A practical treatise on typhoid and all other slow fevers broken in fourteen days

Preface

As the writer has so greatly lessened the mortality, and shortened the duration of typhoid fever than as given in text-books, he has for this reason set this work before the public.

The reader is requested to examine the chapter on the treatment and formulas at the close of the book before beginning to read the work.

In order to clearly set forth the basis upon which this work is founded, namely, the vaso-motor capillary systems and the sympathetic nervous system, the author has quoted the direct words of the American Text-book of Physiology, and also from Hare on Practical Therapeutics.

And in order for the author to prove or disapprove his own ideas, he has also quoted some of the exact words of Nothnagel and Osier themselves. In order to prove that some of the commonly accepted ideas of Osier and Xothnagel are illogical and erroneous, the author has quoted a few of the exact words of these authors.

The author is greatly indebted to Hektoen and Riesman for their ideas, as seen in their work on Pathology as pertaining to the probability of the typhoid bacilli being nothing more than a rejuvenated colon bacilli.

Though the writer has unhesitatingly criticised the conflicting ideas of Osier and Xothnagel, such criticism, however, is solely from the firm conviction that their conclusions in these instances are illogical. But the writer must acknowledge his indebtedness to the assistance their work gave him on both Typhoid and Malarial Fevers.

iii

SUMMARY.

As so much already has been written on micro-organisms as the direct cause of all acute inflammatory diseases, I shall describe these fevers largely from a practical, clinical, therapeutic and prognostic standpoint. I propose to show a still deeper, underlying cause than mere micro-organisms as the cause of acute inflammatory diseases, namely: The Faulty Actions of the Yaso-motor Capillary Systems, the Laws of Diffusion, and the Abnormal Isotonic Conditions of the Blood.

In this work I shall briefly refer to the Yaso-motor Systems, the Laws of Diffusion, and the Lack of the Isotonic Conditions of the Blood. And in order to more clearly show how to abort Slow Fevers, it is necessary to minutely describe Malaria. After considering Malaria from a morphological standpoint, I shall show a still deeper, underlying cause than Malarial parasites, namely, the Faulty Action of the Yaso-motor System and the Lack of the Isotonic Conditions of the Blood.

I shall give the divisions of Malarial Fevers first from a morphological standpoint, as given by Xothnagel and Osier, in order to clearly show that their divisions are not upon a clearly defined logical basis. For I propose to show that though these eminent observers have fully agreed, morphologically, a*^ to the divisions of these fevers, nevertheless they hold distinctly opposite views from each other as to whether or not all forms of Malarial Fevers may be aborted with the use of quinine. And I shall further show that these eminent observers not only contradict each other's views concerning Malarial Fevers, but they even contradict their own statements.

I shall then call the attention of the reader to the importance of rejecting the mere statements even of eminent observers, unless to such statements are added logical reasons for saying that their ideas are absolutely correct.

v vi Summary.

After giving many reasons why a division of Malarial Fevers, from a morphological standpoint, is not a good one, I then proceed to show how Malarial Fevers may be divided from a practical, clinical and prognostic standpoint. And in the classification of Malarial Fevers, I divide and describe only those types of fevers that can be diagnosed at a glance as some type of Malarial Fever. For this reason I do not describe Estivio-autumnal Fevers under the head of Malarial Fevers.

I then proceed to show why Estivio-autumnal and Typhoid Fevers should both be described under the head of Slow Fevers. And in order to prove this statement, I propose to show that there are no clearly defined diagnostic signs between Estivo-autumnal and Typhoid Fever.

For I propose to show that there is no especial diagnostic importance in Typhoid Fever of the following signs : The typhoid tongue, rose-colored spots, stepladder-like ascent of the daily rise of the temperature, inflammation of "Peyer's Patches," diarrhoea, the mere fact that the quinine will not abort the fever, the diazo-reaction test, Widal Test, and hemorrhage of the bowels. And I propose to show that the mere presence of typhoid bacilli in the blood is no absolute proof that the disease is Typhoid Fever ; for I propose to show that there is a probability that the so-called typhoid bacilli are nothing more than rejuvenated colon bacilli.

Then I propose to show that the mere presence or absence of Malarial Parasites in the blood is no absolute, diagnostic certainty that the disease is Malarial Fever. And for this reason, the mere presence of Malarial Parasites is no absolute evidence that the disease is Estivo-autumnal Fever.

I then still further proceed to show from a practical, clinical, therapeutic and prognostic standpoint that it is better to classify Estivo-autumnal and Typhoid Fevers both under the head of "Slow Fever."

In order to clearly show how to abort slow fevers in fourteen days, and to do this with a minimum mortality, it is necessary to briefly describe some of the common remedies used in aborting slow fevers.

Therefore, I shall go into minute details to show just

Summary. vii when calomel is indicated and when contraindicated. I shall show when digitalis, gelsemium, aconite, and veratrum are indicated and when contraindicated under given connditions. Furthermore, I shall show when quinine, strychnine, atropia, arsenic, salol, nitro-glycerine, sweet spirits of nitre, and other common remedies, are indicated and when contraindicated.

I further propose to show that it is absolutely necessary to divide slow fevers into types according to their grades of severity. And I further propose to show that the grades of severity increase according to the involvement of the intestinal canal from within outward. And I shall further subdivide these types into different grades of severity. Furthermore, I shall consider involvement of tissues in a longitudinal direction as sequela. The sequela will also be minutely described, and the different grades of severity will be described. And in this work I shall consider all those diseases that are carried by reflex irritation as complications. And these complications will be minutely described. I divide these fevers in this way distinctly from a clinical, practical, therapeutic and prognostic standpoint ; for only in this way can slow fevers be succeessfully managed.

Before taking up the minute details of the various types and grades with their complications and sequela, I shall in this work lay out a broad, general plan to show how to pretty well tell how to determine the tissue of the intestinal canal involved from the objective and subjective symptoms alone. I shall further proceed to tell just how to detect a threatened reflex irritation, and how to prevent such a complication. In fact, a broacl general outline will be given, in order to thoroughly understand how to diagnose and successfully manage all forms, types, complications and sequela of slow fevers.

In order to more clearly set forth just how to successfully manage slow fevers, with their sequela and complications, I have given one or more clinical cases in every grade treated.

Then I have minutely described acute enteritis and acute dysentery. And I have further described acute diseases that may result from the absorption of poison during the inflammatory stages of acute inflammatory diseases, namely, Acute Osteo-mvelitis and Acute Uraemia.

Introduction

The Vaso-motor Capillary Systems* In 1840 Henle demonstrated the existence of muscular fibres in the middle coats of the arteries. Later Henle said : 'The part taken by the contractility of the heart and the blood vessels may be summed up in two words : the movement of the blood depends upon the heart, but its distribution depends upon the blood vessels.'' Later Henle further declared that the vessels contract because their nerves are stimulated either directly or reflexly through the agency of a sensory apparatus. And, still later, Schiff, Bernard, Brown, Scquard and Waller demonstrated and established the fact of the existence of nerve fibres, the stimulation of which causes constriction of the blood vessels to which they are distributed. In 1856 these men showed that there were present also vaso-motor nerves.

"The three classes of nerve cells. It is now known that the vaso-motor apparatus consists of three classes of nerve cells/ The cell bodies of the first class lie wholly within the sympathetic ganglia, their neuraxons (axis cylinder processes) passing directly to the smooth muscles in the walls of the blood vessels. The cell bodies of the second class are situated at different levels in the cerebro-spinal axis. their neuraxons passing thence to the sympathetic ganglia by way of the spinal and cranial nerves ; and so lie partly within and partly without the other two classes. And the cell bodies of the third class are placed in the bulb and control the sec-

* Taken from Howell in " American Text-Book of Physiology."

Typhoid and Other Fevers.

ond, through intra-spinal and intra-cranial paths, the third class lying wholly within the cerebro-spinal axis.

And here in this connection it might be said that the portal circulation is so connected that changes in the calibre of the blood vessels may alter the quantity of the blood in the lungs.

"The Vaso-dilator and Constrictor Nerves. It was later ascertained that the walls of the blood vessels were controlled by nerves that determine the amount of blood flow to the blood vessels. When these nerves are stimulated, they either narrow the blood vessels or constrict them. Those nerves that dilate the internal blood vessels, thus naturally causing more or less constriction of the peripheral blood vessels, are called "Vaso-dilator nerves." Those nerves that constrict the internal blood vessels, thus naturally causing more or less dilation of the peripheral blood-vessels, "are called vasoconstrictor nerves."

Concerning the Vaso-motor system Hare says : "I am convinced that the importance of considering the condition of the vaso-motor system is not appreciated. Either it is ignored entirely, or it is spoken of indefinitely in much the same way that some practitioners refer to the sympathetic system as the cause of an ailment, probably because it is the simplest way of admitting that they do not know what they are talking about. In reality we may, in view of our knowledge of the functions of the vaso-motor system, assert .that its integrity is as necessary to life as is the integrity of the heart — the organ to which we pay so much attention in every case we see. A heart may be lamed, yet the man live comfortably; whereas an ill-conditioned vaso-motor system will at once cause distress. This system is made up* on the one hand of the vaso-motor nervous apparatus, and on the other of the blood vessels themselves.

"It must be remembered that the tonicity of the arterioles and capillaries offers a resistance to the action of the heart which is as natural as is the atmospheric pressure of fifteen pounds to the square inch on our bodies or in our lungs, and that any variation in this resistance by reason of dilatation or

Introduction.

contraction of the blood vessels is followed by as definite symptoms as ensue when we expose ourselves to rarified air on the one hand, or to compressed air on the other. The resistance offered to the heart by the properly acting vasomotor nervous system, through its influence on the vessels, is identical with the friction offered to the driving-wheels of a locomotive. The locomotive is meant to meet and stand the resistance, and if the resistance is removed by slippery rails the wheels fly around ineffectually, racking the machinery and destroying its usefulness. On the other hand, if the hill be too steep, the resistance is too great, and the engine comes to a standstill or blows out a cylinder-head, though before such a thing occurs the mechanism is much embarrassed, as is evidenced by the heaving impulses of the draught.

"From this we learn some important diagnostic and therapeutic facts : First, that a rapid pulse may be due in no way to a disordered heart, but be due to a vaso-motor relaxation ; and second, that the proper way of treating the pulse is to put sand on the track and increase the resistance, and not to make more steam — or give digitalis — which will only make the engine, or heart, work away on slippery rails with more wear and tear and make no progress. Conversely, if a heart seems to be laboring against a high arterial pressure, the most sensible thing for us to do is not to stimulate this organ to increased and exhausting effort, but to eliminate the resistance offered by the grade by making a cut through which the heart may pump its way with normal resistance. This we do by the use of vaso-motor relaxants, such as nitrites, or by bleeding. Much of the reputation of nitro-glycerine as a cardiac stimulant rests on the fact that under its influence excessive arterial resistance is removed, and the heart has a chance to perform its work properly without direct stimulation. When we consider the enormous space offered by the capillary area when it is relaxed for the flow of blood or its stagnation, the facts I am endeavoring to emphasize become even more impressive. It seems proper, therefore, that in every case to which we are called we should examine the tension of the blood vessels before prescribing for the heart itself."

Typhoid and Other Fevers.

Laws of diffusion* "When two gases are brought into contact, a homogeneous mixture of the two results. This interpenetration of the gases is spoken of as diffusion, which is due to the continuous movements of the gaseous molecules to and fro within the limits of the combining space. Also for the same reasons, when two miscible liquids or solutions are brought into contact, a diffusion occurs, the movement of the molecules finally affecting a homogeneous mixture. If the two liquids happen to be separated by a membrane, diffusion will still occur, provided the membrane is permeable to the liquid molecules, and in time the two liquids on the two sides will be mixtures having a uniform composition. Not only the water molecules, but the molecules of many substances in solution, as sugar, carbonate of soda and chloride of soda, may pass to and fro through membranes, so that two liquids separated from each other by an intervening membrane, and originally unlike in composition, may finally, by the act of diffusion, come to have the same composition. Diffusion of this kind through a membrane is frequently spoken of as dialysis, or osmosis. In the body we deal with aqueous solutions of various substances that are separated from one another by living membranes such as the walls of blood vessels, capillaries, or of the alimentary canal. And the laws of diffusion are of immediate importance in explaining the passage of water and dissolved substances through these living septa. In aqueous solutions such as we have in the body we must take into account the movement of the molecules of the solvent, water, as well as the substances dissolved. These latter may have different degrees of diffusibility as compared with one another or with the water molecules; and it frequently happens that a membrane that is permeable to water is less permeable to the molecules of the substance in solution. For this reason the diffusion stream of water and of the dissolved substance may be differentiated, as it were, to a greater or lesser extent. It is now the custom to limit the term osmosis to the stream of water molecules passing through

Taken from " Howell on Physiology.

Introduction.

a membrane, while the term dialysis, or diffusion, is applied to the passage of molecules of the substance in solution.

"Osmotic Pressure. The osmotic stream of water under varying conditions is especially important, and in connection with the process it is necessary to define the term osmotic pressure. Let us imagine two masses of water separated by a permeable membrane, we can readily understand that as many water molecules will pass through from one side as from the other ; the two streams, in fact, will neutralize each other, and the volumes of the two masses of water will remain unchanged. The movement of the water is not actually observed, but it is assumed to take place on the theory that the liquid molecules are continually in motion, and that the membrane, being permeable, offers no obstacles to their movements. If now on one side of a membrane we place a solution of some crystalloid substance, as salt, and on the other side pure water, then it will be found that an excess of water will pass from the water side containing the salt solution. So it is seen that the salt in solution exerts a certain osmotic pressure, in consequence of which more water flows from the water side to the side of the solution than in the reverse direction. As a matter of experiment it is found that the osmotic pressure varies with the amount of the substance in solution.

"Isotonic Solutions. It appears that the liquid surrounding the corpuscles must have a certain concentration as regards salts or other soluble substances, such as sugar, in order to prevent the entrance of water into the substance of the corpuscle. Normally the substance of the red blood corpuscle possesses a certain osmotic pressure, which is supposed to be equal to that of the plasma by which it is surrounded, so that the interchange of water between is at an equilibrium. If the concentration of this outside liquid is diminished, this equilibrium is destroyed and water passes into the corpuscles; if the dilution has been sufficient, enough water passes into the corpuscle to make it swell and eventually to force out the haemoglobin. Such liquids contain inorganic salts or other soluble substances that possess an osmotic pressure sufficient to prevent the imbibition of water by the corpuscles. Red

Typhoid and Other Fevers.

corpuscles suspended in such liquids do not change their shape nor lose their haemoglobin. When solutions of different substances are compared from this standpoint, it is found that the concentration necessary varies with the substance used. Thus a solution of soda chloride .64 per cent, is isotonic with a solution of sugar of 5.5 per cent., or a solution of nitrate of potassium of 1.09 per cent. When placed in any of these three solutions, red blood corpuscles do not take up water at least in sufficient amount to discharge the haemoglobin.

Chapter II. Acute Inflammatory Diseases

Acute inflammatory diseases named from the location of the malady. Most diseases have been named from the location of the inflammatory product rather than from the micro-organism causing the disease, such a condition resulting in the more or less sudden flow of blood to the affected area. For instance, any more or less sudden flow of blood to the bronchial tubes is called bronchitis; to the lungs, pneumonia; to the meninges, meningitis; to the stomach, gastritis; to the region of the kidney, under the name of nephritis, or if very severe grade, hematurea or hemoglobinuria; to the intestinal tract, under the name of typhoid, malarial, enteritis, dysentery, etc. ; and many other diseases are named in the same way. The more or less rapid flow of blood to the affected area usually produces a chill or rigor.

Symptoms. There is usually a chill or rigor in all forms of acute inflammatory diseases; in some forms the disease is ushered in with the hot stage. The first stage is quickly followed by the hot stage. After the hot stage the third stage begins.

Etiology. Although it is considered to be absolutely certain that all acute inflammatory diseases are due to some form of micro-organisrn, however, this assertion cannot be absolutely proven, for there is a probability that the micro-organisms in these diseases are rather the result of the increased flow of blood, causing the inflammation of the affected region which furnished food for the micro-organisms.

It is not clear that micro-organisms are the sole cause of acute inflammatory diseases for the following reasons : For instance, it cannot be known, absolutely, that microbes are the cause of pneumonia, for these micro-organisms are often found in the air passages in health; and so if found in health, their presence in disease is of no especial diagnostic import. Then, too, it is admitted by all scientific men that the micro-organisms may be -lodged in a healthy individual with sufficient resistive power without any evil effects. Is it not only reasonable to decide that lying on a damp, cold ground, sitting in a cold room, or getting wet feet, rather is a direct cause of bronchitis, rhinitis and pneumonia, thus causing an abnormal flow of blood to the affected area rather than micro-organisms that often are found in health?

So there must be a deeper, underlying cause for acute inflammatory diseases than mere micro-organisms, namely, a faulty vaso-motor system.

Therefore, in order to be in good health, we may conclude from what has already been said that so long as there is an isotonic condition between the corpuscles of the blood and its outer blood plasma, and so long as the capillary and vaso-motor systems are in perfect working order, just so long will a person remain in good health. For even if a person who is in good health be exposed to irritants from without or within, such irritation in an ordinary amount will not affect him so long as his vaso-motor and capillary systems keep in co-ordination with each other. Under such conditions his system is able to keep the blood flow in different portions of the body at a normal equilibrium.

But when the vaso-dilators and vaso-constrictors become unduly irritated by some irritation from without or within, as a result, blood flows toward the internal surface of the body, or at least to the affected area; in such cases, then, on account of the overheat production with lessened heat dissipation, there is more or less rapid rise of temperature. In this way the fever occurs.

As we name diseases from the location of the inflammation, then it is evident that acute diseases are named largely from the location of the disease rather than from the parasatology of the disease.

On reflection it is evident that there is a much closer relationship existing between all acute inflammatory diseases than is generally supposed to exist between them. But in this work we shall minutely describe only the acute inflammatory diseases that have their origin in the intestinal canal. These diseases now will be described.

Section II Chapter I

MALARIA.

Etiology. Formerly it was supposed that Malaria was carried to persons through drinking water. But this theory is now entirely discarded. But it is possible in some cases that malarial poison may enter the alimentary canal through drinking water. Such a thing is possible from the fact that the mucous membrane of the alimentary canal in malarial fevers is usually more or less inflamed, as is often shown by the vomiting of bile, which shows inflammation in the region of the bile ducts. In the next place, any close observer who has always lived in a malarial district has often noticed that chills and malarial fevers are much more common among those who habitually drink stagnant water or impure well water. In such cases, however, instead of the malarial parasites developing in from eight to fourteen days, it takes some months for them to develop. I have often found patients ill of some grade of malarial fever whose illness could be plainly traced from their swimming in stagnant water.

Air theory. The oldest theory was the supposition that malarial parasites rise from the soil into the air, and gain entrance into the respiratory tract. But this theory has been entirely abandoned. Nevertheless, anyone who lives in an intensely malarial district during the summer months may sometimes feel the bad effects of the poisonous decaying matter. And such persons will always feel much better by going for a few weeks to a location of a higher altitude. And, besides, it is noticed in all grades of malaria that the mucous membrane of the respiratory tract is usually more or less info)

io Typhoid and Other Fevers.

flamed. Then, too, hawking often precedes a bilious attack. And, furthermore, acute catarrh in the summer time often precedes some grade of malarial fever. All these conditions seem to point to the probability that the air in some way may transmit poison that later will be carried through sufficient different processes to cause some grade of malarial fever.

Mosquito theory. Then the mosquito theory was brought forth. This theory is the one accepted to-day. In favor of the "mosquito theory'' isolated experience was adduced to show that infection may be avoided in severe malarial regions by the use of mosquito nets ; and, also, it is known that a fire at hand makes it the less dangerous to sleep at night on a damp soil.

* The mosquito malarial cycle of development. At the present time we know that the cycle of development by the parasites in the human host is only one in its evolution, the other being completed in a second host, the mosquito. In the human host, however, the parasite undergoes a complicated metamorphosis, consisting in growth, reproduction and auto-infection of the special cells which furnish its habitat, the red blood cells. To one of these asexual cells the fever of malaria is charged, called "pyrotogenic," which fevers are quartan, tertian and estivo-autumnal fever.

Besides the pyrotogenic cycles which are brought about by the full growth of the parasites, the young parasites, before getting their growth, grow into two sexual cells. The growth of these two cells requires a new host, the mosquito, which completes the growth of the parasites. The male cell, is the flagella, which now is in the stomach of the mosquito. The male cell, flagella or microgamete, and the female cell, or macrogamete, are seen to become free in the gut of the mosquito. Soon the microgamete penetrates the macrogamete, the product of the union being a zygote. The zygote becomes encysted, and is then called an oocyst. Within these develop sporoblasts, that give rise without any spores to sporozoites (sickle bodies). These eventually leave the mosquito during

* Taken from Nothnagel.

the act of biting, and infect the fresh blood corpuscles of a new host, and so the sexual cycle is complete.

Nothnagel divides Malarial Fevers from a morphological standpoint as follows :

x'. "Malarial parasites that sporulate, but do not

FORM CRESCENTS.

(x) "The quartan parasite.

(y) "The tertian parasite.

y\ Malarial parasites that sporulate and form

CRESCENTS.

(x) "Pigmented quotidian.

(y) "Non-pigmented quotidian.

(z) Malignant tertian parasite.

(x') "The -quartan parasite completes its development from spore to sporulation in seventy-two hours. In its young condition it appears as a non-pigmented organism, looking like a small, clear speck in the infected blood corpuscles. It remains at this stage for twenty-four hours, increasing only a little in size. A deposition of pigment then takes place in the outer layers of parasites, consisting of very large, darkline granules, which show no movement. With increased pigment formation, the parasite loses its slight power of movement, until it appears as an immotile, spheric body, filling from one-third to one-half of the red blood corpuscles ; when, especially in unstained preparations, nothing more of the red blood corpuscles is visible. It now prepares itself for sporulation, in that the pigment granules clump themselves compactly in the centre of the organism, and a spoke-like arrangement occurs at the periphery of the plasma, which gradually extends to the centre. These radial lines becoming gradually sharper divide the parasites into a number of segments, usually not exceeding ten. These lines broaden into grooves, until the segments previously outlined become separated from one another as oval organisms, "daisy form." In each of these a circumscribed, glistening speck usually appears, which represents the nucleus. This gives to the segments the character of independent organisms. These fully formed spores break apart by rupturing the thin membrane around this.

This completes the life cycle of the parasite. The remaining clumps of pigment are carried away by the leucocytes as dead matter.

"The segmentation of the parasite occurs immediately after the paroxysm. The sporulation forms may vary more or less in shape and size. For instance, it sometimes happens that sporulation may occur at a time when sporulation has not yet reached the size of a red blood corpuscle. Under these circumstances the spores are usually from four to six. The infected red blood corpuscles remain unaltered in size and shape, or become somewhat smaller without change of form. The color of these shrunken, though round, corpuscles is darker than the non-infected. The infected corpuscles are not all decolorized or only slightly decolorized ; or, in fact, as already mentioned, they become somewhat darker. In this they are especially differentiated from the corpuscles infected with the tertian parasites. So in this type the protrusion of flagella is seldom seen. The course of development is more regular than in other species both in the relation of the duration of the development and the progress in growth of the single individuals. Moreover, sporulation forms are more frequently found in the peripheral blood, since the whole cycle of development usually takes place within the vascular system.

(y) "Tertian type. The duration of the tertian type requires forty-eight hours. When first seen within the corpuscle, it appears as a small, somewhat clear spot. In this stage it is now pigmented, or contains only extreme, fine pigment dust. It possesses a lively, amoeboid movement, readily visible for a long time (an hour or more) at the room temperature. After the removal of the blood the parasite remains at almost this stage, growing gradually for almost twenty-four hours. More arid more pigment in the form of fine granules and lines collect, particularly of the plasma, when it usually manifests a lively, swarming movement. Simultaneously, these lose in color, look pale in comparison with the non-infected, and often increase in size. Sporulation takes place after a life cycle of about forty-eight hours. At this time the parasite has lost its motility, being almost the size of a red blood corpuscle. Its host is enlarged and almost completely decolorized, and the swarming of the pigment is suspended. Segmentation usually takes place as follows: While the pigment concentrates itself in the centre of the organism as a thick lump, the plasma of the corpuscles breaks up into fifteen or twenty round, strongly refractive, small spheres (spores). These sometimes arrange themselves regularly in two concentric rows, "Golgi's sunflower," but usually irregularly, like a mulberry. The spores of the tertian parasites are rounder and smaller than the quartan. The most characteristic feature in the sporulation of the tertian parasite is the large number (fifteen or twenty) of small, round spores. As in the quartan, also in the tertian, the act of sporulation corresponds to the paroxysm of the fever.