Eclectic Medicine Part Ia

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PREFACE.

I offer neither apology nor excuse for placing before the professionan oth er P ra ctice of Medicine. Eclecticism ha s won its wa y into th e homesof many thousands, since Wooster Beach and the Fathers taught amore successful way of treating the sick. The methods of the NewSchool are being examined and tested as never before, and men fromall schools are recognizing the efficiency of our splendid materia medica.

In wr iting a New P ra ctice, I do not desire it t o be un derst ood th at mostof the m at erial u sed is n ew, for it is one of the funda men ta l principles ofSpecific Medicat ion (Modern Eclecticism), th a t when once th e r elat ion of

drug action to diseased conditions is found, it is found for all time; thatan agent that will correct a specific condition to-day, will correct thesame condition to-morrow, next year, or a hundred years hence;therefore many of the remedies used twenty-five, thirty, or fifty yearsago, a re u sed to-da y.

We have faith in t he E clectic Pr actice, and t he desire on th e par t of th estudents of our colleges to use a Practice more. modern than the olderEclectic work s on Medicine, one t ha t is u p-to-da te in et iology, pa th ology,description, diagnosis, and tr eat men t, is r esponsible for th e pu blicat ion

of th is work .

The et iology and pat hology must necessa rily be th e sa me in all work s onPractice and this will only materially differ from other works of likecharacter in presenting a treatment that is proving successful in theha nds of more t ha n t en t housand practitioners. I am indebted to a h ostof able workers, who have, at the bedside, tested and proven many ofth e agents used.

To W. B. Saunders & Co., Lea Bros. & Co., The Hahnemann Press, P.

Blakiston's Son & Co., D. Appleton & Co., and P. A. Davis Co., I amparticularly indebted for courtesies shown in the use of illustrations, Ihave endeavored to give explicit credit to each author where referencesar e cited, an d my th an ks a re du e them for favors extend ed.

I t ru st th at th e rea der will find t he t wenty-five years experience of th ewriter, as well as those of his many brother practitioners, a help in



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successfully relieving t he sick.

ROLLA L. THOMAS, M. D.CINCINNATI, O.

February 10, 1906.

PREF ACE TO SE COND EDITION.

The disposal of the first edition within a year has been most gratifyingto the author, and I desire to thank the Profession for the cordialreception of th e work . With th e except ion of a corr ection of min or err ors ,which were overlooked in the hurried preparation of the manuscript, Ihave not found it necessary to revise the second edition. Owing to morerecent knowledge of the transmission of yellow fever, the article on this

disease ha s been rewritten .

While due attention has been paid to the etiology, pathology, anddiagnosis of diseased conditions, the writer believes that the physician'sgreatest success in treating the sick is due to his knowledge oftherapeutics and the readiness with which he is able to apply hisrem edies to diseased conditions. It is along th ese lines t ha t h e is to ma kehis most enduring reputa tion with his patients an d th e public.

An experience of twenty-seven years, coupled with that of thousands of

my fellow practitioner s, ena bles me to present a tr eat men t t ha t is direct,pleasant , and at tended with a m inimum morta lity.

ROLLA L. THOMAS, M. D.CINCINNATI, OHIO.

S eptember 1, 1907.



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INTRODUCTION.

It ma y be well to sta te our position in t he m edical world, for t her e seemsto be a great deal of confusion or ignorance as to what Eclectics teachand practice, the idea prevailing among a large class, that Eclecticismconsists in choosing the best remedies from all the other schools, andwhile this is true to some extent, it applies equally to all schools, forevery conscientious physician has and does exercise the sameprerogat ive, choosing what he t hink s is th e best r emedy.

Choosing the best therefore is not characteristic of Eclectics; neither isthe use of vegetable remedies the distinguishing difference, though wehave been developing a materia medica for the last seventy-five years,till to-day it stands without an equal, and it is not unlikely that we do

use m ore r emedies pr epared from indigenous plant s, tha n oth er schools.

Modern Eclecticism's most characteristic and distinguishing tenet isSpecific Medication. Thirty-five years ago, Dr. John M. Scudder wroteThe medicine of the future will be direct or specific, and publishedthose little masterpieces, Specific Diagnosis and Specific Medication;and Eclectics, recognizing it to be the most rational method ofprescribing, began testing and proving the system, till to-day, tenth ousan d physician s ar e su ccessfully pr acticing Specific Medicat ion.

The prejudice against this system is due to the fact that it is generallymisu nders tood. Eclect ics do not advocat e or a dminist er specific rem ediesfor specific diseases, such as a remedy or combination of remedies forpneumonia, typhoid fever, dysentery, etc., but do prescribe specificremedies for specific pathological conditions.

Every change from the normal, or every pathological condition, givesexpression to such change by symptoms, and experience has proventhat the same pathological change is always expressed by the same setof sympt oms , an d h aving once lear ned to recognize such a cond ition, we

ha ve it for a ll time. Thu s a n excess of hea rt power a s seen in s th enia, isalways expressed by th e full boun ding pulse. Irrit at ion an d excitat ion ofth e cerebra l cent ers in a ll sthen ic conditions, is always evidenced by aflushed face, bright eyes, and contracted pupils. The pallid tongue witha white pasty coating always tells of acidity, while the dry, red tonguealways tells of a lka linity of the blood. So, ofevery deviat ion from h ealth ,each change is expressed by definite symptoms. Now there is a direct



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relation between drug action and disease expression, and having oncelearned this relation or the affinity that a remedy has for a specificcondition, we have learned it for all time. Thus, if veratrum willinfluence the h ear t's a ction to-day, when th ere is a full boun ding pulse,and this is the basal lesion, it will do it under the same conditions to-

morrow, next year , or a hu ndr ed year s hen ce. It will do it in pn eum onia ,in cerebritis, in nephritis, or wherever it is found. If gelsemium.willrelieve irritation of the cerebral centers, as shown by the flushed face,bright eyes, an d cont ra cted pu pils, no ma tt er wha t t he disease, we ha vefound the affinity or drug relation for this condition. So of everypat hological chan ge, and th e diagnosis, so far as treatmentis concern ed,consists in determining the pathological condition present, rather thanin n am ing th e disease. While I r ecognize t he im port an ce of being a ble todiagnose the disease in its entirety, and believe that the bestdiagnostician, other things being equal, will be the most successful in

the treatment of his patients, at the same time it were better for thedoctor if he can forget that his patient has typhoid fever, pneumonia,dysentery, or wha tever h e may ha ve, and st udy th e conditions tha t a represen t. This m ay be wrongs of th e circulat ion, of th e ner vous system, ofthe secretions, of digestion, of assimilation, or wrongs of the blood, butwhatever the basal lesion, it must be overcome if the patient is to bebenefited by medicat ion. I a ppreciat e th at it m ay n ot always be possibleto recognize th e pa th ologica l cond ition, bu t u nt il we do, we can n ot hopeto treat our patient in a rational manner. This, then, is SpecificMedicat ionSpecific Remedies for Specific Condit ions.

We are indebted to a host of able workers, pioneers in the field ofra tiona l medicat ion, an d who builded better th an th ey kn ew. Especiallyare we indebted to Prof. John M. Scudder, who by pen and voicedirected our school in this better way; to Prof. John Uri Lloyd, whosework in giving u s Specific Medicines of su ch superior qua lity as t o ma kesuccess possible; to my colleagues and fellow practitioners who have solargely assisted in more firmly establishing the principles of SpecificMedication.

For th e benefit of stu dent s a nd th ose who are n ot fam illiar with Eclecticmethods, I have added a chapter on the indications of remedies, andalso poisons and their antidotes, together with a table of weights andmea sures, an d a list of incompa tibles.



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PART I.

INFE CTIOUS DISEASES.

TYPH OID FEVER.

S y n o n y m s .Typhus abdominalis; Typhus nervosus; Ileo-Typhus andAut um na l Fever, are t he most comm on t erm s, although Mur chison's listincludes fort y oth ers.

Defin i t ion .An acut e, infectious disease, derived from a specific causeand characterized pathologically, by inflammation and generally byslough ing of Peyer's glan ds, swelling of the mesen ter y an d en gorgemen tof the spleen.

Clinically, by a slow fever of gradual invasion, lasting from three to sixweeks, a rose-colored eruption, diarrhea, tympanites and acharacteristic delirium, typhomania.

H i s t o r y .This is the most universal of all fevers. It is not confined toany country or climate; to any age, sex, or condition. Wealth has nopower to bribe or beauty to charm this insatiable foe. Wherevercivilization has made its way, there typhoid fever has been anunwelcome guest. Although its authenticity does not date back of thepresen t centu ry, we ha ve every rea son t o believe th at it can be tra ced to

preh istoric times.

In 1813, Bretonneau of Tours recognized this fever as differing fromoth er cont inued fevers a nd t erm ed it Doth inent rite, while Pet it ter medit Ent eromesen ter ic fever. In 1829, Louis offered t he-na me Typhoid, butit remained for Gerhard, of Philadelphia, a student of Louis, todistinguish between typhoid and typhus as separate and distinctdiseases. He published his views in the February number, American

Journal, 1837. Drs. E. E. Hale and James Jackson, Jr., of Boston, alsostudents of Louis, corroborated the observations of Gerhard, and

typhoid fever was recognized, especially in America, as a distinctdisease. In Europe, however, there was still doubt as to its identity,many believing that the two were only different phases of the samedisease.

Stille, of Philadelphia, who was house physician to Gerhard, assistedlargely in ma king clear to th e people of Fra nce th e distinction between



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th e t wo diseases, during h is car eful st udy of typhoid while in P ar is.

Shattuck, of Boston, visited the London fever hospital, studied thedisease in all its minutiae, which he carefully tabulated and presentedto th e Societe Medicale d'Observa tion. These observat ions were a ccepted

by prominent writers from various countries, and since 1850 there hasbeen a general acceptance of the truth, that typhoid fever is a distinctdisease. It will be observed that to America belongs the honor ofisolat ing one of th e most comm on a nd preva lent of all fevers.

E t i o l o g y .The predisposing causes are twofold. On the one hand areall th e conditions t ha t favor t he growth of th e infective mat erial an d itsaccum ulation. On th e oth er ha nd a re all the conditions t ha t impair t hevita lity of th e individual, rendering him su scept ible to the poison.

Age.One of the most frequent predisposing causes is age, overseventy-five per cent of its victims being between fifteen and thirtyyears of age. It was formerly believed that children were exempt, butsince Murchison, in 1864, presented to the London Pathological Societyth e intest ines of a child six mont hs old, who had died from t he disease,all doubt has been removed, and nearly every physician of experiencecan bring his own evidence to subst an tiat e th e fact, tha t from infancy toold age th ere is no exempt ion.

S ex.Some h ave tr ied to prove th at ma les are m ore pr one t o th e disease

than females, but the cause is rather to be found in the fact that menare more exposed to the infection than women, and not to anydifferen ce in t he s exes.

Season.Typhoid fever prevails most frequently in the fall, hence theterm Autumnal Fever. Hirsch found that of five hundred epidemicstwenty-nine occurred in the spring, one hundred and thirty-five insummer, two hundred and fifteen in the fall, and one hundred andfort y in t he winter .

Weather.The condition of the weather plays some part as apredisposing factor in this disease. Hot and dry seasons favor it, whilecold an d wet sea sons ten d to check it.

E x c i t i n g C a u s e .The exciting cause is now generally recognized bythe medical world as being due to the entrance into the system, of onesusceptible to the poison, of a specific germ, the bacillus of Eberth,



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which he has termed the bacillus typhosus. These micro-organisms,taken into the system through the digestive tract, when not destroyedby the acid of the stomach, pass into the alkaline constituents of theintest ine, where t he conditions ar e favora ble for th eir mu ltiplicat ion an ddevelopment.

The ba cilli penet ra te t he solita ry follicles an d Peyer's pat ches, an d t her eform colonies. These migrate by way of the lymphatic vessels to themesenteric ganglia, and by way of the radicles of the superior vein toth e liver, to be finally distr ibuted by th e blood cur ren t t o th e spleen a ndother organs. Such is the view held by a large part of the profession.Tha t th ese bacilli ar e foun d in t he cont ent s of th e intest ine, the st ools, inthe urine, in the mesenteric glands and spleen, none can deny,although ma ny contend t hat they are th e result , rath er tha n t he cause,and that the toxins are not generated from the micro-organisms. Of

these doubters the most prominent authority on fevers is Murchison.Unfortunately they are unable to furnish a tangible substitute to taketh e place of th e specific germ . The life of th is bacillus is very t ena cious .(See frontispiece.)

Pruden found that after being frozen for over three months it wascapable of growth, and that it maintained its vitality after being heatedto a temperature of 132 C., and that after repeated freezing andth awing its vitality was un impaired.

M o d e s o f C o n v e y a n c e .While it is possible to receive the poison byinhalation, by far the most frequent mode of entrance is through thedigestive tr act in eat ing and dr inking. Cont am inat ed water ra nks firstas a car rier. Of two hun dred epidemics th at were stu died, pollut ed wat erwas found to be the source of infection; only two will be named,however, to show the dir ect r elat ion t o th is sour ce.

In 1885, in Plymout h, P a., twelve hu ndr ed persons, out of a populationof eight thousand, were attacked with the fever. The water supply wastaken from a reservoir which received its supply from a mountain

stream, upon the side of which resided a typhoid fever patient. Duringthe months of January, February, and March the stools were emptiednear th e banks of th e str eam th at supplied the city with water. Typhoidfever a t t he r at e of fifty cases per da y broke out, an d did not cease u nt ilth e num ber reached twelve hu ndred.

In 1898, at Maidstone, England, an epidemic occurred, in which



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eight een h un dred cases out of a populat ion of th irt y-five th ousa nd couldbe tr aced directly to cont am inat ed wat er.

Milk.Milk is a lso a comm on car rier of th e infective ma ter ial, alth oughnea rly always the r esult of pollut ed water being used, eith er in diluting

the milk or in washing the cans. Several epidemics have been traced toth is sour ce in Fr an ce.

Oysters. Articles of food may also contain the poison; notably, oysters,more than one hundred cases being attributed to the luscious bivalves,which ha d been fat tened on cont am inated wat er.

Dr. Conn, of Middletown, Conn ., tra ced t he cause of the ep idemic whichprevailed among the students of Wesleyan University in 1894 to thisarticle of diet. The oysters came from a creek where they had been

fattened by being kept in brackish water, the oyster-bed being onlyth ree feet from t he m out h of a s ewer which em ptied th e cont ent s of twotyphoid fever patients. Students from Amherst College, who receivedoyster s from th e sa me locality, also developed t yphoid fever. Th e oyster swere eaten raw in every case. Thus we find that polluted water, eitherdirectly or indirectly, is the common carrier of the infection, whatevertha t ma y be.

P a t h o l o g y .The lesions resulting from this fever may be divided intotwo parts. First, those which are primary and distinctly characteristic;

viz., the lesion of the intestinal canal, Peyer's patches, the solitaryglands of the ileum and cecum, and more rarely of the colon andrectum , th e mesen ter ic glan ds, especially th ose opposite t he ileum, a ndchanges in the spleen. Secondly, those resulting from sepsis occurringduring the long period of fever, and affecting the tissues and organs atlarge.

The lesions of the intestines are better described under four stages,infiltration, necrosis, ulceration, and healing. The first effect of thepoison, typhotoxin, ba cilli, or wh a tever it m ay be, is to cause hyper emia

of the lymph follicles; the capillaries become engorged, cell infiltrationproceeds till the glands extend from an eighth to a quarter of an inchfrom their base, the solitary glands varying from the size of a smallbird-shot to that of a small pea. The follicles most involved are those inthe lower third of the ileum and the upper part of the cecum, althoughthe follicles of the entire tract may be involved. The infiltration reachesits height by the eighth or tenth day, when it terminates by resolution

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or dea th . In th e milder cases, by resolut ion, the follicles un dergo fat ty orgranu lar degenera tion, an d ar e car ried away by th e absorbents, duringwhich process there may be slight hemorrhages. More frequently,however, the infiltration is so excessive that resolution can not takeplace, the capillaries become engorged and choked by infiltration, and

necrosis and sloughing follow.

A gland may have several necrotic spots with mucous membraneintervening, or an entire patch may be involved. The necrosis isvariable, depending upon the severity, sometimes involving only themucosa or sub-mucosa, again extending to the muscular and serouscoa ts . This st age occup ies eight or t en days, a nd is followed by th e st ageof ulcera tion.

The ulcers are shallow or deep according to the amount of necrosis or

sloughing. The ulcers of the solitary glands are round, while those ofPeyer's patches are irregular and ragged. Where the ulcers extend tothe deeper portion of the bowel, hemorrhages result. Perforation mayfollow, alth ough a ra re cond ition.

This stage is followed by healing or cicatrization; granular materialforms in the bottom of the ulcer; the mucous membrane of the edgesprojects; the glands with their epithelium reform, and the bowel isrest ored to its n orm al condition.

The mesenteric glands undergo similar changesviz., hyperemia,necrosis, and ulcerationthose opposite the lower third of the ileumbeing more often involved. They vary in size from that of a pea to awalnut. The spleen in nearly all cases is early involved. Congestionear ly ta kes place, followed by soften ing.

It is difficult many times to separate the secondary from the primarylesion; in fact, in some cases we get the tissue changes first. The systemis so profoundly impressed by the poison that there is very early adegeneration of tissue. The liver becomes hyperemic, swollen, and soft,

which m ay be followed by a bscess form ation.

Cloudy swelling, with granular degeneration, takes place in thekidneys. There may be ulceration of the larynx, while the congestion ofth e bronchial mu cous m embra ne is shown by an irrita ble cough.

Congest ion of th e lun gs is a very comm on a nd ser ious complicat ion. The



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heart shares in the general infection, although pericarditis andendocarditis aren rare, myocarditis is not uncommon, the cardiacmu scles become weak ened, an d th e mu ch dr eaded h ear t-failure is t o beear ly comba ted.

S y m p t o m s .IncubationThis stage is of several days' duration, fromseven to twent y-one or more. The sympt oms ar e t hose of depression; th epat ient feels lan guid, and complain s of feeling tired, a lthough t her e beno exertion. His rest is disturbed at night, and he rises unrefreshed, asweary as when he retired; the appetite is impaired, the tongue isgenerally coated, and the bowels are slightly constipated; he complainsall th e tim e of being tired a nd of having more or less hea dache. Bleedingfrom t he n ose may occur for severa l days. These symptoms in crea se fromday t o day u nt il th e period of invasion is ush ered in.

Many times it is difficult to draw the line between the period ofincubation and that of invasion, so gradually does the one run into theother. While the chill may be pronounced, at other times slight chillysensa tions ar e th e only evidence of its appea ra nce. Epist axis is comm onand affords slight relief to the headache so often experienced; thetem pera tu re h as been slightly above norma l for severa l days previous t othe chill, but now reaches 101 or 102, and the patient is now fullyentered upon his long siege of fever, which is to be characterized bydaily remissions .

The pu lse var ies, is full an d frequen t, alth ough soft, or qu ick a nd sh ar p,if there is much nervous irritation. There is evidence of depression evenin the early stage; the face is slightly flushed, the eyes heavy andexpressionless, the tongue is moist and dirty, the appetite is gone. Theskin, at first , becomes m oist an d somewha t clam my, with a n u npleasa ntodor. The bowels a t th is time a re u sua lly const ipat ed, although if activecathartics have been used diarrhea early ensues; the urine is butslightly lessened in quantity, and as the disease progresses, it becomesslightly increased, an d is pale an d frothy, resembling new m ade beer.

The temperature gradually increases, during the first week being aboutone degree higher in the evening than in the morning. From theseventh to the tenth day the characteristic rash, rose-colored, appearson the abdomen and chest, and although this is regarded as one of thechief diagnostic symptoms, it may be absent altogether. The diarrheal,frothy, pea-soup discha rges m ay begin as ear ly as t he s ixth or seventhday, or it may be delayed until the third week, although usually the



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second week finds t he s tools frequ ent and offens ive.

If there be much nervous irritation, the delirium may be active duringthe early stages, occurring mostly at night and disappearing with theappr oach of day; most frequen tly th e delirium is of a pa ssive cha ra cter ,

an d typhomania is a cha ra cteristic symptom.

The abdomen has been drummy from the invasion, with gurgling in theright iliac region, and by the second week tympanites is a markedfeat ur e. At t his time th ere ma y be a tem pora ry par alysis of th e bladder ,and the patient passes his water involuntarily; or, on the other hand,th ere ma y be reten tion, when t he cath eter a ffords t he only relief.

From the tenth to the twentieth day the evidence of sepsis grows morepronounced; the tongue becomes dry, brown, and heavily coated, or

sleek an d glossy, while sordes a ppear on t eeth an d lips. The loss of tissu eis ra pid an d ema ciation m ar ked. The pulse h as now become dicrotic; th edistur ban ce of the n ervous system is complete, an d we witness su bsultu stendinum and carphology. If ulceration is severe, hemorrhages occur,followed by a drop in tem pera tu re a nd great prostra tion. The extr emitiesare inclined to be cold, the heart feels the strain, and the depression isgrea t. The position is dorsal.

In the more favorable cases, the disease has spent its force by theeighteenth to the t wentieth da y, th e tempera tu re declines, the st ools are

less frequent, the tongue becomes moist and clean, appetite ferocious,and the patient enters the convalescent stage. This may be delayed,however, to th e twen ty-eight h, th irt y-fifth , or even fort y-second day.

Temperature.There is a gradual rise in temperature during the firstweek, and if the forming stage is of long duration, the patient goes tobed with a temperature of 100. Each day, for four or five days, wenotice a slight increase from one degree to a degree and a half, theevening temperature being higher than the morning. These dailyremissions are pathognomonic of typhoid fever. From the fifth to the

seventh day the temperature reaches 104 or 105. During the secondweek it is quit e u niform 103 or 103.5 in th e morn ing; 104 or 104.5in the evening. The temperature, gradually rising from the noon hour,,reaches its maximum between six and eight, remaining there untilmidnight, when there is a gradual decline till six or eight in themorning, when it r eaches its m inimum , rem aining th us t ill nearly noon,when t her e is a r epetition of th e previous day.



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During the third week there is a slight decline, and by the twenty-firstday, in the mild cases, the temperature is normal in the morning,alth ough t he rise in t he evening temper at ur e cont inues for several days.In severe cases the remissions are very slight, from the fifteenth to thetwenty-fifth day the fever being very uniform, with an occasionalincrease of the morning temperature over the evening temperature.Dur ing the decline th e remissions a re m ore m ar ked, ther e being a fall offrom two to three degrees from morning till night, and where theemaciation and prostration have been extreme it is not uncommon tofind a subnormal temperature in the morning for several days of theconvalescent period. The severity of the disease and its duration isdetermined, as a rule, by the temperature range; when this is low the



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fever is mild, th e disease increasing in severity as t he t empera tu re rises.We meet some cases where the temperature never rises above 102 or103.

A disease which shows as much systemic infection as typhoid, would

naturally show more or less wrong of every organ and tissue of thebody, and while this is true, there are some parts more frequentlyaffected than others, notably the respiratory, nervous, and gastro-intestina l systems.

Bronchitis .The toxin may early infect the bronchial mucousmem bra ne, giving rise to bronchitis. The brea th ing is more hu rr ied, an dthere is a sense of constriction of the chest, attended by a frequentha cking cough. Expectorat ion is at first s can ty, and t he m ucus is ra isedwith difficulty; but gradually the secretion becomes more free, often

resulting in bronchial cat ar rh . The sibilant rh onchu s, togeth er with th esympt oms a lready noted, ena bles us to recognize th is lesion.

Pneumonia .Congestion and inflammation of the lungs are notinfrequent, and may occur during the second or third week, rarely inth e first. The brea th ing is sh ort an d ra pid, th e oppression of th e chest isma rked, and th e cough is h ar assing, greatly depressing the pat ient . Theexpectorat ed ma ter ial is u sua lly not so viscid an d ten acious a s in simplepneumonia, nor the sputum so rusty, being more of the prune-juicecolor.

The da rk , dusky h ue of th e lips a nd tongue, the flushed face, oppressedcirculat ion, du llness on percussion, a nd crepita nt rh onchi, are sympt omsth at can not be mista ken. This is one of th e most serious complicat ions,causing great prostration, and rendering the prognosis problematical.The congestion is most frequently due to the dorsal position, and notfrom taking cold nor from germ infection.

Gastro-Intestinal .In some cases we notice, at the beginning of thefever, marked wrongs of the stomach. The tongue is heavily coated with

a dirty, pasty coating; there is loss of appetite, nausea, and weight inthe region of the stomach. There is hyper-secretion of mucus, and foodan d m edicine a re n ot appr opriat ed. The fever is of low gra de, the pulseweak, an d tem pera tu re n ot over 102 or 103. Although t he pr ostr at ionis great, emaciation is not so marked. The extremities are inclined tobecome cold. In su ch cases conva lescence is delayed to the fifth or sixthweek.



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In other cases there is great irritation of the stomach, and the entericlesion is great ly aggrava ted. Diar rh ea is a pr ominen t feat ur e, th e stoolsbeing frequent and offensive. Tympanites is extreme and hemorrhagema y be expected .

Cerebral Com plications .In some cases the nerve centers are the firstto feel the effect of th e poison, an d t he disease is ush ered in with inten seheadache or neuralgia, and if the physician is not careful, he willoverlook t he rea l lesion. All th e sympt oms ar e increased in inten sity; th eskin, especially of th e hea d a nd face, is int ensely hot an d pu ngent . Thecountenance is flushed; there is throbbing of the carotids; the pulse isra pid, full, an d str ong; th e breat hing is frequ ent an d suspir ous; the eyesar e injected a nd su ffused, or dr y and bu rn ing. There is great irrita bilityan d rest lessness, giddiness, intolera nce to light a nd sound , with grea tly

increased sensibility.

Within forty-eight to seventy-two hours delirium of a wild and activecharacter occurs, which is soon replaced by coma vigil, subsultus, andlast ly by profoun d coma . At oth er t imes t he cerebra l affection is int ense;profoun d st upor speedily ma kes its appea ra nce, accompa nied by a slow,oppressed, and intermittent pulse; or the patient is dull from the first,the pupils are dilated, the patient answers slowly, protrudes his tonguewith difficult y, and is car eless of th e r esu lt. The pu lse is feeble, skin cool,temperature not very high, delirium low and muttering, which is soon

rep laced by coma.

Laryngitis and Pharyngitis.Occasionally we meet with thesecomplications; the constriction of the throat, difficult deglutition, andcha nge of voice en ables one t o recognize the lesion .

Heart.We meet with cases where the circulatory apparatus feels theforce of the poison, and, although rare, an endocarditis or pericarditisresults. A myocarditis occurs more frequently.

Afe b r i le T y p h o id Fe v e r .This form is exceedingly rare. Some eightor ten years ago I treated one of our students with this form, thetemperature being sub-normal the greater part of his three weekssickness.

T y p h o i d i n C h i l d r e n .The disease as seen in children needs noespecial description, except to say that the onset is frequently more



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sudden. There is a short forming stage, and the fever runs a shortercour se, the pa tient often being conva lescent th e four teen th day.

D i a g n o s i s .The diagnosis is usually not difficult, although in rarecases it may be uncertain for several days. Osler states that, in four or

five cases in his series, the diagnosis was not ma de un til au topsy.

The h istory of the form ing st age: one, two, or t hr ee weeks of listlessn ess,languor, headache, loss of appetite, general depression, progressivelyincreasing until the patient takes his bed, are the most characteristicsymptoms of this fever, and the regular step-ladder rise in temperaturewith daily remissions, the peculiar dullness of intellect, the markedprostration and feeble pulse, are sufficient to render a most probablediagnosis. If to this we add tenderness and gurgling in the right iliacregion, enlargement of the spleen, diarrhea, the presence of the rash

an d t he cerebral distu rban ce, the diagnosis is complete.

The case difficult to recognize, is wh ere t he usu al sympt oms ar e ma skedby an early complication. A recent case serves as an illustration. Theinvasion was chara cterized by an intense h eadache and great irritat ionof the nervous system; his face was flushed, pulse full and hard, eyesbright a nd cont ra cted, an d h is const an t cry was for r elief from th e painin h is head. The sympt oms were more of meningitis th an typhoid.

Sometimes the respiratory complication is the first to attract the

physicians attention, and if we are not careful we will give a mistakendiagnosis. In a ll such cases t he ph ysician m ust not be in t oo great ha steto name the disease. If we examine our patient carefully, note thetenderness on pressure of the abdomen, the daily remissions in thefever, the evidence of sepsis as shown by the tongue, light will soon befort hcomin g even in obscur e cases.

I ha ve but litt le faith or pa tience with t he m odern sear ch for t he ba cillustyphosus as a means of diagnosis, nor with the serum test as proposedby Wida l, which is a s follows: To a drop of blood t ak en from t he pa tien t

by pricking th e finger wit h a needle, add a few drops of bouillon cultur eof the bacilli. In a sh ort time, from a few seconds to five h our s, th e bacillilose th eir peculiar movement s a nd collect into heaps , and gradu ally int olumps, which, if examined in hanging drops, are visible to the nakedeye. The blood serum of healthy persons, or persons suffering from anyoth er disease, does not h ave th is effect upon t he t yphoid cultu re.



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Vau ghan , in a n ar ticle on pt oma ins, toxins, an d leucoma ins, says of th eWidal t est: There ar e rea sons for believing th at too mu ch reliance ha sbeen placed on the Widal test, and that normal blood serum will oftenhave a similar effect upon the typhoid bacillus, and that the differencein behavior between the typhoid and cholera germs toward the blood

serum of typhoid patients is not so marked as has been generallybelieved. We thus see that we must depend upon the clinicalexamination of our patient, rather than upon the microscopic orchem ical reaction.

P r o g n o s i s .This is a disease t ha t var ies grea tly at different times a ndin different seasons. Some years it assumes a mild character and butfew die, while again it a ssu mes a most ma lignan t form . The m ort ality isusually larger in hospitals than in private practice. If modern Eclectictreatment be carried out, the mortality should not be over three to five

per cent . If th ere be severe hem orr ha ges, pneu monia, or per itonitis, th eprognosis sh ould be gua rded.

T r e a t m e n t .In the treatment of typhoid fever, Eclectics have beenremarkably successful, the mortality having been reduced to five percent or less, and, with t he m odern car e in nu rsing, th e morta lity will bestill fur th er redu ced.

Prophylactic.While we believe that the direct or specific medicationemployed by our school shows t he best result s, we a lso firm ly believe in

using every known means to prevent the further spread of the disease,and at the same time minify the toxin that is destroying the vitality ofour patient. Since the infection is conveyed most frequently throughpollut ed wat er, our first car e should be in this direction. If an epidemic isprevailing, the a tt ention of th e health departm ent will be drawn to thewater supply. This will not, however, release the attending physicianfrom all responsibility. He must insist that all water be boiled beforeusing. The milk should also be trea ted in t he sa me way, as we ha ve seenth at th is is a fru itful mea ns for carr ying th e poison.

Cleanliness is next to godliness was a favorite saying of Dr. Scudder,an d h e would a dd, In some diseases, bett er. This is cert ainly import an tin typhoid fever. Dirt is a fruitful soil in which the poison thrives andmultiplies, and hence we must see that the patient be kept perfectlyclean. The bed linen should be cha nged daily, as well as th e night dress.After each stool the soiled parts should be sponged with an antisepticsolution. Platt's chlorides or a solution of carbolic acid 1 to 50 is very



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efficient.

The secret ions , both ur ine a nd s tool, sh ould r ema in in a chloride-of-limesolution one hour before being emptied. The solution can be made byadding six ounces of pure chloride of lime to one gallon of water. The

porcelain bed-pan should be th oroughly scalded a fter each u sing, and acup of the lime solution placed in it to rema in u nt il it is again used. Toeach stool enough of the solution is added to completely cover it. Afterstanding one hour, it should be emptied, if in the country, in a trench,dug for t he pu rpose, being careful t ha t it does n ot dra in in a ny directionof the water supply. If vomiting occurs, the ejected material should betr eat ed in t he sa me way, as sh ould th e expectorat ions, un less cloth s ar eused, when th ey should be bur ned. The soiled linen , after lying in somest rong ant iseptic fluid, should be th orough ly boiled before u sing.

These precautions may seem unnecessary to many, but as a school weha ve not paid as mu ch at tent ion t o th ese ma tt ers as th e times deman d.This is an age in which antiseptics are demanded, and to fail in ourat ten tions along this line is to cour t defeat . When possiblean d I rea lizeth at ma ny times it is notthe pa tient should be placed in a large room,where good ventilation can be secured, and where the sun can beadmitted at some time during the day. An open fireplace is desirable.The t empera tu re of th e room should be ma inta ined at sixty-five or sixty-eight degrees.

Much depends upon a good nurse, not necessarily a trained one, butone of good judgment, who will carry out instructions. The attendantshould be gentle, but positive. Our pat ient m ust be put t o bed early, an dkept there. Much may be lost by allowing the patient to walk aboutduring the early days. He is in for a long siege, and can not afford theunnecessary loss of a single ounce of his strength; hence a bed-panshould be used. He m ay object t o it at first , insist ing tha t h e can not useit; but if the nurse be firm, he is soon convinced of his error. Ifimpossible, which is rarely the case, he should be carefully assisted toth e comm ode, which should be placed by the bed.

He is to be sponged daily with soda-water if the tongue be white andpast y, or acidula ted wa ter if it be r ed a nd dry. This is for cleanliness, notas a tem pera tu re r educer, which will be noticed later . The diet sh ould befluid, preferably milk, and should be given about every three hours,unless there be great prostration, when it may be given every hour. Ifth e pa tient objects to sweet m ilk, it can be peptonized by adding essence



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of pepsin, or make a sherry whey by adding one-fourth of a cup ofsher ry-wine to th ree-four th s of a cup of hot milk, stir till it cur ds, str ain,an d add a litt le sugar. This is a favorite wh ey, an d I find it a ccepta ble toma ny; oth ers pr efer but ter milk, while again ma lted milk, which m ay beprepared in many ways, will answer better. Broths do better in the

advanced stages of the disease; if used early they are apt to aggravatethe diarr hea.

Sick people soon tire of one food, and it is a good plan to change thebroth from time to time; say beef broth one day, lamb broth another;then change to clam or oyster broth, or chicken broth, when we mayreturn to the beef broth. Give plenty of cold boiled water. If he does notask for it , give it a s a medicine ; it will help n at ur e wash out th e poisonby way of th e kidneys. Do not a llow an y solid food un til th e tem pera tu rebecomes norma l and a ll tender ness disappear s from th e abdomen.

The position of the pa tient mu st be cha nged occasiona lly to prevent bed-sores.

In th e giving of dru gs in t his disease, a s in every other , it is well to bearin mind the object of our medication. We are to remember that ourpatient is to contend for weeks with a febrile condition that will tax tothe utmost his vitality; that the fluids of the body and of every tissueand organ will be impressed by the poison; that every agent that isgiven must tend to conserve his vitality, and that every remedy that

depresses it m ust be discar ded. We ar e to guide our fever pa tient sa felyth rough t he t roubled sea of fever, r ender him as comfort able as possible,and so modify the morbid processes that may arise, that the voyagerma y safely reach th e desired h aven, health.

While we recognize that this is a true zymotic disease, with theintestines bearing the bru nt of th e at ta ck, we do not tr eat it entirely byantiseptics. We most heartily concur in the teaching of Dr. Scudder inregar d t o the u se of sedat ives in th is disease. An experience of twenty-five years convinces us of their beneficial action. We are aware of the

fact that the fever is the result of a toxin in the blood, and thattheoretically the treatment should be to give agents to neutralize orantidote this poison; at the same time we are satisfied that the feverma y be modified, th e irr itat ion of the n ervous system better cont rolled,and the secretions promoted by their judicious administration. We maynot succeed in materially lowering the temperature, but we mostfavorably influence the heart's action and fortify it, so that it may



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with sta nd t he str ain t ha t it is always called upon t o bear. Sedat ives maybe given t o improve the circula tion.

Aconite.This is the seda tive wher e th e pulse is sma ll an d frequen t, anevidence that the heart's action is weak and is beating rapidly to make

up for loss of power. Aconit e in t he sma ll dose does not depr ess, but addstone to the heart. In proportion as the circulation is controlled, thesecret ions from t he sk in an d kidneys ar e increa sed. Echina cea possessesstr ong a nt ispetic qua lities, and ma y be combined with itth us:

Specific Aconite. 5 dropsSpecific Echinacea . 1/2 to 1 drachmAqua Dest 4 ounces. Mix

Sig. Teaspoonful every one or t wo hour s.

Veratrum .Although there is usually debility with this fever, weoccas iona lly find t he s tr ong, full pu lse, showing excessive hea rt 's action,an d her e vera tr um ta kes t he place of aconite. With excess of th e hea rt 'spower, there is generally great irritation of the nervous system, whichgives us the flushed face and bright eyes calling for gelsemium. Hereth e prescription will rea d:

Specific Vera trum 10 to 30 drops.Specific Gelsemium 10 to 15 drops.Aqua Dest 4 ounces. Mix

Sig. Teaspoonful every two or t h ree h our s.

Rhus.This is an agent to relieve irr itat ion, either of th e ner ve cent ersor an irritable stomach. These conditions are present with the small,sharp pulse, and if the tongue be pointed with elevated papilla theindicat ions ar e still more pr onoun ced:

Rhus Tox 8 drops.Aconit e 5 drops.Aqua Dest 4 ounces. Mix

Sig. Teaspoonful every h our .

Lobelia.This is an excellent dr ug where t here is a n oppressed pulse, asif th ere wer e some obst ru ction t o th e free flow of blood. In a ddition t her eis a sen se of oppression in th e chest , difficult br eat hing a nd u npleasa ntsensations in the region of the heart. These are symptoms often foundwith respiratory complications. Here specific lobelia, 10 drops, is added



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to th e a conite solution above na med.

Jaborandi .Where the skin is dry and the temperature running high,Dr. Webster r ecomm ends J abora ndi:

Specific J aborandi 1 drachm.Aqua Dest 4 ounces. Mix

Sig. Teaspoonful every one, t wo, or th ree h our s.

Bryonia.Where there is bronchial irritation, with harassing cough,with sharp chest pains, and where the pleura is involved. bryonia isespecially valua ble. With th ese cond itions t he pu lse is usua lly vibra tile:

Specific Aconit e or Vera tr um.Specific Bryonia . 5 to 8 drops.

Aqua Dest 4 ounces. MixSig. Teaspoonful every h our .

Antipyretics .For the high temperature, the temptation is to resort tosome of the many antipyretics, chief among which are the coal-tarproducts, a nd qu inine. These should never be used. The pa tient is beingconstantly depressed by the disease, and if to his depression we addremedies t ha t ar e recognized by all medical men as hear t depressants,our pat ient mu st necessar ily suffer.

Baths .To assist the action of the sedatives, baths are the safestadjuncts in reducing the temperature. The early Eclectics used the wet-sheet pack with great success, and we would do well to revive thispractice. The Brand treatment, the submerging of the patient in coldwat er every time th e tempera tu re rea ches 103, is not pr actical in privat epra ctice, but th ere a re n one so poor wh ere t he wet-sheet pa ck could n otbe used. Frequen t sponging may ta ke th e place of th e pack, an d will befoun d very useful. Tepid wat er is th e best.

Antiseptics .Very ear ly, an tiseptics m ay be indicat ed. The dusky hu e of

the mucous membrane tells of the progress of the poison, and suggestsechina cea an d ba ptisia. Where th e t ongue is broad, full, slight ly coat ed,an d with a dusky hu e, face and t issues full, give:

Specific Echinacea 1 drachm.Aqua Dest 4 ounces. MixSig. Teaspoonful every h our .



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Baptisia .Where the face is dusky and presents a frozen appearance,th e tongue is dusky an d th e stools frequen t, baptisia ma y tak e the placeof echin acea, or, wha t would be bett er, combin e th em.

S odium S ulphite.Where t he t ongue is m oist, dirty, an d pa sty, th e facefull, eyes du ll, extr emit ies inclined t o be cold, emaciat ion not very ra pid,a saturated solution of sulphite of soda will be found invaluable.Tablespoonful every two hour s.

Potassium Chlorate.This is the remedy for bad odors, offensive skinan d brea th , fetid st ools; in fact, gener al cada veric odor:

Potassium Chlora te 1 drachmAqua Dest 4 ounces. Mix

Sig. Teaspoonful every t wo hour s.

Hydrochloric Acid.This is by far the most frequently indicatedantiseptic used in typhoid fever. By the end of the second week, andsometimes earlier, the tongue becomes dry and brown, or, dry, sleek,an d glossy, with sordes on t eeth an d lips. The tongue is protr uded withdifficult y, th e ema ciat ion is r apid, here:

Hydrochlor ic Acid. 15 to 20 dropsSimple Syrup a nd

Aqua Dest 2 ounces each . MixSig. Teaspoonful every one, t wo, or th ree h our s.

Cider.With these same symptoms, sharp, sparkling cider is not onlyvery refreshing, but also curative. Buttermilk is another agent that isgra teful in t hese cond itions .

S ulphu rous A cid.The moist, dusky, red t ongu e, resembling spoilt beef,calls for su lphurous a cid.

Sulphurous Acid. 2 drachms.Aqua Dest 2 ounces. MixSig. Teaspoonful every two or t h ree h our s.

N ervous S ystem .We find that one of two conditions may be present.Where th e patient is restless and irr itable, gelsemium a nd r hu s tox. willbe called for; here the flushed face, bright eyes, hot head, and



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restlessness, calls for gelsemium. If the patient suddenly starts in hissleep, ha s a shar p str oke to the pulse, rhu s ha s th e preference.

Belladonna .If ther e is more or less coma , th e pupils will be dilat ed, thepu lse will be sma ll and t he ext rem ities inclined to be cold,we will add

ten drops of specific belladonna to a half a glass of water. Teaspoonfulevery h our .

Quinine.We do not use quinine as an antipyretic, but where there islack of innervation, with moist skin and moist tongue, quinine is anexcellent agent :

Quinine 2 gra insPhosphate of Hydrast ia 1/4 gra in . M

Sig. A capsu le every th ree or four hour s.

I n s o m n i a .The pa tien t wh o fa ils to secure sleep is doing badly, as th edry, brillian t eye, pinched featu res , and cont ra cted n ose will test ify.

Passiflora . Pa ssiflora in full doses will often secur e th e desired r est:

Passiflora andAqua Dest 1 ounce each M.

Sig. Teaspoonful every one, t wo, or th ree h our s.

Diaphoretic Powder.The old diaphoretic powder of the fathers,consisting of camphor, opium, and ipecac, is one of the most reliablerem edies which can be used. The ind icat ions calling for it a re, moist skinand tongue. From five to eight grains should be given every four or fivehours. Th e second dose r ar ely ha s t o be given.

Sulphona l and Triona l.These a gents m ay be given in ten -grain d oses,adm inistered in very h ot wat er. It is best dissolved in boiling water , th enstir till cool enough to drink. The sulphonal should be given two hoursbefore sleep is desired, as it is very slow in its action. Trional is much

quicker, and should be given thirty minutes before bedtime. Beforeusing a ny of th ese dru gs, th e nu rse will ha ve tried sponging th e face incologne-wat er, r ubbing t he spine, using t he hot foot-bath , cha nging t hepillows, etc., which will, very m an y times, secur e t he desired r esult , sleepand rest.

Gastric Complications.Wrongs of the stomach should have been



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considered, perhaps, before lesions of the circulation: for many timestreatment has to be directed to correcting this before any othermedicat ion can be carr ied out .

Irritation .The irritable stomach will be easily recognized. The

elongated tongue, reddened at tip and edges, tenderness over theepigastric region, the constant nausea with persistent retching, will beovercome by th e use of specific ipecac an d rhus t ox. five to ten dr ops ofeach to a half a glass of mint water. Tea-spoonful every thirty or sixtyminu tes; or sub-nit, bismut h, dra chm s 1 to water four oun ces.

A cold pack over the stomach will assist materially in overcoming thiscondition. An infusion made from the bark of the young twigs of thepeach-tr ee, and given in sm all doses, ma y also be very useful.

Atony .At other times there is marked atony of the stomach withhypersecretion of mucus. Here the tongue is broad and pallid, with ahea vy coat ing from base t o tip. The pa tient is dull, an d t he t issues full.

S odium S ulphite.Un til these condit ions a re cha nged, neither medicinenor food can be appropriated. With these symptoms, place sulphite ofsodium, drachms 2, in a half a glass of water, and give a teaspoonfulevery two or t hr ee hour s.

Diarrhea.If mild, nothing will be required, but if profuse, bismuth

subnitrate or bismuth subgallate will be useful, three to five grainsevery t hr ee or four hour s; or specific epilobium , ipecac, or dioscorea ma ybe given, ten t o twent y drops in a ha lf a glass of wat er. If th e tongue bepast y, sulph o-ca rbolate of zinc will be foun d of grea t benefit.

Hemorrhage.There will be few cases of hemorrhage if the doctor hascarefully met the conditions from the beginning; however, we willsometimes have it even under the best of care. Gallic acid, five grainsevery three or four hours, will usually promptly arrest it. The decoctionof erigeron cane is advised by Webster. There is usually great

prostration following a hemorrhage, and stimulants will be called for,st rychn ia grs . 1/60 being one of th e best.

Tympanites .If th e distent ion of th e abdomen be grea t, t he sm all doseof tu rpen tine will be foun d useful. The tongue in t hese cases is dry a ndclean. An emulsion containing one drop of the drug at a dose, every twohours, will not disturb the stomach or kidneys, and will give good



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results. Specific xanthoxylum, 20 drops, to water four ounces,teaspoonful every hour. is good treatment. The common tincture ofPrickly-ash berries, an ounce to a pint of warm water, and used as anenem a, will also prove of ma rk ed benefit in stubborn cases .

Constipation .I am not yet a convert to cat ha rt ics in t yphoid fever, an dI am persuaded that a little constipation is better than the irritatingeffect of a cathartic. I would allow the bowels to remain quiet twenty-four or forty-eight hours before resorting to means for an evacuation,when an enema of warm water and glycerine may be used. Ifunsuccessful, tablespoonful doses of pure olive-oil or broken doses ofepsom sa lts mav be given.

Bladder.The condition of the bladder must be carefully looked after,for the patient may have retention and the nurse overlook it for several

hour s. If ur ine has n ot been voided for t went y-four hour s, sma ll doses ofsantonine may be used. Strychnia, 1/60 gr. every three or four hours isalso an excellent agent. If there be much distention of the bladder, thecat het er, of cour se, mus t be used.

C o n v a l e s c e n c e .Great care must be exercised during convalescence;as the fever subsides and the tongue cleans, the patient develops avoracious appetite, and, if the nurse be not firm, will take more thancan be digested. The nurse should give nourishment frequently and insmall quantities, rather than the usual meals, three per day. As the

strength is regained, the patient may be assisted about the room, butshould not undertake to walk far till the stools become normal and thehea rt 's action h as r egained its tone.

T YP HUS F E VE R .

S y n o n y m s .Famine Fever; Ship Fever; Jail Fever; Hospital Fever;and Pu trid Fever.

Defin i t ion .An acute, infectious fever, endemic and also epidemic,where grea t m asses of people are congregat ed without r egard t o propersan itat ion. It is cha ra cter ized by a su dden inva sion, high gra de of fever,a peculiar rash, great nervous derangement, and terminates in fromtwelve to sixteen days by crisis.

H i s t o r y .Accord ing t o Murchison, to stu dy the hist ory of typhu s fever



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would require an historic study of Europe for three hundred and fiftyyears, during which time severe epidemics have proven moredestructive than war. Until the latter half of the present century butlittle attention was given to sanitation, in the army, on shipboard, in

jails, prisons, or even in hospitals; hence the great loss of life; but the

great improvement of modern sanitary regulations is rendering thedisease less drea ded a nd far less fat al. Typhus fever is still epidemic inIreland, En glan d, Poland, Russia, Hun gary, an d Ita ly.

In 1807 the fever appeared in the New England States, and visitedeach in ra pid succession. In 1812 it a ppear ed in Ph iladelphia, an d againin 1836, in 1865, and in 1883. New York was visited in 1881, 1882, and1893 by epidemics of this fever. In all of these epidemics the, diseasesustained its reputation as the deadly typhus. Since 1893 but few caseshave been reported, and, with improved sanitation and the rigid

quarantine regulations adopted by this country, typhus fever will soonha ve only an historic inter est for th e American physician.

E t i o l o g y .The predisposing causes are, filth, poverty, andovercrowding, without due regard to cleanliness, especially in regard toth e removal an d destr uction of hu ma n excret a.

Intemperance, one of the most fruitful causes of poverty, weakens andsaps the vitality to such an extent that its victims readily' succumb totyphus. Poor food naturally makes poor blood, and poor blood is a soil

where toxins flour ish a nd mu ltiply.

E x c i t i n g C a u s e .The specific cause has not yet been isolated,although undoubtedly similar in character to that of other infectiousdiseases, and when once it finds entrance into the system of onesusceptible to the poison or germ, it has the power of multiplying andreproducing the original toxin. Although highly contagious, theinfection h as but a short ra nge an d only th ose in close cont act with th epatient ar e apt to cont ra ct t he disease ; hence nurses a nd ph ysicians a rein special da nger. In th e Crimea n war 1854-56dur ing th e h eight of

the epidemic, in a single period of fifty-seven days, typhus feverattacked six hundred and three nurses in a total of eight hundred andforty in the service; and in the Russo-Turkish war, 60 per cent of thephysicians Were attacked. Those who handle the soiled linen arepeculiarly liable to the infection, as the linen retains the poison for along per iod.



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P a t h o l o g y .There are no characteristic lesions of the viscera. Theblood is dark and diffluent, the result of the intense fever and rapidwork of th e poison. The liver is somewha t enlar ged an d soften ed, as a rethe kidneys and spleen, and each becomes dark-red in color. There isgenerally a bronchial catarrh, and many times hypostatic congestion of

th e lun gs.

Extravasation into the pericardium gives it an ecchymotic appearance,which is also seen in t he gas tr o-intest inal m ucosa. The int estina l lesionis not characteristic as in typhoid fever, and while there may behyperplasia of the lymph follicles, there is never ulceration as in theform er. Peyer's plaques a re a lso int act, alth ough congest ed.

There is often granular engorgement, but the process stops short ofsuppu ra tion. The muscular t issues ar e of a da rk -red color, and t he hea rt

often shows granular degeneration, and is of the same dark-red color.There may be cerebral congestion, with effusion into the subarachnoidspace and the ventricles. The coagulability of the blood is greatlydiminished. The skin shows a cha ra cter istic ra sh, a nd ecchymotic spotsar e foun d on t he more dependent pa rt s after death .

S y m p t o m s .The period of incubation, the time from exposure toinvasion, varies from three to twelve days, according to the intensity ofthe infectious material and the susceptibility of the patient. Althoughthe onset is usually sudden, we may have during the last three or four

days prior to the invasion the usual prodromal symptoms thataccompany most fevers; viz., headache, languor, loss of appetite, achingof back an d limbs, insomn ia, an d par tial a rr est of th e secret ions. Theseincrea se pr ogressively un til th e chilly sensa tions or a rigor proclaim t heinvasion.

Invasion .The chilly sensations continue for several hours or a sharp,short chill may announce the unwelcome guest. The patient complainsof severe pain in his head, and the muscles seem sore as if bruised.There is now great prostration, and the patient is compelled to take to

his bed. The temperature rises very rapidly, and by the end of twenty-four or forty-eight hours the temperature may register 104 or 105.The pulse is rapid, full, and bounding, with throbbing of the carotids,although after the first forty-eight hours the pulse loses its strongimpulse and becomes small and feeble, showing the influence of thetoxin on th e hear t.



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The face is characteristic. There is a dusky flush, with injected andcont ra cted pu pils. The skin is dry an d pun gent; the tongue is at first bu tslightly coated, but soon acquires a thick, dry, and brown coating. Thereis often nausea and vomiting during the first forty-eight hours. Thepain in the head becomes intense, and the symptoms of meningitis are

often present. The mind is early impressed, and delirium may occur asearly as the second day, varying greatly in character, from the mild tothe most intense. Usually, however, the patient becomes dull, and isimpressed with difficulty, and stu por is an early feat ur e.

Eruption .From the third to the fifth day the eruption makes itsappearance, at first on the abdomen, gradually encroaching upon theother parts of the body, although singularly sparing the face in mostcases. The rash is characteristic, first appearing as bright red macules,disappearing on pressure, and soon changing to a dark, dingy red,

becoming hemorrhagic in character, and petechia follows, the rashrema ining after deat h.

There is no abatement of the fever with the appearance of the rash. Bythe end of the first week the fever is intense and uniform. Temperature104, 105, or 106. The tongue is dry and almost immobile; sordesappear on teeth and lips; the skin is hot, dry, and constricted; the urineis scanty and contains albumen. With the appearance of the eruptionth ere is often ret ent ion of th e ur ine. The pa tient lies upon his back, an dtends to slip towards the foot of the bed. Although there is stupor, the

eye may be open and the patient muttering; or the delirium may bevery active. From th e seventh to the four teenth day th e symptoms a requite uniform, showing great depression and much deprivation of theblood. There is increased suppression of muscular power, and anincrease of involuntary action, as tremors, subsultus tendinum, andslight convulsive action.

The symptoms of the crisis have been thus described: At the end of thethirteenth day a more serious exacerbation than any former one takesplace; the heat is more glowing, the arteries pulsate more strongly, the

bra in is more affected, an d th e stu por pa sses int o sopor. In t welve hour safterward, and on the fourteenth day, the parched skin shows atendency to perspiration. In some cases slight epistaxis occurs, withrelief to the head; the nostrils become moist; the tongue, at the pointand edge, moist, clean, and red, and perspiration more copious andgeneral.



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A free expectoration often takes place, especially if the chest has beenaffected. When the perspiration is salutary, it is uniform, not clammy,ha s a peculia r odor, an d occur s du rin g sleep. The st ools ar e now copious ,loose, and offensive; the urine plentiful, muddy, and slightly colored,and deposits a copious sediment. With these changes, or within a few

hours afterward, the patient seems as if awakened from a dream, orfrom a state of intoxication. and, with the return of completeconsciousness, all the severe sympt oms a bat e. Conva lescence is usua llyquite rapid an d un eventful.

C o m p l i c a t i o n s .The most frequent, and quite common complication,is bronchitis, which occur s from t he t hird to th e sevent h dav. There is asense of constriction of the chest, hurried respiration, dry, hard, andharassing cough, with an aggravation of all the symptoms. There maybe hypostatic congestion of the lungs, rendering the respiration more

labored; the duskiness of face increases, showing imperfect aeration ofthe blood. Thus more work is thrown on the heart, which greatlyenda ngers th e patient 's recovery.

T e m p e r a t u r e .As will be seen by studying the chart, the range oftemperature in typhus fever is higher than in any other fever,frequently running for ten days at 105 or more. In the milder cases thehigh range does not occur, and after the seventh day there is a morera pid decline, conva lescence comm encing the eight h or ten th da y.

D i a g n o s i s .The diagnosis is readily made. The known presence of anepidemic, th e sudden invasion beginnin g with a rigor, t he h igh grade offever, the more intense disturbance of the nervous system, the duskyflush of the face, the characteristic petechial eruption occurring theth ird da y, ren der t he d iagnosis compa ra tively easy. We diagnose it fromtyphoid by the long forming stage of the latter, the less intense febrilerea ction, an d a lso less distur ban ce of th e ner vous system, t he a bsence ofthe intestinal lesion, the difference in character of the eruption, and.also th e time of its appear an ce.

In sporad ic cases, if not careful, we ma y mista ke it for sp ina l-men ingitis,although in the latter the head symptoms are more pronounced, withretraction of the head, marked tenderness on pressure over the cervicalregion, an d an absen ce, on t he t hird da y, of th e petechia l rash.

P r o g n o s i s .The prognosis depends upon several conditions,theseverity of the epidemic prevailing; the character of the complications;



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the vitality of the patient, the mortality being great where this isreduced; the age of the patient, but few children dying, while, aftermiddle life, the mortality increases; the intensity of the lesion of thener vous system, an d the sever ity of th e blood lesion.

Race is also to be considered, the colored race succumb more rapidlyth an th e white ra ce. The m ort ality is given a t from t en t o th irty-five percent, but with the sanitation now in vogue, and the use of remedieswith which we have been successful in overcoming sthenic fevers, andth e septic cond itions , the m ort ality should not be large.

T r e a t m e n t .The pr ophylactic tr eat men t should cons ist of disinfection,immediat e isolation, an d a persisten t effort a t cleanliness. Ther e shouldbe plenty of pur e, fresh a ir in t he sickroom.

In the treatment of this disease there are three conditions toovercome,sepsis, high temperature, and wrongs of the nervoussystem ; th e two lat ter , no doubt , being- due to the firs t, sepsis.

The room, where possible, should be large, well ventilated, and thetem pera tu re, if in wint er, not a llowed over 68 degrees.



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Veratrum .Where there is a full, bounding pulse and throbbing of thecar otids, vera tr um , dra chm s .5 to drachm s 1, to water 4 oun ces, will bethe indicated remedy. In connection with this, the wet-sheet pack maybe used, if temperature be very high, 104 or 105. Where the poison isinten se, th e extr emities ar e cold, th e pat ient is dull an d drowsy, an d th e

pulse feeble and oppressed, blankets wrung out of hot mustard-water,an d placed about th e pat ient, with a st imulat ing emet ic of caps icum an dlobelia, will give good results.

Belladonna will be called for wh ere t her e is dullness a nd coma .

Gelsemium will be the rem edy where t her e is great irr itat ion a nd a ctivedelirium.

Hyoscyamus will also be used where th e pat ient is restless a nd u na ble to

sleep.

Echinacea .This remedy should give a good account of itself in typhusfever. The furr ed tongue, th e dusk y hu e, calls for t he a gent. Echina cea,drachms 1 to water 4 ounces, teaspoonful every hour. It should becont inued with th e proper seda tive.

Baptisia .The full tissues with pu rplish h ue, as if th e pat ient h ad beenfrozen, ca lls for ba pt isia.

Sodium Sulphite.Where the tongue is broad, moist, and heavilycoated with a dirty, pasty coating, a saturated solution of sodiumsulph ite, in t ablespoonful doses, will not disappoint .

Potassium Chlorate is the remedy for bad odors, and where the tongueis moist, dirty, and the breath foul, potassium chlorate will be theremedy.

Hydrochloric Acid.Where the tongue is dry, brown, or red, sordes onteeth and lips, nothing can take the place of hydrochloric acid, C. P., 20

drops, simple syrup and water 2 ounces each. Teaspoonful every twohours. This is one of the most severe forms of fever; but, with goodnursing, the proper antiseptics, the proper wet-sheet packs, and the useof belladonna, gelsemium, and hyoscyamus for the nervous lesions,ma ny will recover.



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R E L AP S I N G F E V E R .

S y n o n y m s .Typhus Recurrens; Bilious Typhoid; Famine Fever;Hu nger Pest ; Spirillum F ever.

Defin i t ion .An acute, infectious, and contagious fever, characterizedby a series of exacerbations and remissions, each lasting from five toseven days, and prevailing epidemically.

H i s t o r y .There is but litt le doubt th at th is fever pr evailed previous t o1739. Some indeed believe that it existed during the time ofHippocrates, and cite, as evidence, his description of an epidemic whichprevailed during his time. The first authentic account, however, datesfrom t he epidemic which prevailed in Irelan d, Scotlan d, an d E ngland in1839, since which time it has gradually extended to other parts of the

world, few countries escaping, notably Spain, Switzerland, Italy, and inFr an ce only a few sporad ic cases.

It made its appearance in the United States in 1844 at Philadelphia,being brought by Irish immigrants. In 1847 it appeared in New Yorkand Buffalo. In 1869-70 it again appeared in Philadelphia, and in thesame way; viz., through Irish immigrants. In 1872-73 it made its lastvisit to our sh ores . New York being th e place of its visita tion.

E t i o l o g y .The predisposing causes are similar to those of typhus

fever: viz., filth, poverty, and overcrowding. This combination ofconditions is prolific in furnishing a soil which readily generates toxinsof an intense character, and occurs among a class whose vitality islowered by insufficient and defective food.

Age and Sex.Age has but slight bearing upon the etiology, althoughth e great er n um ber of victims a re between t he a ge of fifteen a nd t hirt y.More m ales a re a ffected t ha n females.

Race.Race also plays but a very little part, save that some are more

uncleanly than others, the negro being slightly more susceptible thanother races. Neither season nor climate figures in the spread of thedisease.

Famine.During the time when scarcity of food prevails, theimpoverished are peculiarly susceptible, and no doubt this bears uponits etiology.



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E x c i t i n g C a u s e .In 1873, Obermeier discovered in the blood ofpatients suffering from this fever a characteristic spirillum, which hasbeen termed the Spirillum Obermeier. Since then the same micro-organism has been found by many observers, and this specific germ is

now genera lly recognized a s t he cau sal factor in pr oducing t he disease.It is found in large numbers during an exacerbation, but disappearsduring the period of intermission, small granular bodies being seen atth is time, supposed to be the spores of th e spirillum .

P a t h o l o g y .There are no characteristic changes in the solids of thebody. The voluntary muscles are inclined to undergo granulardegener at ion, a nd where t her e is icter ic discolora tion dur ing th e diseasethe tissues are stained after death. The liver, kidneys, and spleen aresomewhat enlarged, especially the latter organ, and hemorrhagic

infarcts are not uncommon. The kidneys and spleen present a mottled,appea ra nce, with extra vasa tion of blood beneat h t he su rface. The hea rt ,in severe an d pr olonged cases, becomes soft, a nd gran ular cha nges ta keplace. Pleurisy and pneumonia are often present, although not aconst an t feat ur e. The body retains its h eat a long time after death , andth e blood coagula tes slowly, if a t a ll.

S y m p t o m s .The period of incubation is from five to seven days,although it ma y be much short er where t he system is impoverished an dthe infection is intense. The onset is usually sudden, although there

may be the usual prodromal symptoms for twenty-four or forty-eighthours preceding the invasion, which is usually announced in the earlypart of the day by a severe rigor, although there may be only chillysensations.

This is rapidly followed by reaction, extreme in character, thetemperature often rising to 104, 105, or 106 at the end of the firsttwenty-four hours. The pulse is very rapid, from one hundred andtwenty to one hundred and fifty per minute. The prostration is great,an d t he pa tient is compelled t o ta ke t o his bed. The face is flush ed, the

eyes contracted, the skin hot, dry, and pungent, although frequentlyprofuse sweating occurs. There is nausea and sometimes severevomiting. The pain in the head is intense, with more or less vertigo.Myalgia is a marked feature, and the patient complains of pain in backan d limbs; in fact, of achin g all over.

By th e second or th ird da y a cha ra cter istic icter ic discolora tion ma kes its



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appea ra nce, alth ough t his is not const an t. Although th e fever is inten se,there is rarely delirium, the patient retaining his mental facultiesthroughout the disease. Owing to his sufferings he is restless andsecures but little sleep.

From t he t hird t o the sixth day th e fever is intense. There is tension an dpain in both hypochondriac regions, due to swelling of the liver andspleen. The tongue is at first moist, but becomes dry and brown. Theconstipation may give way to diarrhea. Preceding the crisis, there maybe an aggra vation of all the symptoms, when suddenly the tem perat ur ebegins to fall, the skin becomes moist, the urine is more copious, and bythe end of ten or twelve hours the patient is free from pain and thetemperature is normal. Convalescence is rapid, and often by the end ofth e second day he cons iders h imself well.

The period of comparative health lasts from five to seven days, when a

chill ushers in another exacerbation: the headache, myalgia, hightemperature, and all the other symptoms of the exacerbation arerepeat ed. It is u sua lly, however, of short er d ur at ion, t he crisis occur ringth e four th , fifth , or sixth da y, to be followed by conva lescence, alth oughthere may be a second, third, or even fourth exacerbation. Where therear e t wo or more, each becomes shorter in du ra tion.



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The most frequent complications are lobar and bronchial pneumonia,more rar ely acut e nephr itis.

D i a g n o s i s .The course of the disease is so characteristic that, where

an epidemic has been established, the diagnosis is comparatively easy.The rapid rise in t emperat ur e, th e int ense heada che an d myalgia, greatexcitation of the nervous system without delirium, would suggestrela psing fever. We would r ecognize it from t yphu s fever by t he a bsenceof deliriu m, th e cha ra cter istic ra sh , and by th e ear ly crisis ; from typhoidfever, by th e long form ing sta ge of th e lat ter , th e dull intellect, a nd th eintestinal lesion: from cerebro-spinal fever, by a higher and moreirregular temperature range, no tenderness along the cervical region,an d but slight dr awing of th e head backwards.

P r o g n o s i s .The prognosis is usually favorable, the mortality beingfrom three to six per cent. The result depends largely upon thecomplications and the age of the patient. Where pneumonia and acuteneph ritis occur , the prognosis mu st be guar ded, as it m ust also be whenit occurs in elder ly people.

T r e a t m e n t .Although, as a school, we have not had the opportunityof testing Eclectic remedies, owing to the few epidemics which haveprevailed, the general management would be similar to that for typhusfever. We would think of isolation, perfect cleanliness, and plenty of

fresh air. The use of baths, probably sponging with hot water, todetermine the heat to the surface, and constant fanning of the face ofth e pat ient by an a ssista nt . This ra pidly cools the sur face and lowers th etemperature.

Echina cea, baptisia, the su lphites, chlora tes, an d minera l acids as mightbe indicated by the tongue, for sepsis. Macrotys, gelsemium, rhamnusCalifornica, and the old diaphoretic powder would be suggested for themyalgia, while stimula nt s would be used where t he tem pera tu re becam esub-normal or the heart became weak. For the congestion of the liver

and spleen chionanthus and polymnia would be the agents of probablevalue. Should respiratory complications arise, such as pneumonia,pleurisy, or bronchitis, the treatment so successfully employed by ourschool for these diseases would be used; in fact, whatever complicationshould arise, the intelligent physician would meet the condition's byappropriate remedies.



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The diet will consist of broths a nd m ilk in some form till the t empera tu rebecomes n orm al.

MALARIAL F EVER .

S y n o n y m s .Ague; Chills and Fever; Intermittent Fever; SwampFever; Mar sh F ever; Paluda l Fever.

Defin i t ion .A specific, infectious, although non-contagious fever,caused by the hematozoa of Laveran, and consisting of two distinctpar ts: First , a su ccession of exacerbat ions an d int erm issions, or a seriesof short fevers separated by short intervals of health; second, acontinued fever made up of exacerbations and remissions, there beingbut one cold stage. The disease is characterized by congestion of thespleen an d port al circula tion.

H i s t o r y .Although Rome, secure on her seven hills, had conqueredand ruled the world, there was one insidious foe whom slie could notovercome. Intrenched in the Pontine Marshes there lurked an enemythat overcame her bravest sons and fairest daughters, and this sameformidable foe has been found endemically and occasionallyepidemically, from time immemorial, in nearly every clime save theextr emes of latitu de. During th e last fifty years it h as been progressivelydecreasing, and sections where once the disease prevailed in force arenow almost immun e.

It is more prevalent in the tropics, and diminishes as we recede fromth em. In Eu rope, Russia an d It aly ar e th e chief points of infection, whileGermany, France, and England are rarely visited by the disease. It isalso severe in Africa and India. In the United States it prevails largelyin the South, while the East, North, and West are but slightly affected.Even in t he Sout h, however, there is a ma rked decrease in t he n um berof cases du ring th e last t wenty years.

E t i o l o g y .Soil .The condition of the soil has been recognized as a

causal factor for a great many years by a majority of the profession. Ahumid soil, producing a luxurious vegetation, was long regarded as ahabitat for malaria ; and marsh miasm, arising from the decompositionof vegetable matter, was long credited as the principal factor in givingrise t o th is class of fevers.

That low, marshy, and swampy lands are the great breeding places of



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malaria has also been recognized from time immemorial. The PontineMar shes about Rome, a verita ble hotbed for t he disease, is one of ma nyexamples. Fresh-water marshes, situated near the sea, when slightlyinfluenced by salt wat er, ar e especially favora ble for th e genera tion an dmu ltiplicat ion of the par asit e or poison.

The specific cause, then, may be said to reside in the soil made rich byth e decomposition of vegeta ble mat ter , or u pon its su rface. The exposingof virgin soil, either in the overturning for agricultural purposes, or indigging trenches, or in excavations, has exposed the germs, andepidemics have followed where before the disease was unknown. Incontrast to this, malaria has been found to exist in dry, sandy soil,although, in all probability, the poison had been carried by prevailingwinds, rath er th an t ha t such soils are th e nat ur al habitat of th e diseasegerms.

Heat.A temperature of sixty-five degrees is necessary for thedevelopment of the hematozoa, and consequently we find the diseaseprevailing to a far greater extent in the tropics than in the temperatezone. In fact, as we recede from the tropics, there is a progressivedecrease in m alaria.

Moisture.A certain amount of moisture seems necessary for thedevelopment of th e poison, a lth ough th e lar ge number of cases followinga h ot, dry summ er, seemingly cont ra dicts t his sta temen t.

In the tropics the disease prevails to a far greater extent during therainy season, and the disappearance of malaria by draining marshysections confirms th is view.

Winds.That the poison may be transferred some distance by strong,winds has been clearly proven by sailors contracting the disease whileanchored three to five miles off malarial shores; on the other hand,th ese sam e winds, by ra pidly drying th e soil, ma v comba t its in fluen ce.

Trees.The Eucalyptus-tree at one time was supposed to possess somevirtue in combating the toxin, and the marked decrease in large areaswhere th ese trees were plan ted, nota bly in t he Roma n Ca mpagna , werecited as proof; but the more rational view is that by drawing largequantities of water from the soil, it was thus rendered sterile to thegerm, an d th at an y rapid-growing trees would give like r esults.



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Altitude.Tha t gravity influenced th e poison wa s very ear ly recognizedby people settling in malarial sections, for it was soon learned that bybuilding their houses on high lands they rendered themselvescomparatively free from the disease, and that those residing in thesecond stories of buildings were also largely exempt, while those on the

ground floor suffered. The poison is found near the ground, save whencar ried to higher altitu des by high winds.

Season.Heat being an important factor in the development of thepoison or germ, we find the disease prevailing more extensively in thefall, following the hot weather of July and August, the maximumnumber of cases occurring in September. While this is true of thetem pera te a nd sub-tropical zones, in t he t ropics a s m an y cases occur inth e spring as in th e fall.

The Malarial Germ or Parasite.In 1879, Klebs and Tomassi Crudelidiscovered that certain soils, when the conditions of moisture and heatwere favorable, resulted in the development of malaria, and theysucceeded in isolating a specific germ, which they termed the bacillusmalaria, and claimed that it was the specific agent causing all forms ofmalaria. Other observers, however, after most careful and painstakingstu dy, failed to confirm th e claims of th ese two work ers, a nd it r ema inedfor a French army surgeon, Lavaran, in the following year, 1880, todiscover in the blood of malarial patients the specific parasite that isnow recognized by the medical world as the causal agent in all forms of

malaria.

For th ree years his discoveries a nd pu blicat ions cau sed but litt le int erestin t he medical world, but Richa rd, in 1882, an d Ma rchiafava, Golgi, andCelli in 1883, Ita lian observers, published t heir investigat ions, r at ifyingth e observat ions of Lavar an . Since t hen Concilman , Osier, J am es, Dock,and others of the United States; Van Dyke Carter, of India, as well asFrench, German, English, and Russian observers, all unite in theirdeclaration that Lavaran's observati

Eclectic Medicine Part Ia

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