(jw 7 mi 



CLINICAL STUDIES FROM SERVICE IN WARDS 18, 19, 20 AND 
21, THE CHARITY HOSPITAL, FROM OCTOBER 1, 1875, TO 
APRIL 1, 1876. 



Malarial affections presented their usual large ratio to the 
whole number of cases treated in the wards. My case-book 
shows one hundred and sixty-nine cases diagnosed Recording to 
the various classifications of the malarial fevers. This is 42 25 
per cent, of all examples of disease treated. The number of 
deaths directly referrable to malarial symptoms is three, which 
is 5.66 per cent, of the aggregate number of deaths occurring in 
the wards under study. In the city of New Orleans, during the 
year ending December 31, 1875, there occurred 483 deaths which 
may be attributed to malarial symptoms. This is 7.89 per cent, 
of the aggregate number of deaths occuring in the whole urban 
population. It is to me a little surprising that such a result 
should obtain . While it is well understood by medical practi- 
tioners in the city that malarial attacks, distinctly recognizable 
by the boldness of their symptomatic phenomena, may originate 
in every district of the city, it is not a very frequent event that 
deaths occur from this cause among the favorably circumstanced 
of our population. It is in the suburbs chiefly, that fatal cases 
of malarial disease exhibit themselves. Again, it is to be re- 
membered that this is a commercial city, and that commercial 
pursuits involve travel and exposure to all the causations of 
disease which different climates develop. There is every proba- 
bility that many of the victims of malarial attacks in the pri- 
vate practice of the city have received the poison into their 
systems outside the limits of the city. 

If the same ratio of mortality (1.77 per cent.) to the number 
of attacks, prevailed in the city, that my wards exhibited in the 
hospital, it would indicate that very nearly 30,000 attacks of the 
various forms of malarial fever had occurred during the period 
under consideration. I am satisfied that this computation is not 
correct The sources of error are : first, that the report of the 




RC 31 
.N4 C5 
Copy 1 



BY S. 'M. BEMISS, M.D , 



u 

Theory and Practice of Medicine, and Clinical Medicine, Medical 
Department, University of Louisiana. 



FEVERS TREATED. 



182 Original Communications. [Sept. 

Board of Health includes the mortality returns from the hos- 
pital, and consequently are to a certain extent affected as to re- 
sults by these returns. Next, it is a reasonable inference that 
the death-rate of malarial cases is very much greater in private 
practice than in hospital practice. It is easy to perceive why 
this difference in results should obtain. The cases occurring 
outside of the hospital are for the most part in the suburbs, 
remote both from the physician and the apothecary. The phy- 
sician is often not called until the symptoms are of the gravest 
character. Valuable time is thus lost in a form of disease which 
requires the most prompt and energetic treatment. Superadded 
to all these obstacles, a medical attendant has never the expe- 
rienced judicious nursing a hospital affords, and is often doomed 
to experience the mortification of beholding his best matured 
plans of treatment thwarted by ignorant and inefficient efforts 
to put them in practice. The year 1875 was remarkable through- 
out the Mississippi Valley for an unusual amount of rain-fall 
and an unusual prevalence of malarial cases. In the city of 
New Orleans the aggregate depth of rain, as measured by the 
gauge at the Board of Health office, was 48.83 inches for the first 
half year, and 34.21 for the latter half. A similar meteorological 
condition seemed to extend over the greater part of the Missis- 
sippi Valley, and to furnish the requisites for wide-spread and 
intensely active evolution of swamp poison. 

In previous papers upon the subject of malarious affections*, I 
have more than once alluded to the fact, so well known to prac- 
titioners, that certain epidemics of miasmatic fevers are liable to 
be marked by symptoms seldom seen, or it may be, altogether 
wanting in other epidemics. While as yet there has been no 
satisfactory explanation of the influences which occasion these 
changes of livery, they are still interesting subjects to be noted, 
for they become the salient points which call for essential modi- 
fications of treatment. 

In the present paper, it is my intention to confine the remarks 
I shall make upon malarial affections to differences in sympto- 
matic phenomena, whether relating to the epidemic of 1875 or to 
individual cases, and the modes of treatment which I have found 
most efficient in combatting the morbid states which these vari- 
ous groups of symptoms represent. 

Two pathological changes were so common to the malarious 
attacks presented during last winter's term of hospital service , 

* is. O. Medical and Surgical Journal, New Series, July, J 878. 



187G] Bemiss— Clinical Studies: Sivamp Fever. 183 

attacks presented during last winter's terra of hospital service, 
as to have formed a topic of almost ' daily study and comment. 
These were a degree of auaemia altogether unusual, both as it 
respects commonness to the aggregate number of cases, and as 
it respects the profound degree of blood changes often attending 
its presence; and splenic enlargements. Many patients entered 
the wards whose u tallow skins" and bloodless tongues revealed 
at a first glimpse the almost utter devastation wrought upon 
the vital fluid. In a large majority of these typical cases of 
anaemia, effusions were found to have occurred into the areolar 
tissues — generally of the lower extremities, often of the face- 
sometimes in the lungs to a degree sufficient to give rise to 
limited oedema, and not at all uncommonly a greater or less 
amount of ascites was found to be present. Under these circum- 
stances it was quite natural that the appropriateness of the new 
nosological epithet, "pernicious anaemia," should become a sub- 
ject of discussion. Certainly, while in the presence of one of 
those worst examples of blood deterioration and anaemia produced 
by the swamp poison, the observer is forced to confess that the 
adjective is applicable to the case even when used in its most 
intensive sense. A simple exsanguinated state of the system, 
carried to the extent that serious lesions ot secretory functions 
result, is in itself a condition of perniciousuess, since the continu- 
ance of these functions is vital in the sense of being essential to 
life. But the anaemia of malarial intoxication has a quality of 
perniciousuess superadded to that of mere exsanguination, be- 
cause it is associated with a positive blood inquination, due to 
the presence of the primary, or some secondary poison in a fluid 
which has also undergone structural lesions. These considera- 
tions help us to apprehend the difficulties in our pathway, when 
we undertake to cure the anaemia of malarial disease. We have 
not only on the one hand to endeavor to restore the blood to a 
healthy state as it concerns its own normal constitution, but in 
the mean while we have continually to guard the patient lest his 
incompetent circulatory fluid— incapable of relieving his system 
of waste material through the usual emunctories — should under- 
go further deterioration from effete accumulations. 

There is yet another point to be vigilantly observed, which is, 
to protect the patient as much as may be in our power, against 
malarial paroxysms. We are somewhat prepared to understand 
that a well-marked malarial paroxysm shall involve anaemic 



184 



Original Communications. 



[Sept. 



changes, through the circulatory remora of the first stage — > 
through the abnormal temperature of the second stage, and 
through the excessive function of the sweat glands of the third 
stage. But my experience has on more than one occasion taught 
me, that an almost undiscernible approach to a paroxysm is 
capable of increasing in a very obvious manner the patient's 
anseinia. I think this statement applies with more certainty to 
those instances in which the paroxysmal phenomena are attended 
by marked elevation of temperature, and formerly I believed 
that the damage was due to this cause. Later observa- 
tions indicate that similar, if not equal results, follow par. 
oxysmal returns where elevation of temperature is so slight 
that an appeal to the thermometer is necessary to determine 
the question. Perhaps, after all, the most reasonable explana- 
tion may be found in the assumption, that lesions of nutritive 
changes throughout the whole system, belong essentially to the 
assemblage of disturbances of nerve function attendant upon the 
malarial paroxysm. 

In accordance with the ideas of pathology as just announced, 
we may formulate the indications for treatment under three pro- 
positions : 

1. To restore a normal constituency to the blood. 

2. To rid it of impurities, secondary accumulating in it. 

3. To ward off malarial paroxysms. 

The first indication mentioned, suggests chalybeates as the 
remedies best suited to the physician's purposes. I do not wish 
to under-estimate their great value. But when I recall the large 
number of cases in which their use has, in my hands, failed to 
cure, together with a small number in which their exhibition 
was not tolerated, I feel obliged to enter a protest against their 
indiscriminate employment. The forms of iron from which most 
benefit has been obtained are mentioned very nearly in the order 
of their estimated value. 

Iron by Hydrogen. I prescribe this preparation in my hospital 
practice more frequently than any other chalybeate. A combi- 
nation from which great benefit is often obtained is : R — Eeduced 
iron; sulphate quinine (or sulphate cinchonidia), aa gss.; arsenious 
acid, gr. j. Make xv. pills. S. Oue twice or thrice daily, given at 
times of taking food. Occasionally, with a view to combat un- 
usual nerve exhaustion, the arsenic was omitted, and extract 
nux vomica, or strychnia, was substituted, the former in doses 
of gr. ss. to gr. j. to pill s the latter one-thirtieth grain to pill. 



1876] Bemiss— Clinical Studies: Swamp Fever. 185 

Citrate of Iron and Quinine. This was generally prescribed in 
solution of 3j. to gss. in infusion of gentian, %iv. S. One table- 
spoonful twice to thrice daily. Sometimes 3j. tinct. nux vomica 
was added to this solution. The dose is exceedingly bitter, and 
often not well borne, but in many cases its benefits are striking. 

Tinct. Ferri. Chloridi. was often exhibited in doses varying 
from fifteen drops to half a drachm. In truth the most usual 
mode of prescribing was to order an ounce mixture containing 
equal parts of tincture of iron and simple syrup, and direct a 
teaspoonful in water twice or thrice daily. It sometimes occurred 
that I made solutions of quinine by means of the tincture of iron, 
and found the combination a valuable one. The prescription 
commonly used was sulph. quinine mur. tinct. iron £ij., cin- 
namon water ,svj. -m?. & Sol. S. Teaspoonful every 6 to 8 hours 
mixed in sweetened water. 

Wine of Iron was often prescribed, and not uncommonly the 
solution of arseniate potash was added in suitable proportions. 

Ammonio Sulphate of Iron, and Quinine, made into a solution 
by the addition of dilute sulphuric acid, was exhibited princi- 
pally to those patients whose cases showed greater than usual 
tendency to serous effusion. The formula was: R — Ammonio- 
sulph. iron, 9ij.; sulph. quinine, Bj.j dilute sulph. acid, ^i.; cin- 
namon water, ^vij. \)\ S. Teaspoonful in sweetened water 
twice daily. When indicated, strychnia may be added to this 
prescription. 

Iron alone is not a cure for malarial anaemia. It is probable 
that the agency it exerts in effecting such cures is far more in- 
considerable than is generally reckoned. While the physician 
should not fail to employ it when called for, he should not fall 
into the error of assigning to it a role quite beyond its sphere of 
capabilities. It is known to be capable of adding a missing con- 
stituent in retrograde lesions of the red corpuscles, but to effect 
this, it is necessary that certain not well- understood conditions 
should obtain which are essential for its absorption and specific 
appropriation. It is probable that these conditions are quite as 
often absent as present. Admitting that every condition and 
circumstance shall concur to favor the administration of iron, 
there is no doubt that other elements of nutrition are required 
to cooperate with it in the blood-renewiug process, before its 
therapeutic value can be made manifest. The alimentation of 
ameuiie malarial patients is with me a most important consider- 



186 



Original Communications. 



[Sept. 



ation. They should be liberally supplied with carefully selected 
and well prepared animal food, to which such vegetables and fruits 
may be added as are regarded suitable to their condition. Diges- 
tion may be aided by acid solutions of pepsine, or by mineral acids 
diluted in some bitter infusion. In my hospital wards the latter 
are more frequently used, and by preference, the nitro-hydrochloric 
or the nitric alone. The list of promoters of digestion is incom- 
plete if we omit to mention alcoholic drinks, or for many patients 
coffee and tea. A very common prescription in my practice is 
the following: R — Compound tinct. cinchona, ^iv. S. Dessert 
spoonful in water after each meal. Whenever considered indi- 
cated, from five to eight drops of nitro-muriatic acid were added 
to each dose. Alcohol may also be given in the form of wine 
or beer. To a, few anaemic patients I have recently given a table- 
spoonful of Trommer's extract of malt after each meal, and have 
added to it, after mixing it with water, either pepsin, the mine- 
ral acids, or a small amount of whiskey, or all of them together. 
The prescription is worthy of further trial. It is needless to 
say that pure air, and such exercise as the patient is able to 
endure, are matters essential to his improvement. 

The second indication includes measures of treatment so often 
called for, that the medical attendant should constantly observe 
for the presence of symptoms justifying a resort to them. These 
symptoms are a coated tongue, with vitiation of the sense of 
taste; a muddy skin; cephalalgia, or vertigo; slight feverishness, 
aud urine for the most part highly colored and heavy. These 
symptoms contra-indicate the employment of analeptic remedies. 
Eliminants and alteratives should be appealed to. It is true that 
I have occasionally adopted a compromise method of treatment, 
which looked to the association of restorative and eliminant 
medication. The prescription generally employed for this pur- 
pose is: E — Sulph. magnesia, Jj. to ^ij.; sulphate iron, 9ij.; 
sulphuric acid, dilute, 33.; syrup orange peel, gvij ; water to 
gvj. Til s - Table-spoonful in water twice daily. I hold it 
to be a wiser and more satisfactory mode of practice to 
direct our energies to the removal of mischievous materials 
whose accumulations obstruct function. Mercurials are our 
most efficient remedies. In hospital I usually prescribe the mild 
chloride. From one to five grains are given, generally in pow- 
der combined, with bicarb, soda and white sugar, or with the 
soda alone. These small doses are repeated, at intervals vary- 



1876] Bemiss — Clinical Studies: Swamp Fever. 



187 



ing from four to forty-eight hours, according to the urgency of 
the case. In certain cases it is desirable to avoid the nausea 
and free catharsis liable to be produced by calomel and soda. 
A very efficient as well as mild mercurial dose will be found in 
the combination of three grains severally of blue mass, comp* 
ext. colocy., and castile soap : make two pills and give at one 
dose. It is by no means infrequently the case that a lienteric 
state of the bowels requires the combination of opiates with the 
mercurial which may be indicated. Under these circumstances 
the following prescription answers a most valuable purpose: 
R — Blue mass, pulv. rhubarb, aa gr. x.; sub-nitr. bismuth, 
morphia, gr. j.: make ten pills. S. One each night; or, twice or 
thrice daily. Again, in certain inveterate cases of malarial in- 
toxication with anaemia, I have found this prescription useful : 
E — Bichloride mercury, gr. ss. to gr. j.; comp. tinct. cinchon., |iv. 
Dessert-spoonful twice daily — after meals and largely diluted 
with water. 

In a few cases, more especially of young persons, adenitis, or 
some suspicions of scrofulous taint, have induced the exhibition 
of iod. pot. and the bichloride in combination. An eligible pre- 
scription may be made by dissolving them in desired proportions 
in a menstruum consisting of syrup pyrophospate of iron and 
pure water. 

I am free to confess that, although I have prescribed 
chloride of ammonium for a number of years, and to many 
patients, I am quite unable to single out those symptoms or con- 
ditions of disease in which its use is most likely to prove of ser- 
vice. It is to be admitted, however, that remarkable benefits 
sometimes follow its use. 

The third indication is best subserved by the preparations of 
cinchona. These may be given habitually, as for example, from 
three to five grains of quinine in one or two ounces of black 
coffee, morning and evening. In case the patient is sufficiently 
intelligent to note the prodromes of a paroxysm, and I may add, 
fortunate enough to have his paroxysms attended with prodromes, 
the exhibition of the drug may be deferred until the patient is 
warned of the approach of a paroxysm, when it should be 
given in positive quantity and in solution. 

Splenic Enlargement, in its association with malarial intoxica- 
tion, is an interesting subject to the physician. It is an easy 
matter for the medical observer to satisfy himself that splenic 



188 



Original Communications, 



[Sept. 



enlargement, to a greater or less extent, attends malarial parox- 
ysms. It is so unexceptionable in its occurrence, that when 
not present we may attribute its absence to a firm, unyielding 
capsule. The greater capsular elasticity may also explain why 
chronic enlargements of the spleen more certainly attend mala- 
rial toxaemia of early life than those of adults. But while admit- 
ting the influence of a paroxysm in mechanically distending the 
spleen, and admitting also, that a frequent repetition of this 
cause may set up an actual new growth, or true hypertrophy, 
there is still ground for the belief that chronic malarial intoxica- 
cation, without paroxysmal manifestations, is capable of pro- 
ducing a similar result. Hertz writes : "The very evident and 
almost constant way in which the spleen is involved in inter- 
mittent fever, suggests the idea that the two are very nearly 
related. "With our present knowledge we can no longer attri- 
bute the swelling of the spleen to an over-filling of the organ 
with blood during a chill alone, as it may attain to the very 
largest size in chronic infection without chills. ,? ^Ziemssen's Cy- 
clopaedia, Yol. II., p. 265.) According to either of these views, 
when endemic or epidemic prevalence of malaria is attended 
with an unusual number of cases of splenic enlargement, it indi- 
cates longer exposure to the poison rather than intensity of toxic 
action. It is not at all improbable that the climatic conditions 
of the Mississippi valley during 1875 were so continuously favor- 
able to the evolution of the swamp miasm, that a more perpetual 
dosing (so to speak) of persons exposed, was the consequence. 

However we may differ in respect to the mode of production 
of splenic enlargement, there can be but little question in regard 
to its troublesome influence when a complication of malarial 
anaemia is present. Serous effusions are more common events 
under such a complication, and aside from their occurrence, the 
anaemic state — the destruction of ratio between the red and white 
corpuscles, is more hopeless of cure. Close clinical observation 
may show that these remarks are more especially true in in- 
stances where the enlargement is a genuine hypertrophy, and 
thus establish a relation between such cases and the leucocy- 
themia of Bennett, or splenic anaemia of Wagner. At present I 
am unable to make this distinction. 

None of the cases of enlarged spleen required any treatment 
to be addressed to inflammatory states of the organ. Well- 
marked splenitis is, under my observation, an unusual event. I 



1876] Bemiss — Clinical Studies: Stvamp Fexer. 189 



have, however, seen two cases of abscess of the spleen occurring 
in chronic malarial disease. One was after a very long horse- 
back ride by a man unaccustomed to such exercise. On the 
o£her hand, the capsule is often the seat of inflammation to such 
an extent as to roughen its surface, giving rise to such illustra- 
tive examples of friction murmur that I am in the habit of aus- 
cultating all very large spleens to determine if it be present. 

I know of no treatment having any specific influence in reduc- 
ing an enlarged spleen. The treatment previously advised for 
the cure of anaemia, is as effectual for its cure as any treatment 
by drugs known to me. I have repeatedly tried Maclean's oint- 
ment of biniodide of mercury, as suggested in Reynold's System 
of Medicine (Yol. I. p. 68), but I am unable to report an instance 
in which benefit resulted from its use. In the meantime, both 
my own experience and the teachings of the older authors lead 
me to believe that constipation, and its attendant visceral en- 
gorgements, should be very carefully avoided. A daily dose or 
two of the solution of sulphate magnesia and iron mentioned on 
a previous page is an excellent prescription. Sending the patient, 
whenever possible to do so, out of a malarial region, is a wiser 
course to pursue. In the meantime it is proper to be mentioned, 
that, even in those cases where the enlargement appeared to be 
an unquestionable hyperplasy, a striking degree of diminution 
in size would accompany and follow convalescence Iroin the 
malarial cachexia. The lesson to be derived is important clini- 
cally, since we are able to assure those unfortunate patients to 
whom immense spleens are an incumbrance and source of mor- 
tification, that they may at least hope for some reduction of 
volume. 

Simple Intermittents . The number of simple intermittens ad- 
mitted in my wards was 147; about 87 per cent, of the whole 
number of malarial cases treated. It is not my intention to 
occupy any portion of the space at my command with remarks 
concerning the symptoms, or treatment of the simple intermit- 
tents under observation. Nothing new or valuable would be 
revealed by such a history. In my remarks upon the cases of 
remittent fever admitted for treatment I shall, by way of com- 
parison, place in juxtaposition records of temperature of both 
simple and pernicious intermittents, and remittent cases. 

Pernicious Malarial Attacks. These attacks are matters of 



190 



Original Co m m u nica turns. 



[Sept. 



the most serious concern to the practitioner, since the exercise 
of all his energies and of his highest skill is requisite to avert 
fatal results. They are also full of intense interest as points of 
abstract scientific study, since they involve many abstruse ques- 
tions of pathology. The term ^pernicious*' is not limited to some 
one form of malarial diseases, but includes all those cases which 
are atteaded by the quality ot •'perniciousness,'' or unusual gra- 
vity, or which are more than usually injurious, or hurtful to life. 
This element of danger, possessed in such a notable degree by 
pernicious malarial attacks, is a marked point of distinction be- 
tween them aud simple intermittents. Simple intermittents are 
never fatal except through some complication- the pernicious 
cases are accompanied by frightful mortality. As an abstract 
nosological classification the distinction is easily drawn; at the 
bedside, it is often a more difficult matter than the bold contrast 
just presented would indicate. This difficulty of diagnosis arises 
from the fact that the mode in which, pernicious attacks destroy 
life is by an exaggeration of some symptom, stage, or pathologi- 
cal state, normally connected with the simple forms of malarial 
disease. For example: it is well understood that more or less 
congestion of organs in the shut cavities attends all simple inter- 
mittents, but an exaggeration of the congestion to a dangerous 
degree converts the simple intermittent into a pernicious case. 
Exaggeration of the cold stage is a common cause of pernicious- 
ness. Again, it is true that the presence of the swamp poison 
in the blood interferes with its chemical and metamorphic changes, 
and in this manner occasions the accumulation of secondary 
poisons in that fluid. Ordinarily this does not reach a limit 
which is at all inconsistent with the performance of vital func- 
tions. An aggravation of this condition so as to approach, or 
pass this limit, transfers the case to the class of pernicious. 

Hemorrhage in any considerable amount and from a deeply- 
situated surface, is always a grave complication of fevers, and 
its occurrence at once places the case within the classification of 
pernicious. The symptoms and conditions which, in accordance 
with these illustrative examples, characterize perniciousness as 
connected with malarial attacks, afford a division of pernicious 
cases, quite true to nature, into three forms. 

1st. The algid, or congestive form, in which the perniciousness 
is due to an aggravation of the cold stage, or to dangerous con- 
gestion of some important viscus. 



1876] Bemiss — Clinical Studies: Swamp Fever. 191 

2d. The comatose form, in which the pernieiousness is due to a 
state of blood impurity sufficient to impair, or destroy its nutri- 
tive functions. 

3d. The hemorrhagic form, in which the perniciousness is due, 
first, to the hemorrhagic diathesis present; second, to the locali- 
zation of the bleeding — often occurring at points where extrava- 
sated blood produces dangerous lesions and obstructions of 
function; third, and least often, to the amount of blood lost to 
the system by the hemorrhage. 

This classification does not include the diaphoretic, or sweat- 
ing form, nor the ardent or intensely inflammatory form. 
It must be a rare event — in this country, at least — that the 
sweating stage of a malarial fever is exaggerated to such a 
degree as to place life in danger, while it is well understood 
that unusual elevations of temperature call for the physician's 
ministrations, whatever may be their cause or the conditions of 
their occurrence. 

Five cases of pernicious malarial fever were admitted to the 
hospital under my charge during my term of service. These 
were classed as follows: congestive, 1; died, 1; comatose, 3; 
died, 1; hemorrhagic, 1 — recovered. 

Case of Congestive Chill. Nicholas Delia, aged 16 years, by 
profession a hotel waiter, was brought to the hospital on the third 
of February. No history was procured, except that he had been 
unconscious since the preceding day, aud that he had been 
spending some months in a very unhealthy place near the lake 
shore. The assistant house surgeon, Dr. G. W. Lewis, pre- 
scribed £ss. bromide potash in enema to be repeated in two 
hours. The next morning, when I saw the patient he was 
entirely unconscious; all efforts to arouse him or induce deglu- 
tition unsuccessful; pulse irregular, and feeble; skin bluish, 
moist with perspiration, but not cool; pupils a little dilated, 
but correspond in movements; sensibility to light diminished; 
no paralysis; urine passed in bed; no stools. A scruple of qui- 
nine made into a solution with dilute sulphuric acid, and twenty 
drops tinct. opium, were given in two ounces of flaxseed emul- 
sion as an injection. During the day two injections were given, 
each consisting of |j. of water, 3j. bromide potash, and twenty 
drops of laudanum. The quinine was repeated at night, and 
again on the morning of the 5th ♦ 



192 



Origina I Communications. 



[Sept. 



The patient died during the night of the 5th. An autopsy 
was not permitted. # 

This is an illustrative case of the algid form of pernicious ma- 
larial fever, in which a partial reaction has occurred. Conges- 
tion, however produced, may destroy life either through its sheer 
physical force in arresting function by infarction, or through the 
inevitable consequences which arrested circulation entails upon 
the blood. It is highly probable that the latter mode of pro- 
ducing death more often prevails. Separation of blood constitu- 
ents due to its stasis, entails as results the formation of coagula 
in the congested vessels, the deposit of pigmentary matter, and a 
general damage to function proportionate to the lesions inflicted 
upon nutrition. Where death occurs as long after the chill as 
in this instance, it is reasonable to suppose that it is due to some 
condition included in the latter class of causes. 

The cure of a congestive chill is one of the most diflP cult problems 
the physician can possibly encounter. It is nothing less thau a 
proposition to cure an altered mechanism of the system supposed to 
be dependent upon some influence exercised over a nervous appa- 
ratus, whose therapeutics or experimental physiology are illy 
understood. While a satisfactory solution of this problem is 
probably a remote achievement in medicine, it was long ago 
empirically ascertained that certain agents exercised some degree 
of control over the cold stage of febrile attacks. For the most 
part these agents are addressed to the nerve element in the 
pathology of a chill, and are identically the same remedies which 
we use to allay other forms of nerve irritation. Opium, chloro- 
form, belladonna, chloral hydrate, and bromide potash, have 
proved more or less valuable according to the idiosyncrasy of 
the patient or the circumstances under which they were used. 
I consider opium the most valuable 01 these agents, and nearly 
always combine it with such other drug as I may select as an ad- 
j uvant. It is better to use it in moderate doses, and repeat these 
at short intervals. Twenty drops of laudanum with half a tea- 
spoonful of chloroform is an efficient prescription. One-sixth of 
a grain of morphia with one-fortieth of a grain of atropia may 
be injected subcutaneously. Nitrite of amyl is highly recom- 
mended upon another page of this issue of the Journal. I 
have never used it, but have no question in regard to its value. 
These remedies may be used at any stage of the chill without 
fear of prejudicing the subsequent career of the case. It is true, 



1876] 



Bemiss — Clinical Studies: Swamp Fever. 



193 



however, that expectations of abridging the congestive stage 
must vary with the length of time the chill has endured before 
the remedies have been applied. Frictiouing the extremities, 
and indeed the whole surface with ice, is another mode of prac- 
tice which 1 have never used, but which is well worthy of atten- 
tion and trial. In the event of inability to procure ice, douches 
of cold water, followed by frictions with coarse towels, may be 
substituted. The value of the hypodermic syringe in congestive 
chills must not be lost sight of. The suspension, or even reversal 
of normal systemic currents, is made evident by the serous vomit- 
ing and purging attending congestion of the abdominal cavity* 
Medicine placed in the stomach under these circumstances is 
virtually thrown away. It does not reach the circulation* 

Comatose Cases. Case 1. — Bernard A. Hagan, a laborer, 35 
years of age, was brought into ward 21, December 29th, in an 
insensible condition. At time of admission his temperature 
was 103°. Dr. Lewis ordered gss. of quinine by enema. Morning 
of 30th still unconscious, but able to swallow fluids placed upon 
the base of the tongue; urine and stools passed in bed; skin of 
a muddy yellowish hue; temperature 100.2°; pulse 120; respira- 
tions 33. A scruple of quinine in solution was given immedi- 
ately, and during the day carbonate of ammonia in five grain 
doses, was alternated with the same quantity of quinine every 
fourth hour. A liberal quantity of milk, concentrated beef- 
essence, and milk punch was given, both by mouth and rectum. 
Evening temperature 103.1°. December 31st. — But little change 
in patient's condition; temperature 100.3°; pulse 130; bowels 
and bladder voided in the bed; continue treatment. Evening 
temperature 103.2°. January 1st. — Morning temperature 102.3°; 
pulse 130; respirations 42. Death during the day. 

Case 2. — Charles Lacrosse, fisherman, aged 44; brought into 
ward 20 in an insensible condition, November 18th. Tempera- 
ture at time of admission 104.8°; pulse 120; respirations 40; able 
to swallow liquids placed far back in his mouth. Ordered £ij. 
of quinine in solution, ten grains to be given every fourth hour. 
Nov. 19th. — Patient has taken and retained all the quinine 
ordered, is perspiring profusely; temperature 97.8°, pulse 88; 
more conscious; takes food and water when offered him. Or- 
dered blue mass, com p. extr. colocy., aa gr. v. Make two pills; 
take at once; to drink through the day bitartrate potash <f j ., 



191 



Original Communications, 



[Sept. 



dissolved in lemonade, until the bowels are moved. Evening 
temperature 99.3°. November 20th. — Temperature 98°; patient 
placed under convalescent treatment; discharged from hospital 
November 29th. 

A third comatose patient was admitted to ward 19 on the 29th 
of October, entirely insensible. He was treated by large doses 
of quinine in solution per rectum, and by calomel xx gr., bicarb, 
soda gr. v., placed in the fauces and a tablespoonful of water 
trickled over it. 

As the patient began to improve, it was discovered that his 
right arm was paralyzed. A history subsequently obtained 
showed chat the patient was an engineer, and had been engaged 
in making some land surveys in a swampy portion of the State, 
and had been often obliged to wade or swim across the bayous, 
and to sleep at night in the open air, sometimes without any 
protection from the weather. He had previously enjoyed good 
health, and was altogether unable to account for the paralysis of 
his arm. During convalescence he was treated by iron, strych- 
nia, and the preparations of cinchona, and by cold douches, and 
frictions to the paralyzed arm. Convalescence was slow, but he 
was discharged completely recovered on the 20th of iSTovember. 
It would appear that Eomberg's instructive apothegm, that 
"neuralgia is the prayer of the nerve for healthy blood," may be 
properly extended to include cases of paralysis also. 

It is not necessary to make further remarks regarding the 
"comatose' 5 form of malarious disease. In typical cases the dif- 
ferential diagnosis between the congestive form and this, is made 
without difficulty. In congestive chill the surface is cold, blue, 
or livid, the pupils dilated, the pulse generally slower than 
natural and irregular. In the comatose form the surface is pre- 
ternaturally warm, of a muddy, semi-jaandiced hue, the pulse 
and temperature both indicating the feverish rather than the 
algid state. In congestion impeded function associates itself 
with the above mentioned symptoms, and unerringly shows not 
only its presence but which one of the shut cavities is the seat 
of the congestion. 

I have seldom lectured to students upon the subject of con- 
gestive fevers, or congestions, without feeling it my duty to ad- 
monish them against the employment of the term in that inde- 
finite and inconsiderate manner which has become common 
among some of our profession. If the death certificates which 



1876] Bemiss— Clinical Studies: Swamp Fever. 



195 



were sent in to the Board of Health of this city, in 1875, were 
based upon correct diagnoses, it would indicate that one person 
in every 1088 of the population living iu New Orleans died of 
some form of congestion during that year. Is any one prepared 
to believe that this represents a truth? If the term is abused 
at all, it is more often in respect to its use in accounting for 
mortality from brain symptoms. In New Orleans, in 1875, 117 
deaths are returned as having been due to congestion of the 
brain. This is 1.90 per cent, of the whole mortality of the city, 
and one death from this cause in every 1794 persons living in 
the city. In New York city, in 1873, 167 deaths are ascribed to 
congestion of the brain— .57 per cent, of total mortality, and one 
in every 5988 ot the living population. According to these 
figures, the danger of death from congestion of the brain is more 
than threefold greater in New Orleans than in New York. Ob- 
servation teaches me that such is not the case. 

Hemorrhagic Malarial Attack. The only case treated was an 
Irish laborer, 44 years of age, admitted to ward 18 on the 26th 
of October, with malarial haernaturia. No notes of the case are 
preserved, but the patient was discharged, cured, on the 6th day 
of December. 

In this, as in all grave forms of malarial disease, the leading 
indication is the production of early and decided cinchonism. 
After this, the most important question is, how the hemorrhage 
is to be treated ? In my observation it has seldom been so con- 
siderable as even to jeopardize the life of the patient by the 
amount of blood abstracted from the circulation. We might 
therefore dismiss the hemorrhage from among those symp- 
toms calling for special remedies if ifc were poured out upon a 
free surface only, and escaped at once from the system. But 
this is not the case; it is liable to accumulate in the kidneys, 
impeding or destroying function, perhaps by physical pressure 
upon the vascular supply of these organs. It is therefore a 
symptom of the most serious concern when viewed in this con- 
nection. Becent observations have satisfied me that haemosta- 
tics often afford valuable aid in curing renal hemorrhage in ma- 
larial disorders. To give them every opportunity for beneficial 
effect, they should be resorted to at the earliest practicable mo- 
ment, before serious damage has been produced by extravasated 
blood. Turpentine, ergot, gallic acid, the astringent salts of 



196 



Original Communications. 



[Sept. 



iron, or mineral acids, may be employed in accordance with the 
j)ractitioner's estimate of especial applicability to the case or his 
convenience. Some ot the best practitioners in the South have 
expressed perfect satisfaction with the action of turpentine. 
The revulsive effect over the circulation from the application of 
cups over the loins must not be lost sight of. 

Remittent Fever. Seven cases of remittent fever were treated, 
all of which recovered. The thermometer, or generally the un- 
aided senses of the physician, are sufficient to establish the 
differential diagnosis between remittent and intermittent fever. 
This difference, as it regards the febrile march in the two forms 
of fever, is the salient point of varying indications respecting 
treatment. In intermittents, febrde movement is for the most 
part a very unimportant event; in remittent attacks, the fatal 
result is often to be attributed to excessive elevations of tem- 
perature. 

Case. — Eobert Lesley, 24 years of age, was admitted to ward 
18, bed 265, on the 9th of February. The attendants who 
brought him to the hospital stated that he had been attacked 
with fever three days before admission. When the patient was 
first seen (February 10th), he presented the suffusion of face 
and eyes so illustrative of this form of fever. His tongue was 
dry and covered in the middle with a brown coat; abdomen 
tumid and tympanitic. Attendants state that he has been 
freely purged by cathartics taken without medical advice. He 
was so delirious and restless that a nurse was constantly required 
to keep him in his bed. Morning temperature 103°; evening 
temperature 104.8°. Ordered quinine Bj., blue mass gr. v j , pal. 
opium gr. j. Make 6 pills : two every third hour until all are 
taken. February 11th. — Patient had short snatches of sleep 
through the night; still delirious, but calls for drinks; had two 
liquid stools; passed urine; temperature 102.2°; evening tem- 
perature 103.1°. Ordered teaspoonful of the house solution of 
quinine every fourth hour; cloths wrung from hot water to be 
applied over abdomen. Diet of milk, milk punch, and beef 
soup, ice and iced drinks to be given often. 

12th. — Patient has slept rather more during the night; is less 
delirious; temperature 102°; pulse 100. Ordered solution acetate 
ammonia, siiiss; spts. nitre, syrup morphia, aa gij. Mix. Table- 
spoonful every fourth hour; to be omitted during night. 



1876] Bemiss— Clinical Studies: Swamp Fever. 



197 



13th. — Condition same; moruing temperature 102°; evening, 
102.8°. Continue treatment and diet. 

14th. — Morning temperature 102°; evening, 102.2°; pulse 100. 
Patient more rational. 

loth. — Patient slept quietly for several hours; had free perspi- 
ration. Morning temperature 99.3°; pulse 80; evening temper- 
ature 102.1°. Ordered house solution of quinine, teaspoonful 
every fourth hour during day. 

16th. — Morning temperature 99.2°; evening temperature 102.6°. 
Continue quinine. 

17th. — Morning temperature 99°; evening temperature 103°. 
Continue treatment. 

18th.- — Morning temperature 99°; evening temperature 100°. 
Patient had profuse perspiration during night; is now convales- 
cing. Ordered ^ij. comp. tinct. ciucho. every fourth hour. 

19th to 21st. — Temperature oscillated between 99° and 100°, 
but on the evening of the 21st suddenly mounted to 102.1°. 
Two teaspoonfuls of the house solution were given, and on the 
morning of the 22d the temperature was normal. From this 
period until the 27th, the morning temperature of the patient 
varied but little from the normal standard, while the evening 
temperature was extremely variable, reaching on the 21th 102°; 
25th, 101°; 26th, 100.5°, 27th, 101°; alter which records of tem- 
perature were no longer kept. The patient was discharged from 
hospital March 29th. 

The above resume has several instructive points connected 
with it. First, the patient came under observation after having 
been submitted to improper attempts at cure by purgatives pre- 
scribed by unprofessional persons. In my opinion this is one 
of the most serious complications which physicians encounter in 
treating remittent fever. Popular prejudice and usage both 
agree in instituting this mode of practice before the physician 
is called. One of the tendencies which remittent fever possesses 
to a degree far beyond other forms of malarial fever, is to set 
up local inflammations. The liability of the alimentary canal 
to become the seat of these inflammatory disturbances, is a fact 
sufficiently well known to have become the foundation of a 
special school of pathology. Surely, arguments and cases con- 
cur in teaching that excessive purgation complicates the career 
of the disease : 1st, by producing irritation and inflammation 
which it is probable that the patient might otherwise escape; 



198 



Original Communications. 



[Sept, 



2d, by interfering with nutrition in a disease which runs a pro- 
longed course. Again, there is an instructive item to be gained 
from this case by observing the cooling of the body during a 
sweating stage. On the evening of the ninth day of the disease 
the temperature was 102.2 C ; the next morning it had fallen to 
99.3°, or very nearly 3 degrees. 

In treating remittent fever, I make it an invariable rule to in- 
crease the quantity of quinine largely above the amounts pre- 
scribed for intermittents. From one to two, or even three 
scruples should be given, preferably in solution, but I often give 
it in pill form, combined with calomel or blue mass. I need not 
advert to the happy manner in which this drug acts in a large 
number of remittent cases, as an apyretic to cut short the fever 
present when its administration was begun, and as an antipe- 
riodic to prevent its recurrence. These are among the marvel- 
lous and beautiful results therapeutics is sometimes able to ex- 
hibit. But it is equally well known that in a certain proportion 
of cases, very small benefit, or it may be, no appreciable degree 
of benefit follows the administration of the drug. Under these 
circumstances my practice is to suspend the use of quiniue, and 
to practice only such medication as may be best calculated to 
allay fever and quiet the patient. Solutions of acetate ammonia, 
or acetate potash, with small opiates either in combination or 
separately, cold and cooling drinks; if vomiting is troublesome, 
effervescing drinks, competent doses of opium or chloral, or bro- 
mide potash given at night to relieve insomnia if present, con- 
stitute all the medication I regard as admissible. The patient's 
room should be well ventilated, his hair cut close, his surface 
frequently sponged with tepid water, his bedding and clothing 
changed often, and all his surroundings rendered cheerful and 
quiet. The question of diet is an important one. From the in- 
ception of the case, the physician should keep in view the fact 
that the febrile process involves waste and decay. The wear 
and tear of the economy consequent upon seven or eight days' 
persistent elevation of temperature, must be provided for by 
timely and proper attention to diet. 

After a few days of careful watching and patient persistence in 
the course suggested, the abatement of temperature to a lower 
figure than it had previously reached, or sharper angles of oscil- 
lation than the lines had previously shown on the diagram, will 
indicate the arrival of a period in the disease, when another 
attempt should be made to control it by antiperiodics. 



1876] Bemiss— Clinical Studies: Typhoid Fever. 199 



Hemorrhage in remittent fever is an event generally to be 
deprecated. In a majority of cases the alimentary canal affords 
tbe surface from which it occurs. I have seen more than one 
case of intestinal hemorrhage prove rapidly fatal. I do not pre- 
tend to be able to explain its mode of production. It is, how- 
ever, reasonable to infer that a true hemorrhagic diathesis is 
brought about by the changes of fluids and solids usually pro- 
ducing it, and that intestinal irritation and inflammation deter- 
mine its point of occurrence. However we may reason about 
these points, I can testify to its occurrence in cases which did 
not present the slightest evidence of the presence of typhoid 
fever poison, unless the hemorrhage may be claimed as such. 

Typhoid Fever. No one will dispute the assertion that this is 
the most pandemic of all the essential fevers. It is, however, 
true that New Orleans is generally more exempt from its presence 
than many other large centres of population in the United States. 
During the nine years extending from 1867 to 1875 inclusive, 
the returns made to the Board of Health show that 677 deaths 
have been attributed to typhoid fever. Murchison found that in 
an aggregate of over 18,000 cases the mortality rate was one in 
5.4. If the same rate of mortality should apply to cases of the 
disease in this city, it would indicate the occurrence of 3655 
cases of typhoid fever during the period mentioned. The propo- 
sition which is capable of being deduced is, that of 210,000 
people living in New Orleans for nine consecutive years, one 
in every 57.4 will suffer from typhoid fever, and one in every 
310 will die from this cause. If the population of New York 
be estimated at 1,000,000 for the nine years, 1865 to 1873 in- 
clusive, and be tried for that period by the same comparisons 
and rates of number of cases, with number of deaths to the popu- 
lation, it will be found that one person in each 53.5 would suffer 
an attack of typhoid fever, and one in every 289.3 would die of 
that disease. 

Whatever these figures may be understood to prove, the fact 
must be admitted that typhoid fever has never prevailed as a 
general or fatal epidemic in this city, nor has it been a common 
thing in my terms of service to have over two or three cases to 
treat during a winter's course. Prof. Ohaille's carefully studied 
statistics show that under the various classifications, "Typhoid," 
"Continued," "Enteric," and "Fever," 1262 cases were admitted to 



200 



Original Communications. 



[Sept. 



Charity Hospital during the ten years 1856-1860, and 1866-1870. 
Of this number 440 died and 822 were discharged. If it were 
possible to eliminate the malarial fevers and other cases not really 
typhoid fever, it is very probable that the numbers would be 
reduced to one-half this present scale. 

In regard to the origin and mode of spread of typhoid fever 
in the city and hospital, I know of no definite facts which will 
aid the enquirer in the solution of the various unsettled ques- 
tions connected with this subject. Under my observation the 
disease has never communicated itself to any medical, or hospital 
attendant, or any patient exposed to it in the wards. No disin- 
fecting measures have been resorted to beyond the usual clean- 
liness and good ventilation of the wards. Quite a number of the 
patients treated during my nine years of service have arrived in 
the city sick with the disease. Others have been brought in 
from various portions of the city who must have acquired the 
disease germs here. If we adopt Budd's theory, strongly sup- 
ported by Leibermeister, that typhoid fever is insusceptible ot 
de novo origin by any amount, or conditions of animal excreta 
or filth, without the presence of a germ derived from a pre- 
existent case, the difficulty of accounting for the appearance of 
the disease becomes in many instances absolutely insurmount- 
able. It is true that Murchison's recent discoveries have taught 
us that milk — a food so important and universal in its use — may 
prove a vehicle of transmission of the special poison of the dis- 
ease. We are not able to affirm that the butter and cheese 
which we import so largely are not liable to similar poisonous 
impregnations; but these are unproved hypotheses, which should 
have but little weight in scientific debate. Country villages, or 
isolated rural habitations, afford the best opportunities for 
studying the origin and mode of spread of infectious diseases. 
I am satisfied that a large number of practitioners situated where 
they are able to turn these opportunities to good account, will 
agree with me in considering Murchison 7 s doctrines more con- 
sistent with their observations than the one which we have just 
quoted from Dr. Budd. These doctrines hold that the disease 
germs of typhoid fever may be generated anew from the accumu- 
lation of organic material and filth derived from human bodies. 
It is not inconsistent with this theory, to grant that certain at- 
tendant conditions are necessary to confer upon these collections 
of ordure capability to breed typhoid fever. It may be further 



1876] Bemiss— Clinical Studies: Typhoid Fever. 201 



admitted, that these qualifying conditions are unknown, and 
that they rarely coincide in such a measure as to evolve the fatal 
germ, without yet overthrowing the theory that the poison is not 
dependent upon the introduction of a specific product of some 
other typhoid case for its renewed development. These ques- 
tions are extremely important to the practitioner. His mea- 
sures of prophylaxis are to some extent varied, accordingly 
as he may be governed by one or the other of these 
opinions. My reference to the opportunities afforded physi- 
ciaus situated in isolated localities for the study of this sub- 
ject, is explained by an avowal on my part, that the observations 
made during that part of my professional life which was spent in 
country practice, have led me to adopt Murchison's opinions. 
Oases, time and again, occurred in my practice, which could not 
be accounted for upon any other hypothesis. 

The infectious nature of typhoid fever is an indisputable truth. 
Whatever opinions may be entertained in regard to the mode of 
production of the disease germs primarily, they undergo multi- 
plication in the bodies of the sick, and being thrown off, are 
capable of poisoning the well. In October, 1847, while practis- 
ing in the town of Bloomfield, Ky., two students were brought 
to their homes from St. Mary's College, which had been sus- 
pended in consequence of a fatal outbreak of typhoid fever. A 
few days after their arrival both sickened with typhoid fever, 
and only recovered after severe and tedious illness. These two 
patients formed the foci of an epidemic which was so general 
that I treated 176 cases, from the time of the outbreak until the 
ensuing June. The attendants and families of the young students 
were the first to suffer attacks of the disease, then it became 
general in its prevalence in the village and its environs. The 
topography of the district where this epidemic prevailed, sup- 
ports a belief that the disease germs reached the systems of the 
well principally through the drinking water. The water supply 
was obtained wholly from wells and natural fountains, and the 
dejections were generally emptied upon the surface of the soil 
in such positions, that they might readily reach the drinking 
water either by surface washing or percolation. 

With respect to many of the towns in this country, it may be 
safely asserted that it appears as if they had been located and 
constructed, with the special design of affording the best facilities 
for the spread of those diseases which are propagated chiefly, or 
in part, by ingestion of their germs. 



202 



Original Communications. 



[Sept. 



I have had no wards in Charity Hospital to which colored 
people are assigned, but my own observation aud studies in- 
duce a belief that negroes are more liable to attacks of typhoid 
fever than whites. They are certainly less able to endure attacks 
of the disease than the whites are. I gave this subject pretty 
careful study in 186'), in reference more particularly to the influ- 
ence the disease exerted upon the mortality rates of the two 
races in Kentucky. In 1858, of every 

100 whites who died in Kentucky, 5.44 died of typhoid fever. 
100 negroes " " " 7.03 " " " ", 

1859. 

100 whites who died in Kentucky, 7.26 died of typhoid fever. 
100 negroes " " " 10.25 " " " " 

In South Carolina, during the three years 1857, 1858 and 1859, 
a somewhat different result is obtained : 

Of 100 whites dying in 3 years, 9.78 died of typhoid fever. 
Of 100 negroes " " " 8.48 " " " 

The mortality statistics of the last U. S. Census Eeport, in- 
cluding the year ending June 1st, 1870, show the following 
figures touching these two States : 

Of 100 whites dying in Kentucky, 4.84 died of typhoid fever. 
Of 100 negroes " " " ' 3.95 " " " " 

In South Carolina, same year and same authority : 

Of 100 whites dying during year, 7.06 died of typhoid fever. 
Of 100 negroes " u " 7.61 " « " " 

Further observations are requisite to determine this question. 

Two cases of typhoid fever were treated in my wards, both 
resulting in recovery. It is in my power to give a complete and 
very carefully observed record of temperature, pulse and respi- 
ration, in these cases, together with a statement of all medicines 
prescribed and administered to the patients. This circumstan- 
tial analysis of certain symptoms and the whole treatment, will 
be of interest to those , young members of our profession who 
observed the cases. 

Case 1. — David Chambers, age 21 years, by profession a slater, 
was admitted to ward 20 on the 23d of January. I saw him on 
the 24th. He was then rather listless and dull; complained of 



1876] 



Bemiss — Clinical Studies: Typhoid Fever. 



203 



weakness and slight headache, anorexia, and sensation of fever- 
ishness; no disorder of the bowels; patieut not confined to his 
bed. Typhoid lever was suspected, but it was not possible to 
affirm a diagnosis. Ordered half a teaspoonful of the house solu- 
tion of quinine every two hours until four teaspoonfuls should 
be administered. 

25th. — At my morning visit found the patient sitting near the 
stove, conversing with those around him. Diagnosis not yet 
possible, but the patient asks for more of the house mixture, 
insisting that it helped him. Ordered giv., teaspoonful every 
third hour. 

26th. — No change worthy of note; insists that he is better, 
but a dull expression of countenance and increase of languor 
justify a probable diagnosis of typhoid fever. No remedies dur- 
ing the day; ^ij. of house mixture at bed time. 

27th. — Patient in bed, complaining of weakness, feverishness; 
one loose stool in the latter part of the night; no tenderness, or 
gurgling upon pressure over abdomen. Ordered tinct. cinchon. 
comp. nitro-mur. acid dil. teaspoonful in sweetened 
water three times daily; Dover's powder, gr v., at night. No 
longer a doubt in regard to diagnosis, and records of tempera- 
ture, pulse and respiration directed to be made. The following 
tables will show the variations of temperature, pulse and respi- 
rations throughout the case. This record began on the 7th day 
of the attack, as nearly as could be determined, and terminated 
on the 46th. It will be seen that for 18 days preceding the close 
of observations, they were taken in the morning only. 



Cm 


M 


Tempera- 






Respira- 


O 


o 


ture. 


Pulse. 


tion. 
















S3 
Q 




M. 


E. 


M. 


E. 


M. 


E. 






100.5° 


101.° 


80~ 


100 


20 


24 


8 , 




102 


102 


84 


102 


26 


24 


9.. 




101 


103.5 


86 


104 


28 


32 


10 




101 


103.5 


90 


100 


28 


28 


11., 




102.5 


103 


100 


100 


24 


28 


12.. 




101 


102 


100 


120 


24 


24 


13.. 




100 


103 


108 


120 


24 


20 


14.. 




101 


103 5 


96 


120 


22 


20 


15.. 




102 


102.5 


100 


100 


22 


24 


16.. 




101 


104 


84 


120 


16 


20 


IT.. 




100 


101.5 


108 


120 


20 


20 


18.. 




102.6 


101.9 


108 


100 


28 


24 
28 


19.. 




101 


102.5 


108 


100 


25 


20.. 




99 


102 


96 


100 


22 


24 


21.- 




99 


104 


96 


100 


26 


24 


22.. 




99.5 


103 


100 


100 


26 


24 


23.. 




100 


102 


98 


100 


26 


32 


24 




99.5 


104 


96 


100 


26 


28 


25.. 




100 


103-5 


102 


100 


30 


28 


26.. 




100.2 


101.5 


104 


100 


22 


28 



Day of 
attack. 


Tempera- 
ture. 


Pulse. 


Respira^ 
tiou. 


M. 


E. 


M. 


E. 


M. 


E. 


27 


99.5° 
100 
103 

99.8 
100.5 
100 
100.6 

99 

100.8 

99- 5 
100 
102-5 
100-4 
100.5 

100- 1 
99.5 
99 
993 
99 
97.5 


103.1° 


92 
100 

92 
100 
104 
104 
106 
104 
115 

ris 

112 
114 
114 

95 
110 
110 
112 
114 
105 

96 


120 


22 
30 
20 
22 
22 
24 
26 
22 
22 
22 
24 
36 
20 
22 
22 
23 
25 
24 
23 
20 


28 


28 

29 

30 










31 








32 

33 








34 








35 

36 , . 














37 

38 ... . 












39 








40 

41 .... 

42 .... 


















45 








46 









204 



Original Communications. 



[Sept. 



28th. — Continue treatment: ^ij. of house solution of quinine 
ordered at bed time, as a substitute for the Dover's powder. 
This was done at the earnest solicitation of the patient, who from 
the beginning to the conclusion of his case protested that he was 
better after taking it. [Each 5L of this solution contains qui- 
nine gr. v., tinct. opinm gtt. viiss., dissolved in peppermint water 
by sulphuric acid.J 

29th." — Continue treatment; patient has had two or three 
stools daily, but no measures have been employed to restrain 
them, as they do not seem to prejudice his condition. 

30th. — Bowels loose; gurgling and some tenderness in right 
iliac region; tongue becoming red. Ordered tinct. cinchon 
comp. gij., tinct. opium sj. Mix. Teaspoonful every second 
hour. 

31st. — Continue treatment; gj. of house solution at bed time, 
to be repeated at 2. a. m. 
February 1st. — Continue treatment. 

2d. — Bowels loose and patient feeble; muttering delirium dur- 
ing sleep. Ordered tinct. cinchona comp. jfj., nitro-muriatic 
acid, tinct. opium, aa gtt, XL. Mix. Teaspoonful every three 
hours. This prescription was continued until the 14th of Feb- 
ruary, the intervals between the doses being varied according 
to the urgency of the diarrhoea. 

14th. — Ordered house solution syj, one drachm three times 
daily. 

15 th. — Contin ue. 

16th. — Comp. tinct. cinchon. ^ij., tinct. opium. 3j.; teaspoonful 
three times daily. 

19th — House solution giv.; one drachm every three hours. 

21st. — Some cough; pain in left side of the chest; dull percus- 
sion at base of left lung: hot cloths and flannel jacket over 
chest. B — Brown mixture ^ij., carb. ammonia Bij. Mix. Table- 
spoonful every fourth hour during day. Dover's powder, gr. v., 
at night. 

22d. — Continue treatment. 

24th. — Tinct. digitalis gvj., syrup morphia 31]'. Teaspoonful 
every two to four hours, according to effect. 
25th and 26th. — Continue treatment. 

27th. — Pul. digitalis gr. vj., pul. ipecac, pul. opium, aa gr. iij. 
Make six pills; one every fourth hour. No other prescription 

was made. 



1876] 



Bemiss — Clinical Studies: Typhoid Fever. 



205 



Throughout the whole treatment of this case diet was made 
a point of paramount importance. The patient was carefully 
nourished with milk, rice and milk, essence of beef, and chicken, 
with alcoholic drinks as early and often as indicated. Cloths 
wrung from hot water were placed over the abdomen. No mea- 
sures were resorted to, to check the diarrhoea, unless it became 
so profuse as to weaken the patient. 

Case 2. — Herbert Thiele, aged 18 years, a resident of this city, 
was admitted to ward 18, Charity Hospital, on the 12th of Feb- 
ruary. His friends state that his sickness dates from the 6th. 
He has had bleeding from the nose, diarrhcea, and some delirium. 
The diagnosis was positive. The following table shows march 
of temperature, pulse and respiration, until convalescence was 
well established. 





Temperature. 


Pulse. 


Eespiration. 


Day of 




























attack. 


M. 


E. 


M. 


E. 


M. 


E. 


8 


102.0° 


105.2Q 


88 


100 


28 


20 


9 


102 


104 


86 


88 


28 


24 


10 


103 


102 


88 


80 


24 


20 


11 


102.3 


103.1 


88 


84 


24 


20 


12 


101.7 


100.5 


90 


88 


21 


16 


13 


102.3 


102 


90 


92 


20 


16 


11 


101.4 


103.1 


86 


80 


22 


24 


15. 


100.5 




90 




24 




16 


101.2 


98 


88 


"78* 


16 


16 


17 


99.2 




76 . 




20 




is..:.... 


99.2 




85 




20 




19 


98.3 


102 


80 


ioo" 


18 


"26" 


20 


99.5 


102 


92 


96 


18 


16 


21 


100 


101.3 


80 


104 


18 


20 


22 


101 


104 


88 


100 


20 


20 


23 


101 


102 


88 


100 


16 


20 


24 


100 


102 


92 


100 


18 


24 


25 


100.4 


101 


94 


100 


16 


16 



Treatment.— -When the patient was admitted, on the 12th, the 
assistant house surgeon prescribed z'i]. house solution, to be 
taken at night. 

13th. — Prescription repeated. 

14th.— Ordered acid nitro hydrochlor. dil., ^ij.; syrup ipecac, 
gij.; comp. tinct. cinchona, giv.; water, I]. Teaspoonful in 
sweetened water every third hour; gj, house solution at night. 



206 



Original Communications. 



[Sept. 



15th.— Continue. 

16th. — Tine, ciuchon. comp. sij., nitro-ruur. acid sj. Mix. Tea- 
spoonful three times daily in sweetened water. Dover's powder 
five grains each night. This treatment was but little varied 
until the patient's convalescence was well established. He was 
discharged from the hospital March 6th, 

The treatment in both of these cases was symptomatic purely. 
No efforts were made to control the diarrhsea, unless it was likely 
to interfere with nutrition or weaken the patient by its protuse- 
ness. No attempt was made to abridge the disease by cold 
packing, quinine, or any other supposed abortifacient treatment. 
The only measures resorted to lower the excessive temperature, 
were frequent sponging the surface with tepid water, and a 
liberal supply of ice and iced driuks. Mercurials were not given 
to either patient, for the simple reason that I saw no indications 
for their use. A paramount attention was given to the nutrition 
and hygiene of the patients. May not this account for the fact, 
that the former of these was enabled to survive an abnormal 
temperature extending through a period of more than forty con- 
secutive days? 

Yellow Fever. Three cases of this disease were treated in my 
wards. Two resulted fatally, and one was discharged. They 
were all admitted during the month of December. All came 
from the same point — Eadsport — and had a similar history in 
regard to the quarters in which they slept. The detailed history 
of the first case will sufficiently develop all important facts con- 
nected with their exposure to the contagion. 

Case 1. — Peter G-alvin, a common laborer, aged 18 years, was 
admitted to ward 18, on the 6th of December. The history given 
in regard to him is, that he left St. Louis in the latter part of 
November and went to the mouth of the Mississippi river, where 
he had an engagement to work on the jetties. He was employed 
immediately after arrival in making the willow mattrasses used 
in forming these works. At night he slept with some fifty or 
sixty laborers in a barge fitted with bunks and tied to one of 
the wharves. Prior to the illness of these patients, the barge 
had been driven on the mud during a heavy gale. On Friday, 
December 3d, he had a slight chill, followed by severe pain in 
the head, back, and in his legs. He came to the city December 
5th, and was admitted on the succeeding day, having walked to 



18761 



Bemiss — Clinical Studies: Yellow Fever 



207 



the hospital and up into the ward. The patient was seen imme- 
diately after admission, and although there was a degree of 
suffusion of the countenance, and a puffed, tumid state of the 
eyelids, which attracted my marked attention, they were referred 
to catarrh and their serious import misapprehended. He was 
ordered R — Calomel, comp, extr. colocy., aa gr. v. Make two 
pills; take immediately; follow in four hours with |ss. castor oil. 
As soon as catharsis is obtained, of house solution every three 
hours until ^iv. have been taken. 

December 7th. Still complains of pain in the head and back, 
also of slight nausea and some thirst; countenance still tumid 
and dull in expression; complains of the weight of the hand 
upon the epigastrium; no stools since Dec. 2d. Ordered castor 
oil in repeated doses of gss. Having a strong suspicion that 
this was a case of yellow fever, I obtained some of his urine and 
tested for albumen; none present. 

December 8th. — Patient's bowels well evacuated during the 
night; condition not improved; seems dull, manifesting but little 
interest in inquiries, or efforts to examine him; temperature 102°; 
urine albuminous; diagnosis positive. Ordered broken ice, iced 
"seltzer water," iced milk in small quantities at short intervals; 
absolute recumbency; a nurse to remain continually at his bed- 
side. 

December 9th. — Worse; nausea and epigastric uneasiness 
somewhat increased; some jactitation; urine albuminous. Tem- 
perature, morning, 104J°; pulse 86; respiration 26; evening tem- 
perature 103J°. Ordered 

R — Sodaa bicarbonat., - 3ss.; 
Aquae laurocerasi, - £ss.; 
Morphise sulphat , - - gr. ss.; 
Aquas mentu. pip., - - |iiiss. 
Til ft. sol. S. Tablespoonful every two hours until nausea is 
quieted. 

December 10th. — Delirious through the night; nausea; hiccup, 
and ejection from the stomach of about ^iij. of light yellow fluid, 
containing brown flocculi at the bottom of the night vessel. £To 
urine since noon of the preceding day. Morning temperature 
104°; pulse 90; respiration 24. Eveniug temperature 104°; pulse 
112; respiration 24. 

December 11th. — Condition much worse; completely delirious; 
entire suppression of urinary secretion; black vomit in large 
quantity; death at 10 o'clock in the night. Post-mortem in pre- 
sence of the medical class. 



208 



Origina I Communications. 



[Sept. 



Case 2. — Peter Reiley, laborer, aged 22, had been employed in 
company with Galviu in making mattrasses, and bad slept in 
the same quarters. Xever had malarial fever. Was attacked 
suddenly on the 14th of December with a chill, pain in the head, 
back and limbs. He was admitted to ward 21 on the 18th of 
December. At time of admission he complained of severe head 
and backache, tenderness of epigastrium, nausea and vomiting 
of ingesta, and great restlessness. The face was flushed, eyes 
red and watery, and conjunctiva injected. Morning tempera- 
ture 98.1°; pulse 70; evening temperature 98.1°; pulse 80; urine 
carefully tested, but no albumen present. Prescribed 
E — Bicarb, soda, - - gss.; 
Cherry laurel n-ater, - ^iv.; 
Sulph. morphia, - gr. J; 
Peppermint water, - giiiss. 
Mix. Tablespoonlul every two hours. Mustard plaster to 
epigastrium; ice and iced effervescing drinks to be given; milk 
and milk punch for diet. 

December 19th. — Yery little change in patient's symptoms. 
Morning temperature 98.2°; pulse 68; evening temperature 98.6°; 
pulse 80, more feeble, and disappearing under pressure; no 
albumen in urine. Treatment continued. 

December 20th. — Morning temperature 99.1°; pulse 75; even- 
ing temperature 98.2°; pulse 50; urine albuminous; complains 
of gaseous distension and sense of burning in his stomach; fre- 
quent eructation. Prescribed 

B — Subnit. bismuth; 

Pul. willow charcoal, aa ^ss.; 
Pul. opium, - - gr. j. 

Make six powders : one to be given every three hours, placed 
upon the tongue and swallowed with a little ice-water. 

December 21st. — Morning temperature 98.6°; pulse 75. Even- 
iug temperature 98.6°; pulse 60; urine albuminous, and reduced 
in quantity. Continue treatment. 

December 22d. — Patient weaker and very restless. Morning 
temperature 98.6°; pulse 75; evening temperature 97.2°; pulse 
irregular, very teeble, not counted; urine scanty, and highly 
albuminous. Prescribed: R — Bromide potash Bij tincture 
opium gtt. xv., camphor water Jij. Mix. Tablespoonful every 
three hours. In the afternoon the patient complained of intense 
pain in his left arm, which swelled rapidly, and became livid 
and tense from the shoulder to the wrist. Death occurred dur- 
ing the night, without black vomit or convulsions. jSTo autopsy. 



1876] 



Bemiss— Clinical Studies: Yellow Fever. 



209 



Case 3. — Patrick Eoberts, common laborer, aged 40 years, ad- 
mitted to ward 21 on the 8th of December. Had been working 
and sleeping in company with the preceding patients; was seized 
on the 6th of December with chill, cephalalgia and backache. 
This case was a mild attack of yellow lever; still, it was one in 
which the diagnosis was positive. The facial flushing, and in- 
tense redness and sponginess of the gengival margins and of the 
conjunctiva, and the epigastric uneasiness were distinctively 
marked. On the 7th day of the disease, temperature 97.6°; pulse 
48. On the ensuing day, temperature 97.4°; pulse 44. Urine 
without albumen throughout the whole' case. 

The patient made a very slow convalescence. The presence 
of two complications produced this result. Firstly, he had been 
a subject of malarial poisoning, and occasionally chills impeded 
his recovery. Secondly, he heard of the death of Galvin, and 
witnessed the death of Reiley, who had been placed upon an 
adjoining bed, and knowing that they had died of the disease 
under which he was suffering, the moral shock depressed him to 
a dangerous degree. He was discharged from the hospital on 
the 24th of January. 

In commenting upon these cases, one of the first points to be 
mentioned is the season of the year at which they occurred. 
Yellow fever is not a disease which prevails in the winter in 
New Orleans. But these patients acquired the germs of the 
disease in a locality nearly a degree south of the city. Again, 
the records of temperature taken at the Board of Health office, 
show that 36 degrees was the lowest figure which the thermome- 
ter had marked prior to the occurrence of these attacks. It 
follows, therefore, that no fall of temperature had taken place, 
infereutially sufficient to destroy the germs of yellow fever. The 
assumption is justifiable that they contracted yellow fever at 
Eadsport, and in all likelihood the germs were in some manner 
preserved, or nursed into renewed activity, by favorable con- 
ditions on board the barge where they slept. Many facts are on 
record which prove that yellow fever poison is capable of pre- 
servation for quite a long period of time. It is the opinion of 
many observers, and one in which I fully concur, that cases of 
yellow fever occurring out of season are more to be dreaded than 
those attacked during an epidemic visitation. Perhaps it may 
not be susceptible of proof that the rate of mortality of these 
sporadic cases is largely increased over that of epidemics, but 
it is certainly true that they are more prone to run irregular 



210 



Original Communications, 



[Sept. 



careers and thus place the physician in fault regarding diagnosis, 
prognosis and treatment. The quiet manner in which the yellow 
fever poison sometimes produces death is a curious characteris- 
tic of the disease. Indeed, no greater surprise could be prepared 
for a physician brought for the first time in its presence, than to 
observe a case as devoid of violent symptoms as that of Eeiley. 
It would prove difficult to make him believe that a morbific force 
as resistless as the tornado, could work its fatal ends so covertly 
and silently. 

The swelling of the arm noted to have occurred in Eeiley's 
case, was undoubtedly due to arrest of circulation by coagulated 
blood. I think it was in the autumn of 1868 that I witnessed a 
similar event, but connected with an approach to convalescence. 
The patient ultimately died and post-mortem examination by 
Prof. Chaill6, showed a thrombus occupying the axillary vein 
and perhaps a portion of ihe subclavian. There were also many 
points of purulent accumulation dispersed through the lungs, 
probably due to embolism. Yellow fever affords certainly two 
of the physiological causes of thrombus : blood alterations and 
slowing of the circulation. It is more than likely that the last 
mentioned is the predominating factor in its production. Slow- 
ness and feebleness of the heart's action are well known charac- 
teristics of yellow fever. 

In relation to treatment, these cases afford nothing new or 
especially instructive. I am opposed to the perturbating treat- 
ment of this disease, but if favoring it ever so strongly, all these 
cases had passed the period of its applicability when admitted to 
the hospital. A yellow fever case in its incipiency, will endure an 
amount of therapeusis which would give a fatal turn to the scale 
of life, if applied later in its progress. This statement becomes in 
measure more strictly true, as the drugs applied are more strongly 
contraindicated. Perhaps those practitioners who attempt as it 
were, to j)ommel yellow fever into submission by violent medica- 
tion, may take some comfort from the reflection that they do a less 
amount of harm, if they confine the use of their remediate to the 
formative stage of the disease. I suppose that a physician loyal 
to his profession and of course a believer in the optimism of the 
plan of creation, must of necessity hold that every poison has its 
antidote. But however true such a hypothesis may be, the 
antidote to yellow fever remains yet to be discovered. Neither 
do we understand the mode or channels of its elimination from 
the system. We therefore find those measures the wisest, which 



1876] Bemiss— Clinical Studies: Yellow Fever. 



211 



simply seek to preserve the life of the patient until the storm 
has passed over. If we nourish the patient, preserving as nearly 
as possible a physiological state of his functions, and keeping 
him free from disturbing influences, either physical or moral, we 
discharge our principal duties. The treatment ought to be 
inaugurated with a laxative, if costive bowels so indicate, and 
they generally do. Castor oil is the most manageable and inof- 
fensive in its action. Some good practitioners are very partial 
to a purgative dose of calomel : I never resort to it unless there 
is too much irritability of the stomach to expect the retention of 
other cathartics. Mustard baths to the feet and legs are com- 
forting to patients and seem to be beneficial principally in pro- 
moting perspiration. The cooling and ameliorating effects of 
perspiration are well understood, indeed, one of the most com- 
mon errors of practice is in concentrating all efforts of cure, in 
the one measure of stimulating the sweat glands. Hot drinks, 
hot baths, hot blankets and close rooms are occasionally made 
the means both of torture and of hastening a fatal result. It is 
much better, after reaction is well established to keep the patient 
comfortably cool, giving him cold drinks, in small quantities, but 
often repeated, and sponging the surface with warm or tepid 
water. Oephalagia, or lumbar pain may be somewhat alleviated 
by ammoniated lotions, or sometimes better by a heated flannel 
over the part. Apyretic treatment beyond cold and acidulated 
drinks, is seldom demanded. That quinine acts as an apyretic 
in yellow fever is a proposition verified by many observations. 
To insure its effects in this direction the doses should not be 
less than ten grains. In a majority of cases in which it is ex- 
hibited during the neuralgias special to the disease, it exerts 
some mitigating influence over the pain. During the forming 
stage of yellow fever it often happens that perspirations appear 
and disappear in fitful periods; quinine seems to steady the 
nerve supply governing this function, so that sweating is more 
equable and lasting under its influence. Why, then, shall we 
not prescribe it oftener than we do in treating yellow fever? 
The answer is rational and decided. It does not cure the disease, 
nor does it, according to my experience, even shorten its course, 
although some excellent physicians have attributed to it some 
merit as an abortive remedy. It does in a certain proportion of 
cases increase gastric irritation and irritability, and in another 
proportion, probably smaller however, its physiological effects 
are sources of nerve disturbance, especially insomnia. The 



212 



Original Communications, 



[Sept. 



charge brought against it in the former clause of the last 
sentence is quite enough to decide the physician experienced in 
yellow fever practice, to refrain from its use by way of the 
stomach, at . all events, unless some paramount considerations 
determine him to take the risk. Gastric irritability is so often a 
source of defeat and mortification to the physician that it is al- 
ways a lion in his path. Even if vomiting or retching is absent, 
the disquietude of the stomach reveals itself by some manifesta- 
tion or other, which seems to say to the medical attendant, 
"touch me it you dare.' 7 Not only does this fact worry the phy- 
sician in regard to his medication, but it renders the question of 
nutrition a difficult problem to solve. I have often seen emesis 
followed by black vomit under circumstances which compelled 
me to believe that they stood in the relation of cause and effect. 
Several years ago, a patient well advanced in convalescence, 
obtained furtively an orange and an apple, and ate them both 
on the 13th day of his attack. He died on the ensuing day, with 
black vomit preceding death. If such an event is liable to 
occur late in the progTess of a case running a previously favor- 
able course, how necessary it must be to protect the stomach 
from all sources of irritation during the stadium of the disease. 
Alimentation for the first three or four days of a simple case, 
should be almost nil, and the little which is permitted should be 
in such a fluid and bland state of preparation that simple per- 
colation through the gastro-intestinal walls would be the only 
function put upon these structures. As the case progresses a 
gradual change may be effected to solid food. The end of two 
weeks of satisfactory progress is considered by many observers, 
quite soon enough to permit a beefsteak or chop. 

My thanks are due to Mr. L. Szabary, Student of Medicine at 
Charity Hospital, for the careful manner in which he has pre- 
served the records of the cases mentioned. 

Eruptive Fevers — Rubeola. One case was treated. Edward 
Moore, a newsboy, aged 16 years, was admitted February 11th. 
Stated that he had suffered with high fever aud catarrhal symp- 
toms for four days, or since the 6th. At the time of admission, 
the eruption was well marked upon his face and neck. No reme- 
dies were given except bitartrate potash in flaxseed lemonade, 
and an occasional dessertspoonful of "brown mixture.'' He was 
discharged from the hospital on the 17th of February. The fol- 



1876] 



Bemiss — Clinical Studies: Yellow Fever. 



213 



lowing table affords a faithful exhibit of temperature, pulse and 
respiration, throughout the case. 



Day of 
attack. 


Temperature. 


Pul 


st% 


Inspiration. 


M. 


E. 


M. 


E. 


M. 


E. 


5 


101.2° 


104.2° 


104 


120 


40 


40 


6 


100.1 


100.5 


100 


90 


32 


32 


7 


99.5 


99.6 


88 


90 


32 


24 


8 


98.8 


99.1 


68 


70 


34 


20 


9 


98.5 


98 4 


68 


64 


24 


24 


10 


98 


99 


66 


66 


26 




11 


98.6 




68 




16 






021 623 830 8 



(I