the eruption being the first thing to show the existence of rötheln in
the system. On the other hand, in a certain proportion of cases there
will be present for a half day, or even longer, the general symptoms
of malaise, such as slight nausea, some sore throat, pain in the
limbs, stiffness of the neck, etc. Vomiting is generally absent. J. L.
Smith records one case of convulsions in the stage of invasion, and I
have notes of a single case in which the prodromal stage was initiated
by mild delirium and fever, the latter anticipating the eruption for
two days and a half, and disappearing when the rash came out. As
Thomas well observes, however, such cases are anomalous, and indicate
either abnormal sensibility on the part of the patient or are due to a
secondary rötheln.
Most observers (Emminghaus, Thomas, Smith, Squire) describe the rash
as coming out in the order usual in measles--namely, first upon the
face, scalp, and neck, then the trunk and arms, and finally the legs.
Others (Liveing, Morris) have stated that the rash first appears upon
the back and chest. In many cases in my own experience this has seemed
to be true. It is quite probable that the situation of the exanthem in
rötheln, as in measles and scarlatina, may present various
irregularities; but I am inclined to believe that a careful
investigation will in most instances show that the normal course of
the eruption is as first stated. Now, a marked characteristic of the
rash of rötheln is that, unlike that of measles, there is no period,
however short, in which its maximum is simultaneous over the whole
body; on the contrary, the eruption will have reached its full
development upon the face, and will be almost or quite faded again,
before the exanthem, for example, will have blossomed upon the trunk,
and especially upon the lower extremities. The duration of the
eruption upon individual parts of the body is probably from a few
hours to half a day at most (Thomas). A consideration of these facts
explains, according to Emminghaus, how different observers have
described the eruption as having its seat upon this or that region of
the body; in other words, it is probable that in a certain proportion
of the cases in which the rash was supposed to have begun on the chest
it had already run its course upon the face. The eruption usually
continues altogether about four days, sometimes disappearing sooner,
and sometimes being visible, especially as a fine mottling, for some
days longer. So far as the individual lesions of the eruption are
concerned, there is no question that they present, within a certain
range, varying aspects; and this clinical fact has been taken
advantage of by the opponents of the idea of specificity in order to
make it appear that the disease is not sui generis, inasmuch as it
lacks uniformity of expression. Such an argument wants force when we
consider that in making up a given diagnosis we lay stress {586} not
upon special, but upon the ensemble of, symptoms. For example, no one
would deny to measles an independent position because the eruption, as
is well known, may assume this or that form (morbilli lævis, m.
papulosi, etc.); on the contrary, we recognize a particular case or
series of cases to be measles from a due appreciation of all the
symptoms present. So it is to be expected that while the cutaneous
lesions will present a certain similarity of feature, as they do,
there will also exist minor differences in detail.
In the greatest number of cases in my own experience the exanthem is
composed of ill-defined, roundish, punctate macules, without special
grouping. These are usually discrete, but in certain situations they
may coalesce. The color is of a pale rosy red, quite difficult to
describe, but less purplish than in measles, and not so livid a red as
in scarlatina. I have occasionally observed large irregular spots not
unlike those of measles.[7]
[Footnote 7: According to Emminghaus (_op. cit._, p. 345), the
eruption generally forms roseolæ of pin-head, lentil, or small bean
size. They are mostly round, sometimes oval, and bordered by
well-defined or by blurred edges. The intervening skin is not always
unchanged, for here and there we find upon it small dilated
blood-vessels, and from the spots processes extend with a certain
regularity to other spots in such a way as to give the skin a marbled
appearance.]
Thomas distinguishes three types of eruption--one with large spots,
which is rare; one with medium-sized spots; and one with small spots.
Emminghaus describes a discrete and a more confluent variety. I have
observed one case where the maculæ on the back had undergone a
vesicular transformation. Others have mentioned this occurrence.
Itching of the skin is marked in some cases, and a fine desquamation
is observed after the rash, but by no means invariably.
The mucous membranes are implicated to a slight degree in rötheln, but
the amount of involvement varies considerably. In some cases that I
have observed the catarrh of the mucous membranes has been barely
appreciable. As a rule, however, the eyes are somewhat suffused, and
there is slight lachrymation and photophobia. Sneezing may be noted,
but there is little discharge from the nose. Sore throat is not
uncommon, perhaps the most constant feature, and, according to
Liveing, is apt to persist after the subsidence of the rash. The
fauces are injected, and the tonsils are red and swollen, but with no
evidence of ulceration. J. Lewis Smith and others state that the
buccal mucous membrane shows a more or less diffuse patchy and spotted
redness. The tongue may be, and usually is, covered by a white fur,
through which protrude a few enlarged red papillæ. There may be slight
cough. Loeri[8] describes the mucous membranes of the pharynx, larynx,
and trachea as presenting a spotted or uniform hyperæmia. There is no
marked participation of the intestines in the catarrh. Some few
writers have noted a transient albuminuria, but it is safe to say that
such cases are entirely anomalous, if not, indeed, in some instances,
examples of mistaken diagnosis.
[Footnote 8: _Jahrb. f. Kinderk._, xix. Bd., 1 Heft.]
A very constant feature is the swelling of the lymphatic glands of the
neck, especially those back of the sterno-mastoid; the swellings may
come on before the rash appears. In all the cases that have fallen
under my notice this symptom has not been absent in a single instance.
Less constantly, and it would seem in proportion to the development of
the rash, engorgement of the glands may be noted elsewhere.
{587} There is but slight disturbance of the temperature in rötheln,
and when it does occur it is usually limited to the first few hours of
the eruption. This has been the rule in my observation, and certainly
holds good for the majority of cases. In a minority, varying degrees
of fever may be present; thus, the temperature may reach 102° F. or
103° F., and then rapidly sink by the second day of the disease, or,
having fallen a degree, it may continue at this point till the
subsidence of the rash, or, it is said, may retain its initial height
till the end of the disease. During the following week Squire states
that the temperature may be readily disturbed--either elevated by
exertion or depressed by fatigue or chill. A relapse or recrudescence
of the rash may be looked for at this time.[9]
[Footnote 9: Cheadle (_Trans. Internat. Med. Congress_, London, 1881)
has reported an epidemic of rötheln of a very severe type, all the
symptoms of the disease as ordinarily recognized being very much
exaggerated.]
COMPLICATIONS AND SEQUELÆ.--In the vast majority of cases neither
complications nor sequelæ have been observed in connection with
rötheln. J. Lewis Smith has recorded instances of diphtheritic
inflammation as a complication, which, however, as he justly remarks,
may, when prevalent, attack any inflamed surface. Pneumonia and
bronchitis have been occasionally reported as complicating or
following rötheln. Liveing and Duckworth mention albuminuria, but, so
far as I know, they are alone in this experience. I have known
otorrhoea and ciliary blepharitis to occur as sequelæ. It would not be
a matter of surprise that in weakly children various chronic ailments
should be set up by rötheln, as by any other disturbance of the
general health.
DIAGNOSIS.--There is no other disease which so much resembles rötheln
as measles. Especially is this true of atypical cases occurring
sporadically. In rötheln the whole course of the disease is much
milder than in measles, the incubation is longer as a rule, and the
fact of a previous attack of rubeola is of much importance, since we
know that recurrences are very rare. In measles there is a prodromic
period, having a characteristic temperature curve, and presenting
pathognomonic catarrhal symptoms, which precedes the eruption for
three or four days; in rötheln the appearance of the rash is often the
first sign of the affection. The sore throat of rötheln resembles that
seen in scarlatina more than the angina of measles, and the general
catarrhal implication of the mucous membranes, so marked a feature of
measles, is either absent in rötheln or exists to a very trivial
extent. Measles is essentially a febrile disease, having a peculiar
type of fever; rötheln may run its whole course without appreciable
rise of temperature. As will be seen in the preceding pages, the
development and progress of the exanthem of measles differs materially
from that witnessed in rötheln. In measles the lesions are larger,
more vivid, more angular and indented, more frequently provided with
processes, and therefore more apt to assume the crescentic
arrangement, than in rötheln. Finally, it must be urged that the tout
ensemble of the case should be taken into consideration, and not some
special feature of the skin eruption.
The incubation period of scarlet fever is much shorter than in
rötheln, and all of the constitutional symptoms are, as a rule,
infinitely graver. In scarlatina there is a febrile invasion stage of
twenty-four hours; in rötheln, if fever is present at all, it is most
generally simultaneous with {588} the rash, and rapidly disappears,
while in the former it persists for a number of days longer. Vomiting
is common in scarlet fever, rare in rötheln. In scarlet fever the
lymphatic glands are notably involved at the angles of the jaw, in
rötheln at the sides and back of the neck. Sore throat is a feature
common to both scarlet fever and rötheln, but it is very much less
marked in the latter. Thomas[10] says that in scarlatina only the
posterior parts, the uvula, the arches of the palate and their
vicinity are affected, while in rötheln the anterior parts are also
affected, and both in much the same degree. In scarlet fever the rash,
which mostly begins on the neck and chest, is made up of large patches
formed of minute red spots on a bright-red hyperæmic base; in rötheln
the eruption is composed of roundish pea-sized macules, with normal
integument intervening. In cases of doubt--for example, when the rash
of rötheln consists of very small spots which have become
confluent--the further development and persistence of the scarlatinal
efflorescence, the temperature, the pulse, the angina, and the
character of the desquamation must be taken into consideration. The
complications and sequelæ are very different in the two diseases.
[Footnote 10: Article "Scarlatina," _op. cit._]
The symptomatic eruptions of the skin which pass under the name of
roseola bear no resemblance to rötheln. They usually occur as the
result of some trivial derangement of the system or in the course of
some primary affection. They are not contagious, the lymphatic glands
and the mucous membranes are not involved, and the rash is quite
different in character.
PROGNOSIS.--The prognosis of simple uncomplicated rötheln is
invariably good. Complications arising in delicate children
necessarily affect the prognosis, as would any other disturbance of
the general health.
TREATMENT.--Simple cases of rötheln require no treatment, as the
patients are rarely sick enough to be confined to bed. Graver forms of
the disease must be met by such measures as are indicated by the
symptoms present. The after-management must be conducted on general
principles having reference to the previous and present condition of
the person attacked.
{589}
MALARIAL FEVERS.
BY SAMUEL M. BEMISS, M.D.
In the medical nomenclature of this country the term malaria is
synonymous with swamp or ague poison.
Malarial affections, therefore, comprise all those diseases or morbid
manifestations which the swamp poison produces in the human organism.
This article is not designed to notice in a systematic manner any of
these disorders which are not properly classifiable under the head of
malarial fevers. It will, however, be necessary to make such
references to the pathology of chronic malarial toxæmia as may serve
to explain the influence this condition exerts in occasioning
departures from type in the febrile attacks.
When a poison generated outside the human system obtains admission to
it, and produces deleterious effects, three questions naturally arise:
What is the essential character and natural history of this noxious
agent? How does it obtain access to the human system? What is its mode
of action when received?
In reference to the first of these questions, it must be admitted that
the substantive essentiality of the malarial poison remains as yet
undemonstrated. It is true, however, that the attempts at an objective
study of this poison by means of the microscope and the cultivating
retort point to the conclusion that it is an organism.
Its subjective or analogical study affords quite incontestable
evidence in support of this conclusion. The leading features in the
natural history of malaria are closely coincident with those of
certain known organisms. It requires for its production suitable
conditions of moisture, temperature, and a properly circumstanced
breeding-place. Within certain bounds these conditions are requisite
to the life and perpetuity of all organisms.
Again, when all the above-enumerated conditions correspond apparently
in the most favorable degree, their continuous concurrence for a lapse
of time is necessary before the poison manifests its presence. It is
not improbable that this period of development may differ in different
climates, but in this country we assume it to be about thirty days. If
these facts related to some noxious organism visible to the eye, no
doubt would be entertained that the presence of its germs in the
places where it appeared was the indispensable condition. It would
then follow that the concurrence of suitable meteorologic and telluric
conditions with sufficient time for its growth and maturity were
merely accessories to its perfect development. According to this
theory, the coincidence of five circumstances is necessary before
malaria can be fully matured--viz.: Its own {590} specific germ;
suitable soil or pabulum; suitable moisture; suitable temperature;
sufficient time for its growth and development.
Certain physical qualities which pertain to the malarial poison can
also be profitably made points of subjective study. These are very
closely connected with the answer to the second question, or "How the
malarial poison obtains access to the human system." They will
therefore be briefly noticed in relation to the instrumentality of
each in conveying malaria into the system.
The first to be mentioned is ponderability, which the following facts
prove that malaria possesses:
Those different atmospheric states which affect the range of diffusion
of known air-borne yet ponderable substances exert similar influences
upon the malarial poison.
Altitude illustrates the ponderability of malaria by powerfully
retarding its diffusion.
High readings of the barometer favor its aërial dissemination.
Fogs, smoke, dust, or floating particles presumably more buoyant than
this poison may exert greater or less influence in overcoming the
obstacle which ponderability attaches to malaria as an air-borne
agent.
Currents of air passing continuously and steadily in one direction
over the breeding-places of malaria increase the limits and intensity
of toxic range.
The atmosphere is undoubtedly the medium by means of which malarial
poison is most frequently brought into the human system. Liability to
intoxication is increased in direct ratio to the proximity of points
of exposure to places of development; to similarity of level; to
situation in the line of prevailing winds which have traversed the
breeding-ground; and, lastly, to the extent and fertility of the
locality of production.
Whether malaria passes through the respiratory apparatus directly into
the circulation, or is lodged upon the fauces and absorbed through
some other surface, is not clearly ascertainable. It is certainly not
deprived of its noxious qualities by stomach digestion, and therefore,
sometimes at least, may reach the blood through the alimentary canal.
Malaria is miscible with water. It is capable of being carried by
currents of water through distances and periods of time altogether
undetermined, without losing either its toxic effects or, perhaps, the
faculty of reproduction. It is more than likely that this means of
conveyance has effected its distribution to continents and islands too
widely separated to justify a belief that it was wind-wafted. No
observations need be adduced to establish the water-borne habit of the
malarial poison, or the positive liability to its toxic effects when
received into the stomach through this medium. These facts have been
well understood from the time of Hippocrates.
The matter of communicability of malaria by means of drinking water
should not be dismissed without some allusion to the great probability
that other fluids or solids are open to a similar charge. There is a
widespread popular prejudice, especially notable in the southern part
of the United States, that drinking milk occasions attacks of the
endemic fevers. It is the usual custom to pour the evening supply of
milk into broad uncovered pans, and allow it to remain exposed in the
open air for {591} consumption at the morning meal. This viscid fluid,
so tenacious of ordinary air-borne particles, may well be suspected of
entangling sufficient quantities of swamp poison to produce sickness
if exposed where it is rife during a whole night.
A similar popular prejudice exists in regard to the muscadine grape,
which flourishes best in swampy localities. The rough skin of this
fruit, frequently covered with its own juice, offers favorable
conditions for the adhesion of air-borne particles.
The malarial poison is not reproduced within the human system. This
proposition is undeniable, since no intensification of the poison is
produced by any degree of crowding of the sick which can be practised;
neither do any conditions of contact with the sick ever impart
malarial affections.
Malarial poison is specific. This allegation is sufficiently
established by its specific effects on the human economy. There is no
other agent known which is capable of originating morbid phenomena
characterized by such marked diurnal periodicity.
It is not interchangeable with other specific poisons. This statement
may be rested upon all fairly collected clinical observations.
There are no facts which justify the belief that malaria is capable of
becoming mixed in the atmosphere, or outside the system, with any
other specific morbific germ, so as to produce a third something which
may give rise to compound forms of disease.
The answer to the second question which is best supported is, that the
malarial poison is brought into the system principally by breathing an
atmosphere impregnated with this miasm.
It is also ingested by being held in suspension in fluids used as
drink or food; perhaps also by eating certain fruits or vegetables in
their natural state whose external surfaces afford favorable
conditions for its lodgment.
MORBID EFFECTS AND PHENOMENA WHICH FOLLOW ITS INTRODUCTION INTO THE
HUMAN SYSTEM.--The discussion of the morbid process established by the
malarial poison involves some difficult problems. A period of
incubation must be admitted to follow the inception of the ague germs.
But this period has no definitely marked limits. Perhaps it is a
shifting one, according to the quantity or quality of the poison
received, or the sudden or gradual manner in which it is received, or
the state of receptivity of the system.
Certain facts seem to indicate very clearly that malarial poison is
very slowly removed from a system which has been brought under its
influence. These evidences of long systemic residence of the poison
are principally displayed in those attacks which occur after long
periods of removal from any surrounding where intoxication was
possible. Vernal attacks may be classed in the same connection. In
many instances the subjects of these long-delayed attacks have never
suffered a paroxysmal seizure, and yet when some accidental
derangement of health occurs, as from a fit of indigestion or a sudden
wetting, they fall sick with one or another form of malarial fever.
It does not appear to me that we are justified in assuming that such
attacks as I refer to are to be ascribed to secondary changes produced
in either the fluids or solids of the system by the malarial poison.
In so {592} far as the clinical phenomena are worth anything in
demonstrating the presence and agency of the specific malarial poison
in these deferred attacks, they are precisely similar to those
observed in paroxysms arising after a few hours' or a few days'
exposure to marsh miasm.
But we find further proofs of the long-continued and silent manner in
which malaria exerts its pathological influences in those enlargements
of the spleen which occur without specific attacks of sickness. The
alterations of nutrition in this organ are so characteristic of
malaria that they can scarcely be supposed to depend upon those
chances which determine the nature of secondary blood-impurities.
Intermittent Fever--Simple Forms.
The clinical phenomena of intermittent fevers afford strong support to
the opinion that this type of malarial attacks illustrates more
strongly than any other the primary influence of the poison upon the
human system. Fits of ague often occur very shortly after exposure in
infected localities, and the persons thus suddenly attacked may
present little or no evidence of cachexia before or after the
paroxysm. Indeed, they frequently resume their ordinary avocations
after the paroxysms, apparently as well as if they had not occurred.
It is therefore my opinion that the pathology of an intermittent fever
does not necessarily involve an hypothesis that the attacks are the
results of certain changes which the poison undergoes after its
inception, nor, on the other hand, that certain perversions of
systemic chemistry are required to inaugurate the paroxysms.
In accordance with these conclusions, it seems likely that the
phenomena of intermittent malarial fever result from the primary
effects of its specific poison exerted directly upon the fluids and
solids of the system, and disturbing their functions, and especially
the nerve-function.