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By REYNOLD W. Wilcox, M. D., New York City, and A. A. STEVENS,
M. D., Philadelphia, Pa.
BY ALFRED STENGEL, M. D., AND D. L. EDSALL, M. D.,
GENERAL CONSIDERATIONS CONCERNING INFECTIOUS
DISEASES. E. Walger 1 in presenting some theoretic considerations concerning the importance of the anatomic changes in acute infectious diseases strongly insists that these alterations should not be looked upon as constituting the disease, but as being the expression of the attempt of the system to rid itself of the toxins, and he especially insists that the truth of this view may be seen in certain cases of pneumonia. He records the case of a man of 29 who was taken ill with an acute lobar pneumonia. He was at once injected with 8 cc. of serum taken from a man convalescing from pneumonia. There was no change in the condition on the next day, but on the second day practically all the subjective symptoms had disappeared, and the temperature soon reached normal and remained so, the man's general condition being outwardly practically that of health. Nevertheless, the lung proceeded to consolidation, which ran its usual course, and resulted in entire resolution. This Walger states is good evidence that the exudation in the lung is merely the method used by the system to rid itself of the toxins. [While we may agree with the author's general proposition, the proof adduced seems rather unsatisfactory.]
W. F. Phillips, in discussing clinical thermometry, insists that uniform methods of taking the temperature should be adopted ; until this becomes general, records should be accompanied by some sign showing whether the temperature was taken in the mouth, axilla, or rectum. He recommends the axilla, and that the bulb of the thermometer should be of the same diameter as the stem, so that the entire bulb will come in contact with the skin of the armpit when the temperature is being taken. The bulb should be placed well up in the apex of the axilla. The mean temperature of normal individuals he finds to be 97.4° F. and the normal range 97° to 98.1° F.
E. v. Czyhlarz 3 studied the effects of high temperature upon the animal organism by puncturing the medullas of 10 rabbits. He i Centralbl. f. innere Med., Dec. 10, 1899. 2 Brit. Med. Jour., Oct. 28, 1899.
3 Centralbl. f. innere Med., July 22, 1899.
examined the kidneys, hearts, muscles, and livers of these animals, particularly to see whether there was fatty degeneration or parenchymatous degeneration. In no instance was either found. He also reports that the blood was entirely normal, and that the specific gravity in particular was investigated, and found to be normal. The latter is of interest, in view of the teaching of some, that there is a hydremia in fever.
A. Lode and A. Durig 1 find that animals, dogs especially, show a decrease in the influence of cold baths upon the temperature when the cold baths are repeated. The fall in the temperature on the first day, for instance, was 420 F. ; on the sixth and seventh days the fall had decreased to 32° F. The cause of this declining influence of cold was not increase in metabolism and the consequent increased heat production, but was lessened heat-elimination. It was an evidence of adaptation to new conditions.
E. B. Holbert 2 describes a curious case of a man of 36 who was thought during life to have probable sclerosis of the brain, but autopsy disclosed no lesion. The case is reported chiefly because of the marked hypothermia, which is said to have reached 81.6° F. when taken in the rectum. After treatment with hot baths the temperature is said to have risen as much as 19.5° F. in 18 hours, but fell again, and remained subnormal until a short time before death, when it rose to 104° F.
A. MacFayden and S. Roland 3 report their experiments concerning the influence of liquid air upon bacteria. They exposed a series of organisms for 20 hours to liquid air, the temperature being from
-183° C. to —192° C., without observing any changes in the virulence of the organisms or in their morphology. The typhoid, colon, diphtheria, proteus vulgaris, lactic acid, and anthrax bacilli, the spirillum of cholera, the staphylococcus, and other organisms were used. Later 4 exposure for 7 days was carried out, the organisms being placed in small hermetically sealed tubes and completely immersed in the liquid air. In spite of the enormous mechanical strain to which the organisms were thus subjected, and exposure to a temperature of -190° C. for 7 days, no alteration was seen in their structure and there was no change observed in their virulence except that they grew a trifle more slowly.
W. Wecksberg 5 gives a very interesting report of some experimental work relating to the influence of chemical counterirritants upon inflammation. Experiments were carried out by shaving the skin of dogs and applying counterirritants, chiefly jodin, croton oil, and mustard. The result of the work was to show the presence of decided edema and infiltration, not only of the skin, but of the subcutaneous tissue, and often of the muscles beneath ; this was most marked after the use of croton oil. There was decided hyperemia of the vessels in the superficial area, and to produce such a hyperemia Wecksberg believes that there would necessarily be compensatory anemia in the sur
1 Miinch. med. Woch., Jan. 23, 1900.
2 Lancet, Jan. 13, 1900. 3 Lancet, Mar. 21, 1900.
Lancet, April 21, 1900. 5 Zeit. f. klin. Med., Bd. XXXVII, Hefte 3 u. 4.
rounding regions. But the more important point in his mind is the edema, which causes direct compression upon the blood vessels of the anderlying parts, and therefore would cause anemia in these regions. He then investigated the actual influence of counterirritants upon local inflammatory processes by producing first aseptic abscesses by injecting turpentine, afterward applying iodin around the areas in some cases, and using others as controls. The iodin regularly influenced the subsequent course favorably, and, if irritation had not been too severe, prevented the formation of abscesses, while in the controls abscesses always occurred. Similar results were obtained after injecting staphylococcus cultures. If the edema causes the chief changes, it seems strange at first that the application of counterirritants relieves pain, as it would be thought that pressure of the edema might cause pain. But Wecksberg explains this by the statement that inflammatory edemas are accompanied by hyperemia, while the edema produced by the local counterirritants is an anemic edema ; also the edema produced by the latter occurs very rapidly and is likely to cause such rapid and severe pressure as to obtund the sensitiveness of the nerves.
Weisbeckerl reports the use of the serum of convalescents from measles, scarlet fever, typhoid fever, pneumonia, and diphtheria in the treatment of these diseases, and especially discusses the method of obtaining and using the serum. In the first place, the patient from whom it is obtained must be decidedly ill, mild cases not being of value. In pneumonia, serum should be taken about the seventh to the ninth day, also the patients should not have been treated by any active medication, and antitoxins should never have been used. He disapproves of
, the use of anodynes, expectorants, etc., as well as antipyretic measures or drugs in the subject of the venesection. In typhoid fever he takes blood on the fourth or fifth day of convalescence. The blood he withdraws into glass vessels, taking about 250 cc. on the average from adults, though more may be taken. It is stood aside, and after 48 hours the serum is withdrawn and placed in glass vessels of 10 cc. to 15 cc. capacity. He does not consider it necessary to add an antiseptic, but it is safer to add a few drops of a 0.5% to 1% solution of carbolic acid. The dose is 10 cc. in adults, 5 cc. in children. The injection usually causes some pain. The use of the serum he considers indicated in all cases except those that are very mild, and it is particularly to be recommended in old persons. It should be given very early in the case. One injection is often enough, but if the symptoms become worse afterward, he performs venesection, and then gives another smaller injection.
H. Davidsohn 2 in order to maintain the heat of cataplasms covers them with an apparatus consisting essentially of a rubber tubing placed upon linen. Hot water is passed through the tube constantly. A mattress similar to this has also been constructed which helps to maintain the body-heat, or may be used for applying heat to the back. 1 Münch. med. Woch., Aug. 9, 1899.
2 Berl. klin. Woch., Jan. 19, 1900.