be treated  by the use of the saline baths at
Kreuznach and Reichenhall, or by the hot  baths of Wiesbaden,
Wildbad, Ragatz, and Gastein. 
INDEX.
Aarestrtjp, 100.
Abeille, 81.
Abelin, 44, 60, 99, 128
Ackermann, 50.
Aconite in erysipelas, 478.
Age in epidemic cerebro-spinal meningitis, 693; in ery-
     sipelas, 431, 477; in  hay fever, 542; in influenza,
     522;  in malarial diseases, 573; in measles, 48; in
     miliary fever, 493; in rubeola, 136;  in scarlatina,
     178, 294; in small-pox, 326, 393;  in varicella, 8.
Albers, 39, 222.
Albu, 311.
Alison, Scott, 178.
Amiel, 480.
Anatomy of the skin in  small-pox, 380.
Angerhausen, 467.
 Anstie, 469.
 Aran, 398.
 Arlt, 434, 456, 469.
 Armand, (J65.
 Arnold, 133.
 Arnott, 459.
 Arrigoni, 282.
 Arsenic in malarial diseases, 671.
 Ascites in scarlatina, 257.
 Astringents in erysipelas, 480.
 Aufrecht, 482.
 Auspitz, 384.
 Ave-Lallemand, 509.
 Avery, 443, 466.

 Bactebia in erysipelas, 445.
 Baginksky. 247, 305.
 Baikee,  657.
 Baillie, 43.
 Balfour, 479, 657.
 Ballonius, 36.
  Ballot, 510.
  Barat, 572.
  Barbillier, 44.
  Barclay, 523.
  Barella, 665.
  Barensprung, 382, 631.
  Barker, 196.
  Barnatzik, 663.
Barrant, 672.
Bartels, 99, 101, 103, 123, 124.
Barthez, 47, 91,105, 204, 274, 492.
Basch, 384
Bashan, 314.
Bastard, 503.
Battersey, 43, 101.
Baxa, 657.
Baxter, 673.
Bayer, 443, 458, 459, 461.
Bazin, 499.
Bechi, 571.
Beck, 496.
Becquerel, 81.
Beger, 102.
Behier, 43, 460.
Behr, 44.
Behrend, 165.
Bell, 165.
Bell, Hamilton, 479.
Beneke, 450.
Bennett, 307, 443.
 Bentley, 101.
 Bernatzik, 665.
 Berndt, 40, 659.
 Bernutz, 433.
 Beroaldi, 496.
 Bertherend, 670.
 Berton, 189.
 Betz, 219, 233, 266, 274, 480.
 Bicker, 214.
 Bidenkap, 44.
 Bierbaum,  42, 43, 47, 600, 610.
 Biermer, 22-3, 228,  522, 524, 525, 526, 530, 534,
 Biesiadecki, 444, 452, 455.
 Biett, 426.
 Billard, 474.
 Billroth, 447, 451, 477.
 Binz, 121, 479, 664, 667.
 Bird, Hinckes, 430, 478.
 Blache, 431.
 Blake, 479.
 Blackett, 432.
 Blackley, 540.
 Blanckaert, 91. 
740
INDEX.
 Blandin, 456.
 Blass, 459.
 Blaxall, 566, 587.
 Blood  in erysipelas, 444; in malarial diseases, 624,
     633; in miliary fever, 496; in scarlatina, 233.
 Boeck, 27.
 Bohn, 253.
 Bokai,  172.
 Bonaventura, 664.
 Bones in scarlatina, 232.
 Bonfigli, 481.
 Bonsaing, 693.
 Borchard, 496.
 Borelli, 602.
 Borgien, 481.
 Borsien, 426.
 Bostock, 540.
 Bottiger, 44.
 Bouchut, 206, 474
 Boudin, 580.
 Bourgeois,  496.
 Bousquet, 412.
 Boussingault, 571.
 Bouvier, 667.
 Boxa, 5S6.
 Boyer, 426.
 Brain in epidemic cerebro-spinal meningitis, 705. 717,
    726; in  erysipelas,  462; in scarlatina, 226; in
    small-pox, 387.
Brann, 102, 211,  588.
Bresseler, 44, 101.
Bright, 48C.
Briquet, 665.
Broadbent, 434.
Brochn, 458.
Bromfield, 426.
Bronchitis  in  measles,  92; in  scarlatina,  222; in
    small-pox, 379.
Brotherston,  311.
Brown, 81,  122, 125, 628.
Briickmann, 44,  45.
Brunzlow, 43.
Brylon, David, 507.
Bryson, 657.
Buch, 349.
Buet, 536.
Buffalini, 39, 580.
Bullock, 478.
Burdel,  641, 670.
Busch, 131, 469.

Caisne, 672.
Calmeil, 424.
Calvert, 672.
Campbell, 435, 479.
Canstan, 670.
 Canstatt, 12, 21, 27, 132, 204, 210, 226, 426, 478.
 Carpenter, 178, 198.
 Carroll, 102.
 Causit, 101.
 Cazenave, 426, 469.
 Cellulitis of neck in scarlatina, 217, 225.
 Cerebro-spinal meningitis, epidemic,
     683;  bibliography, 683;  definition of the diseai-e,
     687;  history, 6S7; etiology,  690 ; relations with
     other infectious diseases, 691; influence of seasons
     and weather, 693;  age, 693 ; hygienic influences.
     695;  sex,  696;  the question of contagiousness.
     696;  pathology,  697;  general description of the
     disease, 697; meningitis cerebro-spinalis siderans,
     699;  meningitis cerebro-spinalis abortiva, 700;
     meningitis epidemica  intermittens, 702; typhoid
     epidemic meningitis, 703; pathological anatomy,
     703 ;  emaciation', 703; the skin, 704 ; the calvari-
     um and membranes of the brain, 704; membranes
     of the spinal cord, 705; the brain substance, 705:
     substance of spinal cord,  706;   internal organs.
     706;  organs of  special sense, 707;  analysis of
     symptoms,  707;  headache, 707:  vertigo, 708:
     vomiting, 708;  contraction  of  muscles of  neck
     and  spine, 708; trismus, 710 ; pain in  the spine,
     710 ;  hyperaesthesia, 710 ; cutaneous lesions. 711  ;
     temperature of the body, 712; nervous symptoms,
     717;  the ear and eye, 718;  digestive organs, 719;
     urinary organs, 720; organs of circulation, 720 ;
     respiratory  organs, 720;  complications  and se-
     quelae, 721;  diagnosis,  730; course,  duration,
     and terminations, 732; mortality, 733; prognosis,
     733;  treatment, 733: antiphlogistic means, 735 :
     mercury, 736;  antipyretic  treatment, 737; qui-
     nine and narcotics, 737 ; iodide of potassium, 738;
     diet, 738.
Champouillon, 469.
Cbauffard, 690.
Chauveau, 381.
Chevrey, 664.
Chinnock, 44.
Christie, 512, 514.
Chomel, 74, 431.
CL-rus, 51.
Cohn, P.,  381.
Colchicum in erysipelas, 478.
Coley, 102.
Colin, 456, 462, 586,  657.
Collin, 1.33.
Condamine, 332.
Contagiousness of epidemic cerebro-spinal meningitis,
    69(5; of erysipelas, 432; of dengue, 509; of influ-
    enza,  523.
Conte, 480.
Copeman,  173.
Copland, 478, 481, 534. 
                                                IN]

 Cornaz, 121.
 Cornil, 434, 45S, 475.
 Corson, 173, 567.
 Coulson, 104.
 Coural, 490, 497, 503.
 Cox, 478.
 Coze, 39, 162.
 Cramer, 47.
 Crato, 524.
 Cremen, 177, 178, 278.
 Creutzer, 480.
 Cullen, 40, 426.
 Currie,  120, 673.
 Curschmann, 672 ; on small-pox, 317.
 Czakert, 10, 25.

 D'Alves, 185.
 Dance,  183.
 Dandy Fever, see Dengue.
 Danielssen, 281.
 Daude, 433, 438, 443.
 Dean, 480.
 Declat,  672.
 Deiters, 274.
 Delpech, 13.
 Van Dembusch, 526.
 Dengue, 505; bibliography, 505; history and etiol-
     ogy, 507 ; symptomatology,  510; incubation, 510 ;
     fever, 510 ;  the second paroxysm, 511;  the joints,
     511 ; the eruption, 511;  the mucous membrane,
     512 ; lymphatic glands, 512 ; the urine, 512; the
     heart, 513 ; respiratory organs, 513;  convulsions,
     513 : prognosis, 513 ; duration of the  disease, 513;
     relapses, 513 ;  treatment, 514.
 Derblich, 643.
 Despres, 462, 466, 469.
 Desquamation in miliary fever, 499.
 Desiccation, stage of, in small-pox, 363, 369.
 Diagnosis of epidemic cerebro-spinal meningitis,  731 ;
     of  erysipelas, 470 ; of hay fever,  551;  of influ-
     enza, 535; of malarial  diseases, 652; of measles,
     106 ; of miliary fever, 500; of scarlatina, 2S4; of
     small-pox, 388; of varicella, 22.
 Diemerbroek, 6, 337.
 van Dieren, 42.
 Digitalis in scarlatina, 306.
 Diphtheria in  measles,  99;  in  scarlatina,  217;  in
     small-pox, 380.
 D'Nais, 133.
 Dobson. 480.
 Doepp, 436.
 Doublet, 475.
Drake, 46.
Dropsy in scarlatina, 259.
von  Diiben, 44.
Dnboue, 643.
EX.                                        741

 Dubun, 495, 496.
 Duchek, 581, 625, 627.
 Dujardin-Beaumetz, 459.
 Dumas, 490.
 Duncome, 165.
 Dunkley, 511.
 Dunlop, 133, 140.
 Duval, 277.
 Dusevel, 96.
 Dyrsen, 42.

 Eab in epidemic cerebro-spinal meningitis, 707. 71S,
     724; in measles, 95 ;  in scarlatina,  221, 277; in
     small-pox,  379.
 Edwards, 78.
 Eichorn, 332.
 Eimer, 397.
 Eiselt, 44.
 Eisenlohr,  672.
 Eisenmann, 73, 103, 503.
 Eisenschitz, 248.
 Emmert, 62.
 Emminghaus, ia3, 136, 143,144,147.
 Engel, 391.
 Epting, 253.
 Erickson, 96.
 Erismann, 381, 3S5.
 Eruption in epidemic cerebro-spinal meningitis, 711 ;
     in dengue, 511; in measles, 78 ; in miliary fever,
     498; in rubeola, 143 ; in scarlatina, 441; in small-
     pox, 355; in varicella, 16.
 Erysipelas, 419;  bibliography, 419;  definition,
     423; history, 423;  etiology, 425;  sex, 430 ; age,
     431; occupation, 431 ;  season of  the  year, 431 ;
     exciting causes, 432; contagion, 432; transporta-
    tion of the disease, 433; infection from the cada-
    ver, 435; stage of disease when infection occurs,
    435;  resistance  to disinfectants,  435 ;  inocula-
    bility, 436;  by the use of instruments,  436;  pyoe-
    mic infection,  438;  influence of  crowding of
    patients, 439;  pollution of  soil,  439;  defective
    pipe drainage, 440 ; pathology, 441 ;  symptoms,
    441: course of the skin affection, 441; tempera-
    ture and pulse, 342; the mucous membranes, 442 ;
    angina,  449; anatomical changes, 443 ;  mucous
    membranes, 443 ; congestion and inflammation of
    lungs, 443;  enteritis, 443 ;  the spleen, 444;  the
    kidneys, 444; the heart, 444; meningitic affec-
    tions, 444 ; the blood, 444; the skin, 444 ; globu-
    lar  bacteria, 445 ; general views, 446; symptoma-
    tology,  451;  the  skin,  451; the mucous mem-
    branes, 457 ;  organs of  digestion,  460; the liver,
    461; intestinal canal,  461;  the  kidneys,  461  ;
    cerebral symptoms, 462 ; the fever, 463 ; the pulse,
    464 ; complications and sequelae, 465; pneumo-
    nia, 465 ; pleurisy, 465;  peritonitis, 405;  menin-
\ 
742
INDEX.
     gitis, 466;  pyaemia, 466; the joints, 467; gangrene
     of the skin, 467 ; thrombosis, 467 ; the eyes, 468;
      mental disturbances, 469;  influence of  the dis-
     ease upon  existing skin diseases, 469; influence
     on recent wounds, 469;  diagnosis, 470 ;  differen-
     tial  diagnosis, 470;  stages  and duration, 472;
     relapses, 473; habitual  erysipelas, 473; varieties
     of the disease, 474;  mortality and prognosis,
     476; in existing diseases, 476; sex, 476; age, 477;
     treatment,  477; prophylaxis, 477;  curative meas-
     ures, 478;  local treatment, 479;  expectant treat-
     ment, 483;  general measures, 483; treatment of
     complications, 483.
 Escherich, 526.
 Estlander, 479, 481.
 Etiology of dengue, 509;  of epidemic cerebro-spinal
     meningitis, 690; of erysipelas, 425; of hay fever,
     542; influenza, 522; of malarial diseases,  563; of
     measles,  37; of miliary fever, 491 ; of rubeola,
     134;  of  scarlatina, 161; of  small-nox, 325;  of
     varicella, 8.
 Eucalyptus globulus in malarial diseases, 669.
 Eulenberg, 293, 475, 667.
 Eye in epidemic cerebro-spinal meningitis, 707, 718,
     726:  in erysipelas,  46S; in scarlatina. 220, 264;
     small-pox, 879.
 Exanthematic  Diseases, Acute, 3;  In-
    troduction, 3 ; their common characteristics, 3.

 Farb, 160, 324.
 Faure-Villars, 711.
 Faye, 44, 101.
 Feith, 105.
 Feltz, 39, 162.
 Fenestre, 432, 433, 443.
 Fenger, 481.
 Fenini, 173.
 Fenwick, 211, 227.
 Ferber, 491.
 Fichtbauer, 99.
 Fichter, 670.
 Fiedler, 588.
 Figueri, 39.
 Fitzpatrick, 173.
 Fleischmann, 10, 279,
 Flemming, 43.
 Fleury-, 673.
 Fodere, 503.
 Fontenelle, 584
 Forest, 36.
 Forget, 725.
Formey, 131.
Forster, 99.
Fouquier, 47.
 Fourcart,  494, 497.
Francis, 307.
 Frank, J., 51.
 Frank Peter, 597.
 Franque, 222.
 Frentzel, 696.
 Friedreich,  449.
 Frolich, 120.
 Fuchs, 12, 73, 74
 Fuster, 518.
 Gahn, 481.
 GalU, 518, 526.
 GaUicio, 526.
 Galeazzi, Guisman, 559.
 Galtier, 490.
 Galy, 496, 503.
 Gauster, 43, 44.
 Geissler, 42, 48, 263. 289.
 Gelmo. 133.
 Gerhardt, 27, 44, 73, 90, 92, 13a
 Gessele, 572.
 Gibbs, 618.
 Gibson, 436.
 Giesler, 640.
 Gildemeister, 450.
 Gillespie, 185, 189.
 Gintrac, 425.
 Girard, 172, 626, 627.
 Girtanner, 41.
 Glaser, 253, 263.
 Gley, 104.
 Gluge, 516, 524, 526.
 Goden, 131.
 Good, Mason, 165.
 Goodfellow, 435.
 Gosselin, 433, 477.
 Gonzee, 480, 581.
 Grant, 525.
 Graves, 44, 233, 432, 522, 529, 597.
 Green, 481.
 Gregory, 321.
 Gresser, 503.
 Griesinger, 571, 597, 599, 612, 614, 617, 631, 635, 637,
    646, 667, 668, 673.
 Grippe, see Influenza.
 Griscom, 480.
 Grisolle, 673.
 Groh, 659.
 Groos, 669.
 Grooshans,  581.
 Gruel, 42, 102.
 Gubler, 459.
 Guersent, 47, 165, 162.
 Gummers, 103.
 Gutmann, 196.

Haabtman, 43.
Habisreutinger, 47. 
INDEX.
743
de Haen, 43, 630.
Hahn, 120.
Haidenhain, 450.
Haight, 455.
van  Halen, 47.
Haller, 431.
Hallier, 163.
Hamburger. 172, 233.
Hambur-iin, 253.
Hammond, 610.
Hampton, 673.
Hannover, 559.
Hare, 306.
Hariey, 228.
Harlin, 173, 216.
Hartmann, 96.
Hasse, 480.
 Harvey, 6.
Haser, 529.
Hauff, 174, 233.
Hauner, 90, 92. 99, 100, 121.
 Hay  Eever,  539;  bibliography, 539;  etiology,
     542 ;  influence of age, 542 ;  sex, 542;  social posi-
     tion, 543;  temperament,   543;  hereditary ten-
     dency, 543 ; the seasons, 543; emanations from
     plants, 544; other  exciting  causes,  544; experi-
     ments  with the pollen of plants, 545; symptom-
     atology, 547; the catarrhal form, 547;  the asth-
     matic form, 549; general  symptoms, 550 ; diag-
     nosis, 551; treatment, 551.
 Headache in small-pox,  346.
 Heart  in  dengue, 513;  in epidemic cerebro-spinal
     meningitis, 706;  in erysipelas, 444; in malarial
     diseases, 627; in measles, 98 ;  in miliary fever,
     496 ; in scarlatina,  233,  255.
 Heat, influence of,  in malarial diseases, 568.
 Heberden. 7, 541.
 Hebra, 7, 12, 63, 65.  89, 132, 205, 210, 269, 274, 282,
     332, 340, 358, 377, 443, 446, 481.
 Hecker, 487, 492.
 Hedrich, 51.
 Heim, 7,  10, 14, 27, 38, 131, 140, 166, 266
 Heller, 707, 722.
 Helmholtz. 512.
 Hennig, 133. 164.
 Henoch, 21, 74, 87.
 Hertz on  malarial diseases,  555.
 Hertwig,  527.
 Hervieux, 183, 458, 475.
 Herzog, 503.
 Heschl, 625, 046.
 Heslop, 165.
 Hesse, 6, 9,  15. 16, 29.
 Heusinger. ",s i.
 Heyfelder, '.;. M>, 173, 446,  456, 473.
 Higginbotham, 480.
Hildebrand, 105, 131, 165.
Hirsch,  36, 165, 423, 426, 431, 487, 491, 495, 507,  511,
    518, 526, 567, 572,  584, 691, 693, 696, 711.
History of dengue, 507;  of epidemic cerebro-spinal
    meningitis, 687; of erysipelas, 423; of influenza,
    517; of malarial diseases, 557 ; of measles, 36;  of
    miliary fever, 4S7  ; of rubeola, 130; of scarlatina,
    159; of small-pox, 320 ; of varice
Hochmuth, 69.
Hofmann, 121.
Hoffmann, Fred., 426.
Hoffmeister, 90.
Holm, 462.
Home, 39, 42, 43.
Horing, 52.
Horst, 39.
Horritz, 640.
Huber,  310.
Hufeland, 27,  202, 495^
Huguenin. 226, 228.
Hunter, 429.
Hutchinson, 480.
Huter, 482.
Huxham, 101.
Hydrocephalus in scarlatina, 238.
Hyilropcricardium in  scarlatina, 258.
Hydrothorax in scarlatina, 258.
Hynes, 277.

Immermann, 722.
Incubation of Dengue, 510 ; of malarial diseases, 587;
     of measles, 59, 75 ;  of rubeola, 141; of scarlatina,
     167 ;  of small-pox, 340 ; of varicella, 16.
 Influenza, 515; bibliography, 515; history, 518;
     etiology, 522: predisposition, 522 ;  sex and age,
     522 ; atmospheric conditions, 523; exciting causes,
     523;  contagiousness,  523;  march of epidemics,
     52? ; influence of other diseases,  526; among ani-
     mals, 526 ; pathology, 527 ; anatomical  changes,.
     528;  mucous membranes,  528; pneumonia, 528;
     symptomatology, 52S; fever, 529;  pulse, 529;
     mucous membranes, 529; cough, 529;  digestive
     organs,  5f 0 ; nervous symptoms, 530 ; the urine,
     531; the skin. 531; duration of  the disease, 532;
     relapses,  532; variations in the disease, 532; com-
     plicaHons and sequelce, 533;  diagnosis,  535;
     mortality and prognosis, 536;  treatment, 536;
     prophylaxis, 538.
 Imbert-Gourbeyre, 430.
 Iron, tincture of, in erysipelas, 478.

 Jadioux, 214.
 Jahn,  131, 192.
 James, 481.
 Jenner. 401.
 Jilek,  570,  657. 
744
INDEX.
Jobert, 481.
Joel, 266, 280,
Joints in dengue, 511; in erysipelas, 467
Jones, Handfleld, 528.
Jorg, 48.
Jourdanet, 564.

Kaczorowski, 482.
Kant, 525.
Kapff, 97.
Kaposi, 29, 474.
Karg, 43, 93.
Kassowitz, 8, 21, 27,  43.
Katona, 39.
Keber, 381.
de Keghel, 123.
Keller, 669.
Kellner, 103, 111.
Kennedy, 233.
Kentish,  481.
Kesteven, 47.
Key, 629.
Kierski, 107.
Kierulf, 43, 44.
Kidneys  in epidemic cerebro-spinal  meningitis, 707;
    in erysipelas, 444,  461;  in malarial diseases, 628,
    629,  649; in miliary fever,  496;  in  scarlatina,
    229, 244, 247, 257; in small-pox, 386.
Klebs, 381, 446.
Knapp, 707.
Knecht, 349, 397.
Koch, 44.
Kohn, 29.
Kolb, 293.
van der Kolk, Schroder, 105.
Konig, 428, 440, 447.
Kopp, 199.
Kiirber, 16.
Kiistlin, 44, 136, 164, 201.
Krauss, 166, 289.
Krieg, 90.
Kilchenmeister, 481, 687,  668.
Kuntz, 450.
Kussmaul, 405.
Kuster, 133.

Labbe, 434, 4-13,  460, 478.
Laborde, 458.
Lacaze, 566.
Lafaye, 90.
Lamotte, 426.
Lancisi,  558, 571.
Landouzy, 531, 455,  496.
Lange, 30.
Langenbeck, Max, SOS,
Langer,  452.
Larcher, 434, 444.
Larrey, 481.
Larynx in scarlatina, 222. 273; in small-pox, 380.
Lassis, 480.
Laudenbach, 186.
Laudenberger, 212.
Lawrence, 432, 443, 466, 480.
Leavit,  673.
Lebert,  431, 460, 462, 46'-.
Legrand, 469.
Legroux, 667.
Lentin, 214.
Leo, 349.
Leroy, 162.
Letheby, 166.
Leudet, 534.
Levy, 106.
Lewin, 43, 89, 455, 458, 459.
Lewizky, 667.
Liebermeistcr, 313, 450, 479, 633.
Lietzau, 466.
Lieutard, 73.
Lievin,  116,  176.
Lindstrom, 725.
Lindwurm. 133, 136.
Lippe, 44.
Lisfranc, 480.
Liver in epidemic cerebro-spinal meningitis, 706, 719 :
    in erysipelas, 461; in  malarial diseases, 612, 627,
    629, 643, 650; in miliary fever, 496; in scarlatina,
    228, 280; in small-pox, 348, 386.
Liverani, 47, 490, 492, 496.
Lobel, 478.
Locatelli, 39.
Lombard, 537.
Look, 40.
Loreau, 494.
Lorenzutti,  672.
Lorinser, 669, 671.
Loschner, 44, 90, 173, 201,  211, 274.
Louis, 476.
Lowenhardt, 15.
Loysel. 425.
Lucae, 707.
Luden, 567.
Lucke, 481.
Luithlen, 43.
Lukomsky,  447, 448.
Lungs in epidemic cerebro-spinal meningitis, 706, 721:
     in erysipelas,  443, 465; in influenza, 528; in ma-
     larial diseases, 611, 627 ; in miliary fever, 496 ; in
     measles, 93, 95; in scarlatina, 223. 279.

Machiavelli, 677.
Maclagan. 164, 435.
 Malaria] Diseases,  555 ;  bibliography.  555 : 
INDEX.
745
history, 557; definition of  the disease, 559; geo- ]
graphical distribution, 559 ; etiology, 563 ; soil, '
563; heat,  568; the seasons,  569; the rain-fall,
569; the wind, as a vehicle of spreading disease,
571; predisposing causes, 573 ; race and age, 573;
sex, 574; influence of pregnancy, 574; constitu-
tion, 575 ; weakening influences, 575; changes of
temperature, 575; previous paroxysms, 576; pre-
vious residence,  577 ;  epidemic  forms, 577 ; rela-
tion to other diseases, 579 ; different grades of the
disease, 582; nature of the malarial  poison, 584;
pathology, 587;  incubation,  587 ; general course
of  the  disease,  588;  simple intermittent, 588;
stage of chill, 590 ; hot stage, 591; sweating stage,
592;  deviations  from  this course, 593; intensity
of the paroxysms, 594 ; different types, 595; time
of  attack, 597;  intermittent in children, 597;
masked fevers, 598 ; neuralgia,  599;  other mani-
festations, 600 ;  pernicious fevers,   602; their
characteristics, 604; the prodromata, 604; parox-
ysms, 605; disturbances of the nervous system,
605;  cases of  apparent death,  606;  cerebral  dis-
turbance with delirium, 607 ;  eclamptic and te-
tanic spasms,  608;  the hydrophobic form, 608;
the choleric form, 608; the  pernicious sweating
form, 610;  the  dysenteric type, 610; pneumo-
nic and pleuritic forms, 611;  icteric form,  612;
gangrene, 613;  remittent and continued mala-
rial  fevers, 614; their caracteristics, (ill;   the
different grades, 616; "la  fievre bilieuse hema-
turique,"  618; malarial cachexia, 620 ;  patholo-
 gical anatomy,  624;  blood changes, 624; black
pigment matter, 625; the nervous  system,  626;
 lungs, 627 ; heart, 627;  spleen, 627; liver,  627;
 intestinal mucous membrane, 627 ; kidneys,  628 ;
 the skin, 628;  changes in malarial cachexia,  629;
 the "ague-cakes,"  629; analysis of the  indivi-
 dual symptoms, 630 ; temperature of the body,
 630; changes in the blood, 633; the skin,  036; the
 circulatory apparatus, 637; the respiratory appa-
 ratus, 638 ; the urine, 638; excretion of urea,  639;
 other excretions in the urine,  640;  dropsy,  641;
 disturbances of  the  intestinal canal, 642;   the
 liver, 643; the spleen, 643 ; the blood the vehicle
 of the poison, 645; cause of rhythmical recurrence
 of paroxysms, 646; course and sequela,  647 ; re-
 lapses,  648;  kidney  diseases  as sequela;,  649;
 liver diseases, 650; spleen, 650; other  derange-
ments, 650 ; prognosis, 650; of the simple fevers,
.650 : masked  fevers, 651; pernicious fevers,  651;
the remittent  and continued forms,  652; chronic
malarial cachexia, 652;  diagnosis,  652; treat-
 ment, 655; prophylaxis, 655; prophylactic action
of quinine, 657; treatment of the paroxysm,  658;
in the pernicious fevers, 660; quinine  and  its
mode of administration, 661, 675, 676; its modus
    operandi,  667; the  eucalyptus globulus,  669;
    arsenic,  671;  its mode  of  administration,  672;
    carbolic  acid, 672;  chloride of sodium, 673; sul-
    phites of  soda and  magnesia, 673: cold water
    treatment, 673 ; alcoholics, 674; chloroform, 674 ;
    piperine, 674; other  remedies, 674; treatment of
    sequelae, 677.
Maillot, 661.
Majer, 175, 186.
Malgaigne, 481.
Malherbe, 443, 461.
Malmsten, 44,  467.
de Man, 133.
Mannkopf, 719.
Manson, 510, 512.
Marchioli, 177.
Marcus, 289.
Marken, 672.
de  Marmon, Paluel, 672.
Maroschkin, 673.
Martin, 432, 434, 436, 475, 602, 665, 668.
Martinet, 466.
Martius, 397.
Masarei, 102, 104.
Mascati, 554.
Mason, 100.
Massa, 664.
Mathius, 469.
Mauger, 109.
Maurer, 722.
 Mauriac, 469.
Maury, 565,
 Mauthner, 43, 121.
Magollini, 673, 675.
 May,  184.
 Mayr, 37, 40,  46, 47, 62, 63,  65,  101, 104.
 McDowell, 480.
 Measles, 31; bibliography, 31; history, 36;  etiolo-
     gy, 37; nature of contagious principle, 38; vehicles
     of contagion, 41;  susceptibility to contagion, 42;
     second and third attacks, 42; recurrent form, 45;
     influence  of  race,  46 ; pregnancy in, 46; abortion
     in, 46; other diseases  during, 46; age, 48; sex,
     52; epidemics of, 53 ;  seasons of the year,  56;
     time of infection, 57 ;  length of stage of incuba-
     tion, 59;  pathology, 62 ; anatomical changes, 62;
     the measle-spot, 62;  site of, 64 ; diversity of form,
     64; outbreak of  the  eruption, 65;  duration of
     maximum of eruption, 67; retrocession of erup-
     tion, 67;  colorations of skin, result of eruption,
     68; desquamation,  70; affection  of the mucous
     membranes of the nose, throat and air-passages,
     71; of the conjunctiva, 72; of the tongue,  73 ; of
     the mucous membrane of the intestines, 73 ; of
     the genital mucous  membrane, 74 ; of the pleura
     pulmonalis,  74;  of the spleen, 74; changes in the 
746
INDEX.
     blood, 74; symptomatology, 75 ;  stage of incuba-
     tion, 75 ; prodromal stage, 75 ; stage of eruption,
     78; convalescence, 82 ; anomalies of the course,
     83; measles without catarrh,  83; measles with-
     out eruption, 84; hemorrhagic measles, 85 ; varia-
     tions in the stage of incubation, 87; variations in
     the prodromal stage, 87 ; variations in  the stage
     of eruption, 88;  complications, 90 ; affections of
     the skin, 90 ; the mucous membranes of nose and
     throat, 91; the larynx, 92; bronchitis, 92;  pneu-
     monia, 93 ; gangrene of lung,  95 ;  diseases of the
     ear, 95; the mucous membrane  of the  digestive
     canal,  96;  diseases of the nervous system, 97;
     the heart, 98; the liver,  98;  the  genito-urinary
     apparatus,  99;  the  glands, 99;  acute miliary
     tuberculosis, 99; diphtheria,  99;. ulcerous and
     gangrenous affections, 100 ; scurvy, 102 ; sequelae,
     102;  influence of constitution, 102; measles, pre-
     disposing  to  other  diseases,  104;  influence  of
     measles npon pre-existing diseases, 104; diagnosis,
     106; differential  diagnosis, 106;  prognosis, 109;
     influence of anomalies and  complications,  110 ;
     age in the prognosis, 111;  sex in the prognosis,
     113; mortality of measles, 113;  treatment, 116;
     isolation, 116 ;  ventilation, 118; general hygienic
     treatment, 119; treatment of the various symp-
     toms, 119; treatment of fever by cold water, 120 ;
     inunctions of oil, 121; quinine, 121; sulphate  of
     magnesia,  122; inunctions of  oil of turpentine,
     122; treatment of convulsions, 123 ; of bronchitis,
     123 ;  of broncho-pneumonia,  124; of diarrhoea,
     125; of epistaxis, 126; of  affections of  the eye,
     126; of the ear, 126; of the larynx, 127 ; of gan-
     grene, 127 ; of diphtheria, 128.
Mees, 669.
Meigs, 481.
Meissner, 45, 133.
Menstruation in small-pox, 349.
Mercurialis, 524.
Merkel, 726.
Mertens, 92, 06.
Mettenheimer, 44, 105, 106, 120, 133, 139, 142, 147.
Meyer, 90.
Michael, 631.
Michele, 105.
Michaelsen, 51.
Miliary Fever, 485; bibliography, 485; history
    and epidemiology, 487;  etiology,  491; influence
    of  the  seasons, 491 ; condition of the soil, 492;
    individual predisposition,  493; exciting causes,
    494;  communicability, 494;  relation of miliary
    fever to other diseases,  494 ; anatomical changes,
    495;  decomposition, 496:  the lungs,  496;  the
    mucous  membranes, 496;  the heart.  496;  the
    liver, 496; the kidneys, 496; the nervous system,
    496: the blood, 496 ; contents of the vesicles, 496;
     symptomatology, 497;  the eruption,  498; other
     symptoms, 499;  complications,  500; diagnosis,
     500; duration of the disease, 501;  relapses, 501;
     mortality and prognosis, 501; treatment, 502.
 Miquel, 162, 183.
 Moffat, 572.
 Mombert, 105.
 Monro, 39, 40.
 Moore, 52,104, 174, 321, 663.
 Moreau, 474.
 Mortality in epidemic cerebro-spinal meningitis,  733;
     in erysipelas, 476; in influenza, 536 ;  in measles,
     113; in miliary  fever,  501;  in  scarlatina,  291;
     in small-pox, 391.
 Morton, 36, 198.
 Mosler, 126, 667, 669,  673.
 Moutard, 665.
 Mucarin, 673.
 Mucous membranes in dengue, 512;  in epidemic oer
     ebro-spinal meningitis,  706;  in  erysipelas,  442,
     457 ; in influenza, 528,  529;  in malarial diseases,
     627; in measles, 71; in miliary fever, 496;  in
     rubeola, 141; of  digestive  organs  in scarlatina,
     227, 280 ;  of mouth in scarlatina,  219, 278 ;  in
     small-pox, 360,  367,  379, 385; in varicella, 21.
 Muhry, 642.
 Miihsam, 311.
 Muller, 173, 278,  413, 510, 512.
 Murchison, 165,184, 185,  189, 429, 458, 476.
 Murray, 495.
 Muscular system in scarlatina, 233.

 Nasse.
 Naumann, 131, 431,  450.
 Naunyn, 107
 Neisser, 89.
 Nervous system  in epidemic  cerebro-spinal  menin-
    gitis, 704, 717, 726 ; in influenza, 530 ; in malarial
    diseases, 599, 605,  626, 646, 050; in measles, 97; in
    miliary fever, 496; in scarlatina, 226, 255,  258,
    265, 275; in small-pox, 379,387.
 Neuhold, 658.
 Neumann, 204.
 Neureutter, 95.
 Nicola, 44.
 Niemeyer, 89, 103, 131, 205.
Nieuwenhuis, 581.
Noirot,  211.
Nole, 490, 497.
Nunnely, 464, 480.
Nystrom, 481.

Obe, 433.
Obermeier, 349.
CEdema in scarlatina, 257; of the  glottis, in erysipe-
    las, 483; of the glottis, in scarlatina, 258. 
INDEX.
747
 Ogle, 164.
 Oppolzer, 314, 459
 Ornstein, 636.
 Orth, 437, 447, 449.
 Osiander, 334, 475
 Ottoni, 490.
 Ozanam, 537.

 Paalzow, 450.
 Paasch, 169.
 Paget,  185, 667.
 Palante, 164.
 Pancreas in scarlatina, 227.
 Pank, 103,  106.
 Panum, 41, 48, 59, 79,  526.
 Papoff, 683.
 Parent-Ducha,telet, 466.
 Parrot, 494, 503.
 Pastau, 107.
 Pathology of epidemic cerebro-spinal meningitis, 697;
     of  erysipelas, 441; of influenza, 527 ; of malarial
     diseases, 587; of measles, 137; of miliary fever,
     495; of rubeola, 137; of scarlatina, 202;  of small-
     pox, 340; of varicella, 10.
 Patissier, 480.
 Paul, 266.
 Pepper, 38.
 Percival, 39.
 Pereird, 665.
 Periosteum in scarlatina, 232.
 Peter, 443.
 Petersen, 164
 Petit, 162, 480, 534
 Pezet, 507.
 Pfeiffer, 588.
 Pfeilsticker, 48.
 Pfeufer, 661.
 Pfleger, 448, 451.
 Phoebus, 541.
 Pigne,  503.
 Pihan-DufeUlay, 444
 Pinkham, 123.
 Pioch, 673.
 Piorry, 667, 673.
 Pirogoff, 438.
 Plonviez, 490, 497.
 Polak, 104.
 Polli, 673.
 Politzer, 88.
 von Pommer, 190.
 Ponfick, 385, 387, 388,  437, 443.
Poor, 637.
Porter,  277.
Poumier, 613.
Prevot, 274.
Pride, 196.
Priessnitz, 673.
Primbs, 496.
Prognosis of dengue, 513; of  epidemic cerebro-spinal
    meningitis,  733; of erysipelas, 476; of influenza,
    536; of malarial diseases, 650;  of measles, 109; of
    miliary fever, 501; of rubeola,  147; of scarlatina,
    287; of small-pox, 391; of varicella, 29.
Prophylaxis of  erysipelas, 477; of malarial diseases,
    655; of small-pox, 400.
Pruner, 109.
Pujos, 434, 439.
Pyasmia in erysipelas, 466.
Pyle,  166.

Quadrat, 574.
Quincke, 349.
Quinine  in epidemic cerebro-spinal meningitis, 737;
    in erysipelas, 479; in malarial diseases, 657, 661,
    675,  676;  in measles, 121; in  miliary fever, 503;
    in scarlatina, 306.

Race, influence of, in small-pox, 329.
Radel, 162.
Ranke, 198.
Ranzoni, 673.
Ratzius, 475.
Rautenberg, 107.
Ravitsch, 447.
Ravn, 100.
Rawling, 537.
Rayer, 43, 73,  105, 424,  426, 467, 494 496.
Read, 508.
Redtenbacher, 640.
Rehn, 73, 166.
Reil,  289.
Reiter, 413, 414.
Relapses in dengue, 513; in erysipelas, 473 ; in influ-
    enza, 532; in malarial  diseases,  648; in miliary
    fever, 501.
Reuss, 480.
Rhazes, 36, 322,  337.
Rhode, 466.
Rain-fall,  influence of, in malarial diseases, 569.
Richardson, 164, 177, 293.
Richeraud, 426.
Richter, 426.
Ricord, 480.
Riecke, 44.
Riess, 163.
Rigler, 109, 609, 627.
Rilliet, 47, 91, 105, 204,  274
Rindfleisch, 384.
Ringer, 478, 639.
Ritter, 574, 580.
Ritzmann, 431, 434, 435, 439, 443, 465, 467, 469, 473.
Riviere, 6. 
748
INDEX.
Rivolta, 587.
Roberdiere, 43.
Robert, 386.
Robinson, 189.
Rotheln, see Rubeola.
Rohrig, 450.
Roger, 229.
Rogers, 657.
Rogez, 435.
Roncati, 122.
Rosenstein, 43, 45, 331, 641.
Roser, 106, 175, 438.
Rossi, 39.
Rostan, 162.
Roth, 726.
Rothe, 100.
Roux, 61, 109, 495.
Rubeola (Rotheln, German measles), 129; biblio-
    graphy, 129; history, 130 ; etiology, 134 ; age in,
    136;  subsequent  attacks,  136;  contagiousness,
    136 ; epidemics of rubeola, 136; pathology, 137 ;
    the eruption and its  site,  137; the size  of the
    spot, 138 ; duration of the spots, 139 ;  desquama-
    tion,  139;  diagnosis between the rubeola and
    measles spot, 140;  symptomatology, 141;  stage
    of incubation, 141 ; the mucous membranes, 141;
    lymphatic glands, 142; the urine, 143 ; the stage
    of eruption, 143; the temperature,  145; compli-
    cations, 147;  prognosis, 147;  treatment,  147.
Rufz, 44.
Riihle, 222.
Rush, 507.
Russegger, 259.
Russell, 479.
Rust, 480.
Riittel, 44

Sabatier, 469.
Sadler, 101.
Salisbury, 38, 109, 587.
Salvagnoli, 572.
Salzmann, 85, 90.
Sansom, 307.
Sanson, 455.
Santini, 490.
Santlus, 199, 281.
Saussure, 657.
Sauvages, 426.
Savory, 425, 435.
Scarlatina, 149; bibliography, 149; history, 159;
    etiology, 161; contagiousness of scarlatina, 161;
    isolation of patients, 161; inoculation  of the poi-
    son, 162; length of time of  exposure to  the poi-
    son, 164; milk as a vehicle  of contagion,  165;
    spread of the disease by  clothing of nurses, 165 ;
    animals as a  medium of  contagion, 166; the
tenacity of  the poison,  166;  incubation,  167;
variations  in time  of  incubation, 168;  when  a
patient may communicate the disease, 170 ;  indi-
vidual predisposition, 172; family predisposition,
173; influence of social position, 175;  of soil, 176 ;
of locality, 177; age in,  178; sex in, 182; influ-
ence of menstruation, 183 ; of pregnancy, 183;  of
childbirth, 183 ; of lactation, 183 ;  of  occupation,
183; the disease in those who have undergone
surgical operations, 184 ; influence of previous dis-
ease, 185; of race, 185 ; second attacks of the dis-
ease,  186;  relapse, 190;  third attacks, 191; the
recurrent form,  192;  sporadic  and  epidemic
forms, 193; the influence of  the seasons,  194; of
weather, 195; of  the  drinking-water,  196; ele-
vation and geological structure of  the ground,
196; location, 196 ; condition of the subsoil,  196 ;
personal intercourse  in  the spread of  the  disease,
197; slaughter-house offal as means of contagion,
198; variations in the severity of epidemics,  198 ;
periodicity of epidemics,  199;  supposed relation
between scarlatina and measles, 201; pathogen-
esis of scarlatina,  202 ; pathology, 202; anatomi-
cal changes, 202 ; the skin eruption, 202 ; its site
and general  characteristics,  203; description by
other authors, 204; progress of the eruption,  205 ;
deviations from the  above descriptions, 207 ; the
miliary eruption, 2U9 ;  exudations of blood in the
skin, 210; cutaneous diseases following scarlatina,
210; post-mortem appearance  of the eruption,
211; the desquamation, 212; subsequent  desqua-
mations, 214 ; desquamation affecting the nails and
hair, 214 ; affections of the throat, 214 ; gangrene
of the tonsils, 217; of the connective tissue of the
neck,  217 ; diphtheria, 217 ; the tongue, 218 ; the
gums and mucous membrane of  the  cheeks,  219 ;
the mucous membrane of the nose, 219 ; the eye,
220 ; the ear, 221 ; the larynx, 222 ; the bronchi,
222;  pneumonia,  223;  lymphatic glands,  223;
cellulitis of the neck, 225 ; changes in the brain,
226; the mucous  membrane of  the digestive or-
gans, 226; the pancreas,  227 ; the liver. 228; the
spleen, 228; the genital organs, 229 ; the kidneys,
229; the serous membranes, 231 ; the synovial
membranes  of the joints, 232;  the  periosteum
and  bone,  232; the  muscular  system, 233; the
vascular system, 233;  the blood, 234; different
forms of scarlatina,  234; symptomatology in the
usual forms of the disease, 237 ; initiatory symp-
toms, 237;  the throat, 238 ; the temperature. 238 ;
the eruption, 239;  affections  of  the  lymphatic
glands,  212 ;  of  the  joints, 243 ;  nephritis,  244;
the urine,  245; parenchymatous  nephritis, 247;
irregular course of the disease, 250 ; angina, 251;
cases of scanty eruption, 252 ; rudimentary symp-
toms, 252; cases with blood-poisoning, 253 ; ab- 
INDEX.
749
    sence of local  lesions,  254; cases of normal be-
    ginning and subsequent irregularity, 255 ; irregu-
    larity of  the fever, 255; nervous  delirium, 245;
    intercurrent  nervous attacks,  255;  sudden col-
    lapse, 256 ; hemorrhagic diathesis, 256 ; irregu-
    larity in the eruption, 256 ; in the angina, 256 ;  in
    the inflammation of the cervical glands,  256 ;  in
    the joint affections,  256; in the results of  the
    renal inflammation, 256;  ascites, 257 ;  hydrotho-
    rax,  258;   hydropericardium,  258;   hydroce-
    phalus,  258;  frequency  of  dropsy and  albumi-
    nuria, 258;  date of appearance of  dropsy, 259 ;
    symptoms of dropsical patients, 259; cases irregu-
    lar from the  beginning,  262; high fever, 262;
    the  eruption,  262;  the  throat,  264;  cervical
    glands,  264; the eye,  264;  diarrhoea,  264; kid-
    neys, 264 ;  cerebral symptoms, 265 ;  rheumatic
    affections, 266;  peculiar odor  of  patients, 266;
    duration of irregular cases, 267; causes of death,
    267; progress in favorable oases, 267 ; typhoid scar-
    latina, 268; secondary eruptions, 270; hemorrhagic
    form of the disease, 272; scarlatina occurring in
    the course of other diseases, 274 ; complications,
    274 ;  nervous symptoms, 275 ; the  eye, 276; the
    ear, 277;  mucous membiane of nose and mouth,
    278;  cellulitis of  the  neck, 278; the  air-pas-
    sages and lungs, 279;  intestinal  mucous  mem-
    brane, 280 ;  the liver,  280 ;  the spleen, 281; the
    serous membranes, 281 ;  purulent arthritis, 282 ;
    gangrene, 282;  sequelce,  283;  diagnosis,   284;
    differential   diagnosis,  286;  prognosis,   287;
    mortality, 291 ;  influence of  the seasons,  292;
    the city and country, 293; poverty and opulence,
    293 ;  good nursing and  medical advice, 294; in-
    fluence  of sex, 294;  influence of age, 294;  influ-
    ence of mortality of  scarlatina  upon the general
    mortality, 295; treatment, 297; prophylaxis and
    general sanitary measures, 297; specific and non-
    specific  treatment, 301;  bloodletting, 301; cathar-
    tics and emetics, 302;  anointing  with  lard, 302;
    symptomatic treatment, 302 ; temperature of the
    room, 303 ; care of the patient's skin,  303; cold-
    water bathing, 304 ;  quinine, 306 ; digitalis, 306 ;
    carbolic* acid, 307; suiphocarbolate of  soda, 307;
    transfusion of blood, 307; yeast, 307;  the  warm
    bath, 307; treatment of brain symptoms, 308; of
    the angina, 308; diphtheria, 309;  the ear, 309;
    the eye, 309; cellulitis of the neck, 310  ; isolation
    of  cases of   diphtheria  and gangrene,   310;
    bronchial  and pulmonary  complications,  310;
    intestinal disturbances,  311;  rheumatism, 311;
    inflammation of serous membranes, 311; hemor-
    rhages,  312;  nephritis, 312;  dropsy and anasarca,
    313;  ascites, 314; uraemic convulsions, 314
Schaper, 335.
Scheby, 349.
Schedel, 426, 469, 581.
Schenk, 36.
Scheich, 537.
Schiefferdecker, 525.
Schneemann, 121.
Schneevoogt, 581.
Scholz, 613.
Schonlein, 12, 131, 264 425, 426, 462, 503, 525.
Schott, 480.
Schramm, 599, 621.
Schreiber, 100.
Schroter, 220,  276.
Schulze, 103.
Schultze, 44
Schutz, 44.
Schwalbe, 121, 473, 481, 573.
Schweich, 516, 524.
Scoutetten, 121.
Seasons, influence of, in epidemic cerebro-spinal men-
    ingitis, 693; in erysipelas, 431; in hay fever, 543;
    in malarial diseases,  569; in miliary fever, 491.
Sebastian, 565, 575, 650.
Sedoni, 499,  503.
Seidl, 46, 51, 103,  104.
Seitz, 85, 104,  136, 494 496, 497.
Semeleder, 459.
Senn, 183.
Sennert, 6.
Sequelae of  epidemic cerebro-spinal meningitis, 721;
    of erysipelas, 465; of influenza, 533; of malarial
    diseases, 647 ; of measles, 102;  of scarlatina, 283 ;
    of small-pox, 378.
Serous membranes, in erysipelas,  465;  in  malarial
    diseases, 611; in scarlatina, 231, 381; in small-
    pox, 336.
Sex, in epidemic cerebro-spinal meningitis, 696; in
    erysipelas, 430, 476;  in hay fever, 542; in influ-
    enza, 522; in malarial diseases, 574 ; in measles,
    52; in miliary fever, 493;  in scarlatina, 182, 294;
    in small-pox, £28, 393.
Sheriff, 509, 512, 514.
Siegen, 669.
Simon, 132.
Simon, G., 63, 205.
Simon, Jules, 459.
Sims, 166.
Skin, in epidemic cerebro-spinal meningitis, 704, 710;
    in erysipelas, 441, 444, 451;  in influenza, 531;  in
    malarial diseases, 628, 636.
Skoda, 668.
Small-Pox, 319; bibliography, 319; history, 320 ;
    etiology, 325;  influence  of age, 326;  sex, S28;
    race,  329; influence of  existing  diseases, 329;
    immunity from subsequent  attacks, 331; earliest
    origin and mode of extension, 333; nature of the
    contagion, 333; the most liable period of infection, 
750
INDEX.
     335;  infection through clothing,  336; through
     dead bodies, 336; through  gases, 336;  conditions
     favorable to its spread, 338; pathology, 340 ; symp-
     toms and course of the disease,  340 ; incubation,
     340; the initial stage, 342; the rigors, 343; tempera-
     ture, 344 ; pulse, 344; respiration, 344 ; appetite,
     345; nausea, 345; headache, 346;  brain  symp-
     toms,  346; pain in the back, 347; the spleen, 348;
     the liver, 348; the urine, 348 ; menstruation, 349 ;
     the initial  eruptions, 349;  their frequency, 351;
     varieties  of the initial stage, 352; small-pox with-
     out eruption, 352 ; hemorrhagic  small-pox, 353;
     its symptoms, 354; regular course of the disease,
     355 ; stage of eruption, 355; stage of suppuration,
     357;  the  mucous membranes, £60; febrile  symp-
     toms,  361;  stage of desiccation, 363 ; the itching,
     364 ; the  resulting scars of  the skin, 364 ; date of
     convalescence,  366 ;  confluent variety,  366;  the
     mucous membranes,  367; the fever, 368; vomit-
     ing, 368;  the  skin affections, 368; desiccation,
     369; pustulous hemorrhagic small-pox, 369; vari-
     oloid, 372;  complications and sequelae, 378;  the
     skin, 378; nervous system, 378 ; the eye, 379; the
     ear, 379;  mucous membrane of nose, 379;  the
     joints,  379;  bronchitis, 379; diphtheria,  380;
     laryngitis, 3S0; the salivary glands, 380; abdom-
     inal viscera, 380;  anatomy of the pock, 380;
     changes in the skin, 382; the mucous membranes,
     385; the serous membranes, 386; the liver, 386;
     the kidneys, 386 ; the spleen, 386; the heart, 387;
     the nervous system,  387; diagnosis, 388; differ-
     ential  diagnosis, 389; prognosis, 391; mortality,
     391; influence of seasons,  393;  of age,  393; of
     sex, 393;  of physical  condition,  393 ; treatment,
     395; specific methods, 395; treatment of the erup-
     tion, 397;  diet, 399; complications, 399; prophy-
     laxis, 400; vaccination, 401; variola of the  lower
     animals, 401; course of vaccinia, 403; its efficacy,
     405 ; length of time of protection, 406; objections
     to vaccination, 407 ; transmission of disease, 409;
     performance of vaccination, 411; preservation of
     vaccine virus, 412; choice  of patients, 413; the
    operation, 414 ; compulsory vaccination, 416.
Smart, 526.
Soda, sulphocarbolate of, in scarlatina, 307.
Soil, influence of, in malarial diseases, 563; in miliary
    fever, 492.
Solon,  Martin, 480, 492.
Spleen in epidemic cerebro-spinal meningitis, 706, 710;
    in erysipelas, 444; in  malarial diseases, 627, 629,
    643, 650 ; in measles,  74; in scarlatina,  228, 281;
    in  small-pox, 348, 386.
Spengler, 481,  525.
Speranza, 39.
S-piess, 42, 43,  44, 52, 99.
Squire, 133.
 Stager, 280.
 Starcke, 477, 526.
 Steffen, 313.
 Steiner, 73, 95, 244, 258, 475.
 Steinthal, 99.
 Steudel, 99.
 Steudener, 444.
 Stevenson, 186.
 Stewardson, 628.
 Stiebel, 43, 44, 74, 199, 253, 266.
 Stiener, 396.
 Stilling, 44.
 StofeUa, 73.
 Stosch, 526.
 Stratton, 185.
 Struve, 670.
 Suppuration, stage of, in small-pox, 357.
 Sydenham, 36, 198, 337, 346, 478, 558.
 Symptomatology of dengue, 510 ; of epidemic cerebro-
    spinal meningitis, 707; of erysipelas, 451 ; of mal-
    arial diseases, 558; of miliary fever, 497; of hay
    fever, 547;  of influenza, 528;  of measles, 75 ;  of
    rubeola, 141; of scarlatina, 237; of smali-pox, 340;
    of varicella, 15.
 Synovial membranes of joints in scarlatina, 232.
 Swiney, 281.

 Taglioni, 665.
 Talbor, Robert,  558.
 Tarchanoff, 6b8.
 Taube, 230.
 Taupin, 105.
 Taylor, 165.
 Teilhol, 492.
 Tessier, 566, 672.
 Testa, 103.'
 Thaer, 120.
 Thaly, 509, 511.
 Thaulow, 44.
Theden, 496.
Themmen, 39.
 Thierfelder, 133, 142, 147.
Thoinnet, 443.
Thomas, 464, 673.
Thomas on acute exanthematic diseases, 3; on measles,
    31; on rubeola,  129; on scarlatina, 149 ; on  vari-
    cella, 5.
Thompson, 274.
Thomson, 7.
Thore, 90, 96.
Thoresen, 41, 166.
Throat in scarlatiffa, 214, 238.
Thrombosis in erysipelas, 467.
Thuessink, 39, 41.
Tigri 52".
 Titeea, 626. 
INDEX.
751
Tomasi, 629.
Tongue in measles, 73 ; in scarlatina, 218.
Tonsils, gangrene of, in scarlatina, 217.
Torti, 558.
Tourner,  665.
Tourtual, 183.
Townsend,  261.
Treatment  of  dengue, 514;   of  epidemic  cerebro-
     spinal  meningitis, 733;  of erysipelas,  477;  of
     hay fever,  551; of  influenza, 536; of  malarial
    Diseases, 655; of measles, 116; of miliary fever,
     502;  of rubeola,  147;  of scarlatina,  297;  of
     small-pox, 395 ;  of varicella, 30.
 Tresling, 43.
 Treulich, 672.
 Triboulet, 101.
 Tripe, 133.
 Trousseau, 13,  16, 21,  27, 125,  126, 133, 167,  183, 253,
     311,  358,  425,  427, 427, 433,  438, 443,  458, 459,
     460,  474, 607.
 Trojanowsky, 43, 45, 187,189.
 von Tscharner, 165.
 Tuffnell, 61.
 Tungel, 78.
 Turner, 673.
 Tutschek,  467.

 Uhle, 640.
 Upham, 711.
 Urine in dengue,  512;  in erysipelas, 460;  in influ-
      enza, 531;  in  malarial diseases, 638; in measles,
      31;  in miliary fever, 499; in scarlatina,  245; in
      small-pox, 348.

 Vaccination, 401.
 Valleix, 398.
  Varicella, 5; bibliography,  5;  history, 6; etiol-
      ogy, 8; pathology, 10; anatomical changes,  10;
      the vesicles, 11;  their appearance, 11 ; duration,
      13; symptomatology, 15; incubation, 16; erup-
      tion,  16;  temperature, 19;  relapses,  20;  affec-
      tion of mucous membranes,  21;  diagnosis,  22;
      prognosis, 29; complications, 29 ; treatment, 30.
  Varioloid, 372.
  Vaucquelin, 584.
  Vanory, 508.
  Veale, 133.
  Veillard,  619,  628.
  Veit, 42. 69.
  Velpeau,  443, 459,  466,  480, ,81.
  Veratrum in erysipelas, 478.
  VerneuiL 495, 499.
  Vetter, 10, 27.
  Vezien, 44.
  Viennois, 410.
   Vieusseux, 711.
   Virchow, 444, 446, 450,  457, 475.
Vogel, 38, 140.
Vogel, A., 133, 474.
Vogel, S. G., 51, 186.
Voit, 99.
Volkmann, 425, 427, 436.  438, 439, 444, 458, 462,  466,
    469, 471, 473, 479, 480.
Volz, 73, 172.

Wachsel, 39.
Wagner, 133, 385, 386, 388, 469.
Wagner, E., 228.
Walz, 104, 121.
Water, cold, in erysipelas, 479. 481; in measles,  120 ;
     in scarlatina, 305 ; in small-pox, 398.
 Waton, 608.
 Ward, 600.
 Weber, 73, 229, 282.
 Weber, H.,  283.
 Webster, 43.
 Weigert,  381.
 Weil, 77, 96.
 Weisse, 46, 104, 105.
 Wells, 432, 580.
 Wendt, 40, 44, 103, 126, 221, 277, 309.
 Wenzel, 566, 569.
 Werlhof, 559.
 Wernher, 480.
 West, 127, 132.
 Westerland, 481.
 Willan, 7, 39, 132,166, 186, 436.
 Wildberg, 263.
 De Wilde, 507, 511, 514.
 Williams, 166.
 Wilkes, Samuel, 405.
 Wilkinson, 478.
 Wilks, 444.
 Wilson, 44, 73.
 Wise, 507.
; Wisshaupt, 78.
| Wittwer, 524.
 ! Wood, 177, 282.
  Woodbury, 527.
 J Wunderhch, 44, 133, 265, 280, 429, 463, 665.
  Wutzer,  443, 459, 481.
  Wyss, 385.

  Zehndeb, 175, 260, 263, 278, 282.
  Zengerle, 163, 166.                              _
  Ziemssen,  121, 124,  313; on epidemic cerebro-spmal
       meningitis, 6813.
  Zimmermann, 6-31, 639, 659.
  Zuccarini, 430, 443.
  Zuelzer  on dengue. 505; on  erysipelas, 419; on hay
       fever, 539 ; on influenza, 515 ; on miliary fever,
 i     435.
 I Zulger,  164, 334, 337, 341, 381, 388, 397.
   Ziiin, 166. 
 
 
 
 

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