of a copartnership in which each member exerts equal influence. It is
well understood that when two diseases coincide, that one which is
more violent or excessive in its morbid process holds so much sway as
in some cases almost to extinguish the symptoms of the weaker member
of the combination. Consequently, in typho-malarial fever, the
typhoid, being the graver of the two forms of disease, ordinarily
rules the pathology.
The following notes, accompanied by a temperature chart, will
illustrate the clinical course of a case of typho-malarial fever:
J. L., aged thirty years, of French nativity, but a resident of New
Orleans for three years, was admitted to Ward 21, Bed 311, Charity
Hospital, on the night of December 10, 1881. Had been ill some days
with ague. The house-surgeon administered gr. x. of quinia in solution
and gtt. xv. of tincture of opium.
The records and temperature date from the 12th of December. During the
11th he took drachm ij sulph. cinch. in solution.
{617} [Illustration: FIG. 24. PART I., showing the temperature-curve
from December 12th to 31st, inclusive, during which time the more
characteristic typhoid symptoms predominated. PART II., showing the
temperature-curve in same case from January 1st to 20th, inclusive,
during which the influence of the associated malarial poison was
prominent.]
Dec. 13th, tenderness and gurgling in ileo-cæcal region; epistaxis;
rose spots on abdomen; deafness and ataxia; no stools since 11th.
Ordered
Rx. Acid. Sulphuric. dil.,
Syr. Aurantii Cort. _aa._ fl. drachm ij;
Tinct. Cinchonæ Co. fl. oz. j. M.
S. Teaspoonful in water every four hours.
Also ordered beef-essence, milk-punch, and milk.
Dec. 13th, two very offensive liquid stools; ataxia greater; skin
yellow and countenance dull and listless. Dec. 14th, fresh rose spots;
tongue brown and dry; three stools; much jactitation. Dec. 15th, more
ataxia; some delirium; pulse 100, weak. Gave gr. iiss quinia in
solution, with tincture opium gtt. iii, every two hours. Dec. 16th,
pulse 128, weak; delirious. Dec. 17, new rose spots; belly tympanitic;
tongue brown, dry; sordes on teeth and lips; eyes injected; very
delirious. Treatment continued; nutrition and stimulants given
methodically. From 17th to 22d but little change in condition or
treatment. Diet and stimulants administered regularly. Dec. 22d, coma
vigil; completely delirious. Ordered
Rx. Liq. Morphiæ Sulph.,
Tinct. Digitalis _aa._ fl. drachm iij;
Spts. Æther. Nitrosi fl. drachm ij;
Liq. Potass. Citrat. fl. oz. iij. M.
S. Tablespoonful every three hours.
As the oscillations of temperature became more marked, quinia was
resorted to, apparently with good effect. The patient was discharged
from the hospital Feb. 8, 1882.
It should be observed that after the 14th of December the patient's
bowels were rather costive, and the stools occasionally moulded and
very {616} dark in color. On the forty-fifth day after admission the
patient had a severe chill, followed by a rise of temperature to 104°.
This yielded to competent doses of sulphate of cinchonidia.
This was a typical case of typho-malarial fever. The blended symptoms,
as well as those special to each disease, are sufficiently exhibited
in the clinical account. The presence of typhoid fever was established
by the rose spots and the marked nervous symptoms. The typhoid process
seems to have been unusually mild in so far as evidence of bowel
lesions were made manifest.
The history of the patient before admission, the color of his skin and
stools, and the temperature curves gave abundant proofs of the
malarial element in the pathology of the case.
Perhaps nothing need be added on the subject of diagnosis. I may,
however, remark that I am very cautious in asserting the diagnosis of
typho-malarial cases unless the nervous symptoms, positively-marked
bowel symptoms, or rose spots are present to vindicate such a
decision. The presence of malarial poison may be determined with less
difficulty from the previous history of the case and its special
symptoms in the early stages of an attack. But if the morbid processes
of the typhoid poison are violent, there are likely to be stages of
the disease when it is not possible to detect symptoms which indicate
the presence of malaria. On the other hand, it is unquestionably true
that the typhoid condition, as it is termed, which so often
complicates malarial fevers, can very generally be differentiated from
true typhoid fever. While certain cases, or even epidemics, of
malarial fevers are attended by remarkable adynamia, often manifesting
itself from the very incipiency of attacks, it differs widely from
that utter nervous ataxia which characterizes typhoid fever. Again,
the adynamia of malarial attacks is generally ascribable to some cause
not essential to those affections. Imperfect reaction from a chill,
long persistent hyperpyrexia, diarrhoea or vomiting, or chronic
paludal cachexia, or, it may be, some epidemic influence, may produce
it. The ataxia of typhoid fever is part of its morbid process.
Woodward's statistics show that 49,871 cases of fever diagnosed as
typho-malarial occurred among the white forces of the United States
during the late Civil War. Of this number, 4059 proved fatal, a
mortality-rate of 8.13 + per cent. Among the colored troops 7529 cases
occurred, with 1301 deaths, a mortality-rate of 17.27. Statistics
borrowed from the same excellent authority give the number of cases of
unmixed typhoid fever (or fever classed as typhoid without reference
to any complication) as 75,368 among the white troops, with 27,056
deaths, a mortality-rate of 35.89. Among the colored troops 4094 cases
occurred, and 2280 died, a mortality-rate of 55.68. These figures show
very singular comparative results. They prove that typhoid fever as an
uncomplicated malady, was four and a half times as fatal among the
whites as the same disease when in combination with malarial poison.
Among the colored troops typhoid fever was three and a half times more
fatal than typho-malarial fever.
It is highly probable that inaccuracies exist in statistics gathered
in the confusion of a great civil war, but I am not prepared to say
that the conclusions they point to are incorrect. When an acute
inflammation is complicated by malaria, its prognosis is rendered more
grave. This, no doubt, {618} is due in part to degradations of the
fluids of the system by the malarial poison, and in part to the
revulsions of circulation during paroxysms. But it does not follow
from this fact that the presence of malaria in the blood, or its
effects upon that fluid, exercise an unhappy influence upon diseases
due to other specific poisons. It may, on the contrary, be ascertained
in the future that it modifies the typhoid process, so as to deprive
it of some of its most dangerous features.
Further investigations are required to determine the facts in regard
to these questions. But it may be premised that if such a conclusion
shall ever be reached, it will influence our expectations of cure
rather than our practice. If the malarial poison is capable of
modifying the toxic effects of the typhoid poison, it must do so in
the very formative stages of that affection, if not in its incubative
period, so that, having accomplished all the good it is capable of
effecting, we may proceed at once to rid ourselves of its presence.
In entering upon the treatment of two diseases compounded in the same
patient, if one should ordinarily be amenable to specific treatment,
it must certainly be wise practice to endeavor to simplify the case by
subtracting that one from its composition. This is more especially
true if the treatment does not affect the course of the other disease
in any injurious manner. It is therefore proper to begin the treatment
of a case of typho-malarial fever by administering large doses of
quinia. A scruple may be given every fourth hour, until its effects in
eliminating symptoms ascribable to malaria, and also as an
antipyretic, have been sufficiently tested. In the early stages of
typho-malarial attacks the febrile exacerbations conform to those laws
of periodicity which govern uncomplicated malarial fevers. After the
first week, or when the typhoid process has become well established,
periodic returns of the fever are less plainly observable. It is
possible that in some cases in which the typhoid process manifests
itself with great severity the temperature curves may be very
characteristic of that disease. I am satisfied that the indications
for giving quinia to eliminate the malarial element must be based upon
the fever curves which mark the case. Perhaps a more frequent
application of the thermometer would often exhibit malarial
periodicity where it may otherwise remain unsuspected. I know this to
be very often the case in pneumonia complicated by a malarial fever.
Whether thorough cinchonism in the early progress of the attack rids
the case of symptoms due to malaria or not, only a very few days are
likely to elapse before oscillations of temperature call for its
repetition.
The typhoid processes require very much the same measures which are
applicable in uncomplicated cases of that disease. The stools of the
early stages of attacks should not be checked unless excessive, and
mercurials and laxatives should be more freely used than in simple
typhoid fever. The effects of the malarial fever and of the
hyperpyrexia of typhoid fever, when combined, must almost necessarily
entail more accumulation of excrementitious material in the blood than
would occur either disease existing separately. On this account
eliminating treatment is an important indication. When it becomes
necessary to check the diarrhoea because excessive or on account of
failing strength, diuretics subsequently prove serviceable.
Effervescing solutions of potassium or ammonium, lemonade, Apollinaris
water, iced tea, strawberry, mulberry, or raspberry juice, are {619}
grateful beverages and increase renal activity. The mineral acids may
be given during the ulcerative periods of the disease. Insomnia must
be relieved by opiates, chloral hydrate, or other hypnotics.
Tympanites should be met by warm stupes, large enemas of warm water
with fl. drachm j tincture of asafoetida or fl. oz. j of whiskey.
Small doses of turpentine in emulsion are often beneficial.
In the early progress of cases the diet should consist of farinaceous
foods, with milk and the pulps or juices of fresh fruits, given either
cooked or in their natural state as the physician may determine for
each patient. Methodical and forced nutrition becomes necessary at
more or less early periods in different cases.
The stools and all ejecta of the sick should be disinfected and
disposed of with the same care and for the same purpose as those of
unmixed typhoid fever.
{620}
PAROTITIS.
BY JOHN M. KEATING, M.D.
The term parotitis is applied to a condition of painful enlargement of
one or both parotid glands, inflammatory in nature, acute in its
course, and usually subsiding by resolution, but sometimes ending in
suppuration. The different methods of termination, together with
certain etiological distinctions, form the basis of a division of the
affection into two sub-classes--namely, 1, idiopathic parotitis; and
2, symptomatic or metastatic parotitis. These demand separate
consideration.
I. Idiopathic Parotitis.
Idiopathic parotitis, parotitis epidemica, or mumps, as it is
variously named, is an acute contagious inflammation of one or both
parotid glands, which usually appears but once in a lifetime, and
which, although by no means limited to children, is commonly met with
between the second year and the age of puberty. In certain exceptional
cases the disease affects the submaxillary glands alone.
NATURE.--The undoubted contagiousness of mumps, with the fact of its
frequently occurring in extended epidemics, entitles it to a place
among the zymotic diseases, from which it differs, however, in the
marked disproportion between the local and constitutional symptoms,
the former being well developed, the latter but slight or altogether
absent.
ETIOLOGY.--While it is more than probable that, like the other
diseases of the zymotic class, mumps is due to a contagium that finds
its way into the body in the inspired air or with the food or drink,
nothing is known of the nature of this infecting principle.
The predisposing agencies are better understood. Age is one of these,
the greater number of cases occurring, as already stated, between the
second and the fifteenth year. Infants at the breast are almost
entirely exempt, and so, too, are individuals advanced in years. In
extended epidemics it is not unusual to meet with cases in adults, but
it will generally be found on careful examination that these patients
have escaped the disease during childhood. Sex exerts some influence,
a much larger percentage of males being attacked than females.
Epidemics appear more frequently in the spring and fall than at the
other seasons of the year, so that cold and dampness of the atmosphere
must be looked upon as predisposing causes. Mumps bears a peculiar
relation to measles, scarlet fever, and diphtheria, epidemics being
apt to occur directly before, during, or immediately after the
prevalence of either of these affections, especially {621} the first.
The popular idea of mutual protection is entirely without foundation.
Certain peculiarities are presented by the disease in its mode of
occurrence and in the duration and intensity of its epidemics. Thus,
some localities are visited annually, others only at intervals of
thirty years or more; again, one epidemic may last but a few weeks and
affect a small number of individuals, while another extends over
months and attacks all the children and many of the adults in the
affected region.
ANATOMICAL APPEARANCES.--The exact pathological lesion in mumps is
obscure, since the trifling nature of the disease and the almost
invariable termination in recovery afford no opportunity for
post-mortem investigation. According to Foerster, who seems to have
made examinations in cases where mumps occurred as one of the
accidental complications of other and fatal diseases, the affected
gland at first becomes hyperæmic, and is then the seat of serous
exudation. It is reddened, swollen, and on section presents a uniform
flesh-like, moist appearance, in place of the ordinary granular
aspect. The tumor is often greatly increased in size by a simultaneous
serous infiltration of the periglandular connective tissue, and
occasionally this tissue alone is involved, the gland itself being
entirely free from lesion. The great point in favor of this view of
the pathology is the rapid and complete subsidence of the parotid
swelling by resolution--a termination to be expected only when the
inflammatory process stops short of suppuration or fibrinous
exudation.
Virchow regards all cases of parotitis as the result of an extension
of a more or less malignant catarrh originally affecting the
gland-ducts. This is undoubtedly true in some cases, but that it is
far from being the rule is proved by the infrequency of parotitis as a
secondary complication of catarrhal affections of the mucous membrane
of the mouth.
COURSE AND SYMPTOMS.--The course of the disease is susceptible of a
division into three stages--a period of incubation, of invasion, and
of actual attack.
The stage of incubation extends over a period variously estimated as
from seven to fourteen days. It is marked by no symptoms, though
sometimes a history of impaired appetite and digestion, irregular
bowels, and languor during the last two or three days may be obtained.
The period of invasion is short, lasting only twelve, or at the most
twenty-four, hours. The patient is pale and languid, has slight
rigors, pains in the breast and head, and loss of appetite; later,
local pain in the parotid region on moving the jaws or on taking acid
liquids into the mouth. The surface temperature increases from hour to
hour, and just before the glandular swelling appears it reaches 100°
or 101° F. In some cases the invasion is characterized by the same
train of symptoms that ushers in the acute exanthemata, such as
repeated vomiting, diarrhoea, restlessness and anxiety, a disposition
to syncope, and, in very irritable children, convulsions. Contrasted
with this violent invasion other cases are met with, in which there
are no prodromes whatever except a gradual rise in temperature,
imperceptible without the use of the thermometer.
The first symptom of actual attack is a peculiar slight stitch-like
pain in one parotid region, usually the left. This radiates toward the
ear of the affected side, and is increased by movements of the jaw, as
in {622} chewing or talking, and by external pressure. The pain
rapidly grows more intense, and soon becomes associated with swelling.
The tumor first appears in the depression between the mastoid process
and the ramus of the jaw, which it fills up, and at the same time
thrusts outward the lobe of the ear. As the gland alone is swollen at
first, the tumor has the outline of a triangle, with the apex directed
downward and forward; soon, however, the connective tissue becomes
oedematous and the swelling is greatly extended, involving the cheeks
and neck, in the latter region, in severe cases, running forward as
far as the median line, downward nearly to the shoulder and backward
toward the spine. The most prominent point is directly in front of the
ear. The oedema also extends internally, involving the pharynx, the
tonsils, and sometimes even the larynx. The skin covering the tumor is
either perfectly natural in color or slightly reddened. The central
portion is firm and elastic to the touch, the periphery doughy, and
pressure here often produces pitting. There is but moderate
tenderness. The swelling reaches its height in three days, remains
stationary for two days longer, and then rapidly declines, the oedema
first disappearing and afterward the glandular swelling, the process
of resolution occupying four or five days and being attended with a
slight desquamation of the cuticle.
While mumps almost uniformly begins on one side, both glands are, as a
rule, affected during the attack. The second tumor begins to develop
twenty-four to forty-eight hours after the first, though its
appearance may be delayed much longer, even until resolution has begun
on the side primarily affected. As the course of the inflammation is
similar in both parotids, the whole duration of the attack will depend
on the time of involvement of the second gland.
Among the other symptoms an alteration of expression is prominent. At
first, the head is inclined toward the affected side; later, when both
glands are involved, it is held perfectly erect, and, as the slightest
movement increases the pain, it is maintained stiffly in this
position. The swelling of the cheeks prevents all play of the
features, and this, combined with widely-open, staring eyes and
increased thickness of the neck, gives the patient a stupid, almost
idiotic, expression. The swelling of the neck is sometimes so great
that its diameter exceeds that of the head, and the shoulders, neck,
and head, viewed together, have the outline of a truncated pyramid.
As any movement of the lower jaw greatly augments the suffering, the
mouth is kept closed, often so tightly that it is impossible to see
more than the tip of the tongue. All efforts at mastication are
suspended, and deglutition is so painful, especially when the tonsils
become enlarged, that the sufferer bears the pangs of hunger and
thirst rather than endure the agony entailed in satisfying his wants.
The act of speaking even augments the pain; the voice, when heard, has
a nasal tone. The acuteness of hearing is impaired, there are singing
noises and shooting pains in the ears, headache, and sometimes, in
extreme cases, symptoms of cerebral hyperæmia due to pressure upon the
cervical veins.
The tongue is heavily coated, the mouth is either dry or there is an
increased flow of saliva, and the fluid dribbling from the mouth adds
another element to the idiotic expression already referred to. There
is loss of appetite, increased thirst, occasionally vomiting, and
commonly {623} constipation. The temperature is elevated and the pulse
increased in frequency, both to a moderate degree. The respiration is
unaffected, except when the oedema has invaded the submucous
connective tissue of the larynx; then the movements are increased in
frequency and difficult.
Throughout the attack the pain, unless intensified by some extraneous
influence, as pressure or the act of speaking or swallowing, is only
moderately severe. In ordinary cases the patient rests quietly and
sleep is undisturbed, unless the tonsils are enlarged, when it is
liable to interruption from loud snoring. When the attack is severe
and in nervous, excitable children there is restlessness,
sleeplessness, and slight delirium at night.
The general symptoms keep pace with the local in their increase, but
they commence to subside before, beginning to disappear while the
swelling remains stationary. As soon as resolution sets in the general
and local improvement are both rapid, and by the end of the week
nothing is left but a trifling weakness and pallor, which disappear in
a few days more, leaving the patient perfectly well.
Besides the ordinary symptoms, mumps in certain instances shows a
peculiar tendency to metastasis, or secondary involvement, of the
testicle and scrotum in males, and the mammæ, vulva, and ovaries in
females. This metastasis occurs much more frequently in males than in
females, and is usually met with in pubescents and adults, being very
rare either in childhood or old age. It generally begins six or eight
days after the appearance of the parotid tumor. The latter, as a rule,
subsides on the occurrence of any of these metastatic affections,
though occasionally the two run a simultaneous course. This
occurrence, together with the fact of the secondary inflammation
appearing at the date on which the parotitis naturally begins to
disappear, tends to support Niemeyer's view, that the two affections
are in reality due to the same cause, and that no true transference of
inflammation takes place from one point to the other. Occasionally,
the parotitis disappears a variable time before the onset of the
metastatic affection; then the interval is marked by grave symptoms of
depression and cerebral disturbance, but there are no proofs of actual
meningeal involvement. In these cases there is, at times, an excessive
elevation of temperature, which may account for the brain symptoms.
The most constant secondary manifestation is swelling of the testicle
proper, or true orchitis; less frequently there is epididymitis, and
with it acute hydrocele and oedema of the scrotum. The orchitis in
most cases is unilateral, the right testicle being affected, just the
opposite to the parotids, of which the left is the one first involved.
When the orchitis is double, both testicles do not become swollen at
once, the one preceding the other by an interval of several days.
The course of the orchitis is very similar to that of the mumps, the
inflammation increasing gradually for from three to six days, then
undergoing rapid resolution, the gland returning to its normal
condition by the end of two weeks.
The local symptoms are swelling, the testicle being enlarged to two or
three times its natural size, dull pain, and moderate tenderness,
while in very severe cases there is burning on micturition and a
purulent discharge from the urethra. The spermatic cord does not
sympathize in the {624} inflammation, and neither the swelling, pain,
nor tenderness is so great as in specific orchitis.
The general symptoms are confined to a moderate elevation of
temperature and increase in the frequency of the pulse, thirst, and
loss of appetite. This fever is separated from that of the parotitis
by an interval of two or three days.