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The Medical World
The knowledge that a man can use is the only real knowledge ; the only knowledge that has
like dust about the brain, or dries like raindrops off the stones.-FBOUDE.
not been noted in its connection. Therés
The Medical World fore it would be impossible to detail a fixt
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symptom-complex, and say, “this is la C. F. TAYLOR, M. D.
grippe." Editor and Publisher
The patient begins to have a feeling of
great lassitude long before any other sympBubscription to any part of the Onited States and Canada tom appears. He is tired easily, easily ONE DOLLAR per year. To England and the British
depresst and somewhat despondent, given Colonies, FIVE SHILLINGS per year. Postage free. Single copies, TEN CENTS. These rates must be paid invariably
to looking upon the dark side of things. in advance.
He then complains of pain in the back, and We cannot always supply back numbers. Should a number
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irregular fever, tho sometimes the course Pay no money to agents for the journal unless publisher's
of the fever may closely simulate either receipt is given.
malaria or typhoid fever. The tongue is. ADDRESS ALL COMMUNICATIONS TO "THE MEDICAL WORLD,"
coated, the appetite is affected, sometimes
entirely gone, sometimes increast to voraPHILADELPHIA, PA. city. Sometimes the urine is high-colored.
and scanty, occasionally limpid and pro
fuse. Often there is sneezing and coryza, VOL. XVII. JANUARY, 1899.
frequently the catarrhal symptoms are not
obvious. ALLIED PRINTING
Sometimes the patient has a copious," TRADES COUNCIL
watery diarrhea, associated with colic, PHILADELPHIA
fever, etc., and one is tempted to conclude
that cholera morbus has got him. Son The Symptomatology of Grip. times there is a general aching of the sysA well-known diagnostician, while lec- tem, with pains in location and degree turing in one of our most noted colleges closely resembling those of rheumatism. upon this Russian scourge, after spending Sometimes there are periodic chills and nearly an hour in enumerating apparently fever like those of malaria. Occasionally all the symptoms at any time to be observed nausea and urticaria obscure the main in the human system, concluded in despair: trouble, and the patient is treated for some "In short, gentlemen, whenever you have digestive disturbance. Many times the a set of symptoms that do not seem to fit disease terminates in three or four days by into any known disease, especially when crisis, often there is a gradual reduction of attended with a disproportionate prostra- symptoms, frequently some dangerous comtion, you may safely diagnose the grip.” plication as pneumonia, nephritis, meninAnd truly this seems to be the case, for it gitis, neuritis or insanity supervenes. would be difficult to mention a symptom The typical case, however, can be that has not appeared in one case or an- described as beginning abruptly with lassiother, or think of a complication that has tude, a feeling of general malaise, chilli
ness, febrile elevation ranging between compressible; the urine is scanty and 101° and 103°, and extreme prostration, sometimes albuminous; the bowels There is coryza, sneezing, hoarseness, and constipated. There is great prostration a hard, paroxysmal cough with compara- and pallor. tively little expectoration. There is gener- The patient complains of difficulty in ally pain in the head and the back, and swallowing, and of a stiff neck. There is often a slight diarrhea, altho constipation a tenderness under the jaw, the lymphatic is not uncommon.
glands are considerably swollen and a The crucial symptom, however, is the grayish-white membrane, resembling dirty great prostration, associated with mental white kid, appears on the fauces. There depression. When any of the other symp- is hoarseness, sometimes loss of voice, a toms mentioned are associated with this, croupy cough, progressive difficulty of influenza can safely be diagnosed, even breathing. Sometimes shreds of memwhen there are no catarrhal symptoms brane are expelled in violent fits of coughnoticeable. The finding of the bacillus of ing. Pfeiffer in the sputum would also be good The onset is more sudden in scarlet proof of the character of the attack, but fever, the fever is higher, the tongue has a this is somewhat difficult to demonstrate, strawberry appearance, and the rash apboth from lack of facilities among the rank pears about the second or third day. In and file of the profession, and because the membranous croup all the symptoms microbe is so hard to stain.
enumerated for diphtheria are very much
exaggerated and the constitutional disturbDiphtheria.
ance is much greater. It is also more apt The diagnosis of diphtheria is held now to be followed by sequelae. In follicular to depend finally upon the demonstration tonsillitis the whitish spots conform closely of the Klebs-Loeffler bacillus, the exciting to the lacunae, and can be removed withcause, which is found only in the mem- out causing the bleeding which follows the branous exudation. The disease is detachment of the diphtheritic membrane. acutely contagious and is characterized In every case of exudation which is at by moderate fever, great prostration, all doubtful, examination should be made glandular enlargements and a fibrinous for diphtheria bacilli. The genuine Loeffler exudate located usually in the throat, bacillus has been found in convalescence altho it may be found anywhere upon the from diphtheria and in isolated cases in mucous membrane.
healthy people. It neither always has a The disease usually occurs in children characteristic appearance nor a specific between three and six years of age, altho coloration peculiar to itself. The exact no age is absolutely exempt. "Catarrhal proof can therefore only be furnisht by conditions of the throat are strong predis- culture. A reliable result can be obtained posing factors. The period of incubation by this method in twenty-four hours by of an attack varies from two to fifteen spreading the specimen upon an agar days.
plate. It is seldom necessary to make a The attack usually begins with chills, bouillion culture, and besides the bacilli moderate fever and malaise. The throat develop so typically on the plate that it is feels stiff and is slightly reddened at first, not required. the inflammation becoming deeper as the Still there is apt to be a loss of twentyattack progresses, until it is often a deep four hours before a definite diagnosis is angry color underneath the exudate. The
possible, and it is therefore well to instifever is quite regular in its course, and tute specific treatment at once in any seldom exceeds 104 degrees.
doubtful cases without waiting for the reThe pulse is feeble and rapid, sometimes port from the bacteriologic department.
sidered, are the acute articular rheumatism Every doctor has encountered his case (the so-called rheumatic fever or inflamof some one or other of the manifestations
matory rheumatism), chronic rheumatism, of rheumatism, and most of us have had muscular rheumatism, torticollis, lumbago, at least one or two cases that, in their
gout, sciatica, etc.
These form a group multiplicity of symptoms and obstinacy in by themselves, having many points in comyielding to recommended remedies, have
mon, both in diagnosis and treatment. fairly baffled us. We treat one, two, three, They will be taken up in order and briefly a dozen cases successfully until we begin to treated as to the general points, more with feel the loftiest compassion for poor Dr. a view to encouraging discussion and conWayback, who so ingenuously confesses his tributions in regard to individual cases, lack of success. We have been so uniformly than in the desire to exhaust all that successful, that we unconsciously fall into might be said upon each subject. the routine of using the same prescription for all cases, until at last, behold! we meet
Rheumatic Fever. our Waterloo in some patient who persists The exciting cause of the rheumatic disin the morning greeting, “Doctor, I feel orders is still unknown, altho there is a no better, if anything, a little worse!" strong bias in favor of the theory that they
We cannot convince ourselves at first are due to deranged metabolism, the nitrogthat this can be true. We feel absolutely enous products being converted into sure the patient is “hipped,” and adopt a lactic and uric acids and allied substances, soothing way of telling him, “That is all instead of being eliminated from the econright! You'll be all right to-morrow,"
omy as urea.
These substances over-tax only to be met when to-morrow comes by the excretory apparatuses and finally clog the same wail. Finally, when we begin to up the system. Yet there are many adherget sly hints that perhaps we do not under. ents to the theory that diseases of this stand the case, that Dr. So-and-So has had type are due to some specific infection, and such "splendid luck" in treating cases must be classt with erysipelas, pneumonia, just like this, etc., we begin to realize that etc. Others again regard the rheumatic "given the disease we know the remedy,” affections as purely neuroses. will not always work, since the patient It is, however, known that predisposing may sometimes figure in the equation as factors are heredity, exposure to cold and an unknown quantity of considerable im- wet, and sudden chilling of the system. port. We begin to think there may be Rheumatism is more apt to occur in perother Waybacks than the original one, and sons over fifteen and under forty years o when we once get in this attitude of hu- age, and so far from giving immunity, one mility, we will again be able to cope with attack almost certainly will lead to others. rheumatism, plus the individual,a com- The residents of the temperate zones are bination after all not so exceedingly rare. most liable to attacks, it seldom appearing
It is well to bear in mind that text-books among Esquimaux or even among tempoand colleges, as a rule, deal with the typ- rary residents of the frigid climes, and very ical cases of any disease. Experience rarely in those living in tropic climes. alone, whether of ourselves or others, will Rheumatic fever may be described as an teach us how to adapt the general to the acute general disease with a markt tendency special. This is particularly true of the to affect the heart, and characterized by an diseases having their origin in the uric irregular fever, acid sweats, inflammation acid diathesis, perhaps more true than of of the joints, etc. Secondary inflamany other class of diseases than those mations, such as endocarditis, pericarditis, known as neurasthenic.!
pleurisy and pneumonia, often occur, and Among the forms of disease to be con- in all cases the prognosis must be guarded.
A large percentage of cases end in during an attack, and the diet should recovery, altho a number die of exhaustion consist mainly of milk and oatmeal gruel or of some complication, notably hyper- or barley water. Stimulants should be pyrexia. Occasionally cases end in chronic avoided unless there is some visceral comrheumatism. The disease is very prone to plication strongly indicating their use. relapse and recurrence. When endocar- The free use of lemonade or mineral ditis occurs it frequently leads to slow waters should be encouraged. thickening or retraction of the valves, and The remedies lie between the salicylic to all the phenomena of chronic heart dis- derivatives and compounds, and the alkaease, altho in a number of cases no trouble lies, like the salts of potassium. All beyond the immediate attack may occur. members of the coal tar group of deriva
The symptoms vary very much, being tives are used with great benefit in the very severe in some cases and mild in treatment of the acute form of rheumatism, others. The onset is generally abrupt, where they seem to have an action indealtho it more rarely follows a feeling of pendent of their antipyretic and analgesic general malaise, chilliness, and sore throat. effect. Antipyrin, phenacetin and acetanThe skin is feverish and flusht at the first, ilid are especially well spoken of. but it assumes a paler look later from The salicylates relieve the pain but do anemia. The large joints are usually not prevent relapses nor cardiac complicaaffected-reddened, swollen, tender to the tions. Possibly salicylic acid (ten grains touch. The joints most commonly affected in a capsule every two hours) is the best are the knees, elbows, ankles and wrists, form to give this remedy, but sodium salibut no articulations are exempt, even the cylate in a quantity nearly double is muscles in severe cases becoming painful, thought by many to be more prompt and tender and rigid.
lasting in its effects. Large doses will Fever rises rapidly to about 102 or 103 excite ringing in the ears. Often markt degrees, but is very irregular in course and relief cannot be obtained until symptoms indefinite in duration. There is a copious of salicylism are obtained. The oil of perspiration which has a peculiar, sour gaultheria is lately used a great deal, but smell. Testing by litmus gives an acid there are a great many contradictory rereaction. The urine is scanty and high ports concerning results. The use of salol colored, and throws down an abundant is being gradually abandoned, as it is apt sediment of urates and uric acid. The to produce renal irritation (carboluria), bowels are constipated, the tongue is while its beneficial results can be obtained coated, and the appetite is lost. The dura- from the use of the pure salicylic acid. tion of the attack varies from a few days It is a moot point whether or not the use to several weeks.
of alkalies has much effect in cutting short The first indication in treatment is abso- the course of an attack of acute rheumalute rest in a room free from draft but well tism, altho it is claimed and apparently ventilated. The patient should not be substantiated in fact that they lessen the allowed to lie between sheets, but should tendency to endocarditis. If they are be placed at once between blankets. The used they should be given in liberal doses joints may be painted with iodin and wrapt until the urine has a distinctly acid reacin cotton wool. Some advocate the use of tion, say potassium bicarbonate in halfblisters, while others claim better results dram doses every two hours. It is a good from local applications of cold. The latter plan to combine the alkalies with the salimethod is especially in favor on the Conti- cylates. If there is anemia, Basham's nent. Sometimes great relief is obtained mixture is excellent in combination with by placing the joints in light splints. the alkalies or the salicylates.
The use of meat should be interdicted Liniments are often desired by the patient for the immediate effect, tho no bation, the joints affected becoming swollen doubt the gentle friction with which they and tender. There is no predilection for are generally applied has an equal effect any especial joint, nor any definite limit with the drugs in relieving pain. A mix- to the duration of an attack. Often in ture of chloroform, fluid extract of aconite cases that have lasted for many years the and soap liniment gives excellent results. movements become restricted and the mus
When hyperpyrexia appears it should cles become wasted. Arterial degenerabe treated promptly, there being but little tion and chronic endocarditis are often choice, since
the application of cold co-existent. The outlook for complete reis all that is really effective. Often even covery is generally poor, altho much relief this is ineffective, but there is no means may be had from judicious and long-conto compare with it. It not only reduces tinued treatment. Symptomatic treatthe high temperature, but also subdues ment seems to rule, and advice looking the delirium which so frequently accom- toward prevention should be given. panies it.
If there has been a period of There is very little to be recommended coma, the mind will become clear and for internal treatment, ichthyol adminisnormal sleep be induced. The condition tered in capsules in doses of from ten to of hyperpyrexia is the most serious of all thirty grains of either sodium or lithium the manifestations or complications of sulfo-ichthyolate, having probably the rheumatic fever, and altho comparatively preference. The salicylates have but little rare, is in a large measure responsible for effect, unless there are superadded subthe deaths from this disorder. It is clear acute inflammatory attacks, when these from general experience that the sooner are probably relieved by the drug. The active measures are employed, the better alkalies and potassium iodid also have adare the prospects for recovery. Valuable herents, altho there is much doubt time may be lost in experimenting with whether they have any direct influence. medicinal antipyretics, and it is obviously The warm sulfur and the alkaline best to depend upon measures of known baths are most highly prized in the treatefficacy.
ment of chronic rheumatism, but it is After convalesence is inaugurated, the claimed by many therapists that their benpatient should be enjoined to take as much eficial action is not due so much to the rest as possible, and to avoid all over- mineral constituents of the baths as in the exertion until the immediate danger of warmth and massage, etc., employed in causing a permanent heart lesion has their administration. It is necessary to passt. A general tonic treatment embrac- make a careful examination into the renal ing the chalybeates is clearly indicated. function and state of the heart and circu
latory system before insisting upon the Chronic Articular Rheumatism.
use of the baths in a case of chronic rheuChronic rheumatism usually develops matism. They must not be used if there is late in life among those who have in- any organic disease of the kidneys with herited the tendency to the affection, or general arterio-sclerosis or hypertrophy of who are habitually exposed to the effects the left ventricle. At any rate, even when of cold and wet. Occasionally it results there is no doubt upon these points, it is from an attack of acute rheumatism. The well to not recommend the measure in adpatient complains of stiffness and pain in the joints, which often show noticeable Since exposure to cold and damp is the deformity and present an audible creaking chief exciting cause of the trouble, a warm, upon being manipulated. Barometric dry, and equable temperature is the best conditions such as the approach of a storm for rheumatics, and altho it will be imare often markt by the onset of an exacer- possible for all thus aflicted to avail them