(and from sight), it answers a perfectly satisfactory purpose to
dispense with the absorption-drains and to deliver the main outlet
directly on to the surface of the ground. The effect in both cases is
entirely different from what it would be were the flow of the drains
not regulated by the use of the flush-tank. The moment we have a
constant slight discharge, either on the surface of the ground or into
the absorption-drains, we establish a condition of constant saturation
which leads to the over-fouling of a small area, which is rarely if
ever purified by aëration. For an intermittent discharge some form of
flush-tank is an absolute necessity. It is often found in practice,
where the flow from the house is considerable, that the discharge of
the house-drains into the settling-basin produces such an agitation of
its contents as to set in motion and to carry into the flush-tank bits
of paper partly macerated, grease, etc. This has been met by a recent
improvement, which consists in building a transverse wall in the
settling-basin, which checks the current from the house-drain and
causes the flow from the house side of the wall to pass over its top
in a thin small current which does not materially agitate the contents
of that part of the basin from which the outflow pipe is fed.
(_c_) The cesspool is still the chief reliance of the world at large.
There is nothing to be said in its favor save what may be based on the
old adage that "what is out of sight is out of mind." There is
everything to be said in its condemnation, whether we regard its
contents as a great mass of putrefying and infecting filth, as the
source of oozings which travel through crevices of rocks, through
layers of gravel, through seams in clay, or through lighter soils into
and under cellars and into drinking-water wells and defectively
constructed cisterns, or as an ever-active gas-retort supplying the
pipes of the house with the foulest products of putrefaction. It is in
all respects and under all circumstances a curse, unless placed far
away from the possibility of tainting the air we breathe or the soil
over which we live, or from which we or others take our
drinking-water, and even then it had better be abandoned.
The simple drainage of the soil involves a question of the greatest
importance. If the ground under the house or about it is at any time,
unless perhaps immediately after heavy rains, saturated with moisture,
we have to apprehend a condition of insalubrity more or less serious
in proportion to the degree of saturation and the degree of foulness
with which this is associated. The drainage requirements of land
outside of the house are less easily determined, but it requires
nothing more than a casual {227} examination of the cellar in
ordinarily wet weather to determine whether or not an improvement of
its soil-water drainage is necessary. If it is at such times wet, or
even persistently damp, thorough drainage is demanded; and it is only
necessary to say that this should be secured by some process which can
under no circumstances bring the air of the cellar into communication
with the air of a sewer or foul drain.
* * * * *
I have purposely abstained in the foregoing remarks from invading the
province of the physician or the physiologist by discussing the
influence of bad drainage on the health of those living subject to it.
It may safely be assumed that physicians who care enough about the
subject to interest themselves in investigating the condition of local
or general drainage have convictions concerning it which could not be
strengthened by the opinion of one belonging to another profession.
The assumption is also confidently made that no intelligent medical
man will hesitate for a moment to accept the dictum that the site of
the house must be dry, and that it and its neighborhood must be
entirely exempt from the influence of foul organic decomposition.
{229}
GENERAL DISEASES.
FROM SPECIAL MORBID AGENTS OPERATING FROM WITHOUT.
SIMPLE CONTINUED FEVER.
TYPHOID FEVER.
TYPHUS FEVER.
RELAPSING FEVER.
VARIOLA.
VACCINIA.
VARICELLA.
SCARLET FEVER.
RUBEOLA.
RÖTHELN.
MALARIAL FEVERS.
PAROTITIS.
ERYSIPELAS.
YELLOW FEVER.
DIPHTHERIA.
CHOLERA.
PLAGUE.
LEPROSY.
EPIDEMIC CEREBRO-SPINAL MENINGITIS.
PERTUSSIS.
INFLUENZA.
DENGUE.
RABIES AND HYDROPHOBIA.
GLANDERS AND FARCY.
MALIGNANT PUSTULE.
PYÆMIA AND SEPTICÆMIA.
PUERPERAL FEVER.
BERIBERI.
{231}
SIMPLE CONTINUED FEVER.
BY JAMES H. HUTCHINSON, M.D.
DEFINITION.--A continued, non-contagious fever, varying in duration
from one to twelve days, and in temperate climates almost invariably
ending in recovery. It may arise from any non-specific cause capable
of producing a temporary derangement of one or more of the important
functions of the body, is generally easily distinguished from the
other continued fevers by the absence of the characteristic symptoms
of these diseases, and presents in fatal cases no specific lesions.
SYNONYMS.--Synocha, vel Synochus Simplex, Febricula, Ephemera or
Ephemeral Fever, Irritative Fever, Ardent Continued Fever, Sun Fever.
HISTORY.--Much difference of opinion continues to prevail, even at the
present time, in regard to the existence of a simple continued fever,
which, on the one hand, occurs independently of local inflammations or
traumatic causes, and, on the other, is distinct from typhoid, typhus,
and relapsing fevers; many observers contending that the condition to
which this name is given is only a mild or modified form of one or
other of the graver varieties of continued fever, from which the
characteristic symptoms are absent. Prominently among modern writers,
Dr. Tweedie[1] has taken this view of the subject, for, after
reviewing the arguments for and against the recognition of simple
continued fever as a distinct disease, he asserts that there is not
sufficient evidence to justify us in encumbering our nosology with a
doubtful novelty. If, however, there is room for doubt as to its right
to a place in the list of diseases, there is certainly no good reason
for characterizing it as a novelty, since it has been referred to,
according to Murchison,[2] by many authors from the time of
Hippocrates down to the present day, who not only separate it from the
graver forms of fever, and give a very accurate description of its
symptoms, but seem to have been perfectly familiar with the causes
which give rise to it, and to have had very correct notions as to its
proper management. Thus, Riverius[3] was aware of the existence of two
forms of simple fever--the ephemeral, which lasts, as its name
implies, only a single day, and the Synochus Simplex, arising from the
same causes, but in which the fever continues for from four to seven
days. Strother[4] and Ball[5] also allude to this fever in terms that
leave no doubt upon the mind but that they distinguished it clearly
from other forms of continued fever. {232} Among more recent writers
who have made this distinction may be mentioned Lyons,[6] Jenner,[7]
G. B. Wood,[8] Flint,[9] Murchison,[10] and J. C. Wilson.[11] Indeed,
the weight of authority is decidedly on the side of those who claim
for it a recognition as a distinct and separate disease.
[Footnote 1: _Lectures on the Continued Fevers_.]
[Footnote 2: _A Treatise on the Continued Fevers of Great Britain_,
London, 1873.]
[Footnote 3: _The Practice of Physick, being chiefly a Translation of
the Works of Lazarus Riverius_, London, 1678.]
[Footnote 4: _A Critical Essay on Fever_, 1718.]
[Footnote 5: _A Treatise on Fevers_, London, 1758.]
[Footnote 6: _A Treatise on Fever_, London, 1861.]
[Footnote 7: _Medical Times_, March 22, 1851.]
[Footnote 8: _A Treatise on the Practice of Medicine_, Philadelphia,
1855.]
[Footnote 9: _A Treatise on the Principles and Practice of Medicine_,
Philadelphia, 1868.]
[Footnote 10: _Ibid._]
[Footnote 11: _A Treatise on the Continued Fevers_, New York, 1881.]
Unquestionably, many cases which have been classed under the head of
simple continued fever, are really mild or abortive cases of typhoid
or typhus fever, in which, in consequence of partial protection on the
part of the patient, the characteristic symptoms of these diseases
have not been developed. Such cases are seen in numbers during
epidemics of these diseases. But, making due allowance for this source
of error, there yet remain many cases which cannot be thus explained.
Moreover, the disease occurs at times when no such epidemics exist. It
may, therefore, be safely assumed that there is such a fever, and
that, consequently, it must be accorded full recognition.
CAUSES.--Any non-specific cause which is capable of producing a
profound derangement of one or more of the important functions of the
body may give rise to simple continued fever. It may follow,
therefore, upon excesses of the table, extreme mental or bodily
fatigue, exposure to the direct rays of the sun, or to great heat or
cold, or upon the suppression of a secretion. One of its most frequent
causes is over-exertion in warm weather. James C. Wilson has called
attention to its frequent occurrence as a consequence of the combined
influence of the excitement, the physical exhaustion, and the exposure
to the direct rays of the mid-day sun which are attendant upon
surf-bathing. It is often due in young children to the irritation
involved in the process of teething or to that caused by the presence
of worms in the alimentary canal. Wood taught that it might also
sometimes occur during the prevalence of contagious diseases as an
effect of the epidemic influence in those who were partially protected
by a previous attack of the disease, or from some other cause, but it
is more probable that cases arising under these circumstances are
either mild cases of the prevalent disease or else are attributable to
fatigue from nursing or to over-anxiety. The disease is more common in
the young than in the old, and in children than in adults--probably
from the greater impressionability of the nervous systems of the
latter.
The causes of the ardent continued fever of the tropics, which is
usually recognized as a form of simple continued fever, do not differ
materially, except in degree, from those of the simpler forms of the
disease; but exposure to the direct rays of the sun would seem to be
especially prone to give rise to the disease in those who are
unaccustomed to the heat of a tropical climate. Robust young Europeans
lately arrived in a warm country are, it is said, peculiarly liable to
suffer from it.[12] It is most common in those parts of India which do
not experience much of the benefit of the monsoon rains, and whose hot
season is not tempered by regular breezes from the sea. It is hence
more frequently met with {233} in inland districts in which the
temperature is high, but in which malaria-generating conditions are
absent.
[Footnote 12: Morehead, _Clinical Researches on Diseases in India_,
London, 1856; also Twining, _Clinical Illustrations of the More
Important Diseases of Bengal_, Calcutta, 1835.]
SYMPTOMS AND COURSE.--Simple continued fever occurs in this country
only as a sporadic disease, and almost invariably ends in recovery; in
tropical climates, however, it may prevail epidemically, and sometimes
presents symptoms of a very grave character. In its mildest form it
not infrequently runs its course in a few hours, and is rarely
prolonged much beyond twenty-four, and is hence called ephemera. It
then usually begins somewhat abruptly with a chill, but in a few
instances this is preceded by feelings of languor and weariness.
Febrile reaction is soon established, and is generally well marked;
the pulse is quick and full, the temperature rises rapidly, and the
face is flushed. The tongue is coated with a whitish fur, the urine is
scanty and high-colored, and the bowels are constipated. Other
symptoms are excessive thirst, headache, restlessness, and
sleeplessness, or, on the other hand, a tendency to somnolence.
Vomiting is not common except in those cases which follow upon an
error of diet, but there is generally some nausea and anorexia.
Muscular pains are also occasionally present, and may give rise to a
good deal of distress. The subsidence of these symptoms is often quite
as abrupt as their onset, the crisis being frequently marked by a
copious perspiration.
In other cases, however, the fever is more prolonged, and the
symptoms, although not differing in kind, are apt to be more severe
than those above detailed. The pulse is often full, hard, and
bounding; the headache throbbing or darting in character; the tendency
to somnolence increases, or gives place to delirium; and the pyrexia
is more marked. Frequently an eruption of herpes is observed upon the
lips and upon other parts of the face, from which circumstance the
disease is sometimes called herpetic fever. Davasse[13] also observed
in a few cases pale bluish spots, not elevated above the surface and
not disappearing under pressure, which are identical with the tâches
bleuâtres sometimes seen in typhoid fever and other diseases, and
therefore have no diagnostic value. In this form the duration of the
disease may be from four to ten or twelve days. The defervescence is
usually less rapid than the rise in temperature, and is generally
accompanied by a free perspiration, diarrhoea, a copious deposit of
urates in the urine, or less frequently by hemorrhage from the uterus
or rectum,[14] or from the nose, mouth, or urethra. This constitutes
the synocha or inflammatory fever of the older writers. In children in
whom there is no reason to suspect malarial poisoning the disease
sometimes assumes a remittent form, and then constitutes a variety of
the infantile remittent fever of authors--a name, however, which, it
must be remembered, has been made to include a great many distinct
diseases.[15]
[Footnote 13: Quoted by Murchison.]
[Footnote 14: Murchison.]
[Footnote 15: Lyons.]
When the disease occurs in individuals who are broken down in health
from any cause[16]--as, for instance, previous illness, deficient
food, long-continued anxiety, or great fatigue--it not infrequently
presents symptoms of an asthenic character. The febrile reaction is
then less intense, and the pulse feebler and more frequent, than in
the variety just described. The duration of the disease in this form
is also generally longer. Murchison has proposed for it the name of
simple asthenic fever.
[Footnote 16: Wood.]
Under the name of ardent continued fever, Indian medical writers have
described a variety of the disease which is frequently met with in
tropical {234} countries, and which is usually much more severe than
the varieties already referred to. In addition to the symptoms
presented by these, Morehead[17] says that there is often intolerance
of light and sound, contracted and subsequently dilated pupils,
ringing noises in the ears, anxious respiration, pains in the limbs
and loins, and a sense of oppression at the epigastrium. The bowels
are sometimes confined; at others vitiated bilious discharges take
place. The tongue is white, often with florid edges, and the urine
scanty and high-colored. At the end of from forty-eight to sixty hours
the febrile phenomena may subside, the skin become cold, and death
take place from exhaustion and sudden collapse. In some cases the
symptoms of cerebral disturbance are greater in degree, and in these
coma may soon supervene upon delirium. Convulsions, epileptiform in
character, with relaxation of the sphincters and suppression of urine,
also frequently occur, and occasionally cerebral hemorrhage. In other
cases the symptoms of gastritis are more prominent, or jaundice may
appear and aggravate the disease.
[Footnote 17: _Clinical Researches on Disease in India_, London, 1856.
See also "Croonian Lectures," by Sir Joseph Fayrer, _Brit. Med.
Jour._, April 29, 1882.]
Symptoms closely resembling those just described are occasionally met
with in this country in patients who have been exposed for some time
to the direct rays of the summer sun, but who have escaped a
sunstroke. Indeed, a few writers have been so much impressed with the
general resemblance which this latter condition bears to the fevers
that they have insisted upon including it in this group, and have
given it the name of thermic or heat fever. This view of the pathology
of sunstroke has, however, never been generally accepted.
One of the most characteristic symptoms of the disease in all its
forms is the rapid rise of temperature, which may in ephemera be as
great as from four to seven degrees in the course of a few hours, and
which may be followed in a few hours more by an equally abrupt
defervescence. When the fever is more prolonged, although the
temperature rises rapidly, it may not attain its greatest elevation
for from forty to sixty hours after the onset of the symptoms, and its
fall will be more gradual than in the preceding variety.
Unfortunately, there are no reliable thermometric records of ardent
continued fever. The urine is usually scanty and high-colored during
the height of the fever, especially in the severer forms of the
disease. Its specific gravity is high, and it contains a large amount
of solids, especially of urea. With the fall of the temperature it
rapidly increases in quantity, and is very apt to let fall a copious
lateritious sediment on cooling. According to Parkes,[18] who closely
observed six cases with the view of determining this question,
albuminuria does not occur at any stage of the disease. Convalescence
is usually rapid, and is not liable to be interrupted by the
occurrence of sequelæ.
[Footnote 18: _The Composition of the Urine_, by Edmund A. Parkes,
M.D., London, 1860.]
DIAGNOSIS.--The diagnosis in those cases of simple continued fever in
which the connection between the disease and some one of the
conditions which have been referred to above as capable of exciting it
has been distinctly made out, presents little difficulty. It is
otherwise, however, when this relationship is not apparent. Indeed,
the symptoms of the disease so closely resemble those of an abortive
or mild attack of typhoid or typhus fever, in which the characteristic
eruption is wanting, that the {235} physician may sometimes remain in
doubt as to the nature of the disease he has been called upon to
treat, even after the recovery of the patient. This difficulty will of
course be especially likely to present itself during the epidemic
prevalence of these diseases. Simple continued fever may, however,
generally be distinguished from either of the latter by the much
greater severity of its initial symptoms, and particularly by the
rapid rise of temperature--a rise of from four to seven degrees in the
course of a few hours--which does not take place in these fevers, but
which, it must be remembered, may occur in erysipelas, measles,
pneumonia, and some other diseases. The absence of a characteristic
eruption, although it would not render it certain, would be in favor
of the diagnosis of simple continued fever, as would also the absence
of diarrhoea in cases in which there was difficulty in deciding
between this disease and typhoid fever. On the other hand, Murchison
regards the presence of an herpetic eruption on the lips as almost
pathognomonic of simple continued fever; but in this country such an
eruption is not an infrequent attendant upon fevers of malarial
origin, and many observers attach great importance to it in the
diagnosis of these diseases.
Simple continued fever is not likely to be mistaken for relapsing
fever, except during epidemics of the latter disease. It may be
discriminated from relapsing fever, the first paroxysm of which it
closely resembles, by the absence of severe articular pains, of
tenderness in the epigastric zone, of enlargement of the liver and
spleen, and of jaundice. It may be mistaken for tubercular meningitis,
especially in those cases in which the nervous symptoms are more than
usually prominent, or in which a hereditary predisposition to
tuberculosis exists; but its true nature may generally be recognized
by its more abrupt commencement, and by the absence of the constant
vomiting, screaming fits, strabismus, and paralysis so characteristic
of the latter disease.
It is scarcely necessary to add that a local inflammation or a
traumatic cause may give rise to symptoms simulating those of simple
continued fever, and that the diagnosis of this disease must be
uncertain until these conditions have been positively ascertained to
be absent, or, if present, until they have been proved to be
complications, and not the causes of the disease.
PROGNOSIS.--The prognosis of this disease, as it is met with in this
country, is favorable. Indeed, when uncomplicated it may be said to
end invariably in recovery, except in the aged and feeble, in whom,
when it occurs during the great heat of the summer season, it is apt
to assume the asthenic form, and to be accompanied by symptoms of a
grave character. The ardent continued fever of the tropics, on the
other hand, not infrequently terminates fatally, or may leave the
sufferer from it a chronic invalid for life, which is frequently
shortened by obscure cerebral or meningeal changes, which give rise to
irritability, impaired memory, epilepsy, headache, mania, partial or
complete paraplegia, or blindness.[19]
[Footnote 19: Sir Joseph Fayrer, K.C.S.I., M.D., F.R.S., _Brit. Med.
Jour._, April 29, 1881, p. 607.]
ANATOMICAL LESIONS.--Death so rarely occurs in this latitude from
simple continued fever that the opportunities for making post-mortem
examinations do not often occur. There are, however, a sufficient
number of such examinations on record to show that the disease gives
{236} rise to no specific lesions. According to Murchison and
Martin,[20] inspection in fatal cases of ardent continued fever
usually reveals the presence of great congestion of all the internal
organs and of the sinuses of the brain and pia mater, of an increased
amount of intracranial fluid, and occasionally of an effusion into the
abdominal cavity, and more rarely into the thoracic cavity.
[Footnote 20: _The Influence of Tropical Climates on European
Constitutions_, by James Ranald Martin, F.R.S., London, 1856.]
TREATMENT.--In the milder forms of the disease little or no treatment
is required--a fact which seems to have been recognized and acted upon
long ago, since Strother remarks that the cure of it is so easy that
physicians are seldom consulted about such patients. An emetic when
the attack has been caused by excesses of the table, and there is
reason to believe that there is undigested food in the stomach, a
purgative when constipation exists, and cooling drinks, the
effervescing draught or some other saline diaphoretic, are usually the
only remedies that are called for. In cases in which the febrile
action is more intense and prolonged, in addition to the use of these
remedies an effort should be made to reduce the heat of the skin and
the frequency of the pulse by sponging with cold water and by the
administration of digitalis and aconite. The headache which is often a
distressing symptom may usually be relieved by the application of
evaporating lotions, and restlessness quieted by the bromides.
Subsequently, quinia may be given with advantage. The patient should
be restricted to liquid diet during the continuance of fever.
In the asthenic form quinia and the mineral acids, nutritious food,
and very frequently alcoholic stimulants, must be given from the
beginning. In the treatment of the ardent continued fever of the
tropics the cold affusion or the cold bath, with quinia, would appear
to be indicated, but Morehead and other Indian physicians advise the
use of evacuants with copious and repeated venesections, cupping, and
leeches, aided by tartar emetic, till all local determination and the
chief urgent symptoms are removed; and Murchison expresses the belief,
founded on his own observations, that life is often sacrificed by
adopting less active measures.
{237}
TYPHOID FEVER.
BY JAMES H. HUTCHINSON, M.D.