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