P, 1,403, 534 A
it iſ E M A N A C E M E N T of T H E
Ordinary Heart Cases
sº T H E T R E A T M E N T O F º
Pulmonary Tuberculosis
D I A G N O S I S. A. N. D. T. R. E. A. T M E N T O F
* Typhoid Fever º
B Y C T H O O D M D .
Formerly Professor of Physiology, American College
of Dental Surgery; Lecturer on Electro-Therapeutics;
Professor of Mental and Nervous Diseases; Professor
of Principles and Practice of Clinical Medicine and
Diseases of the Heart in Chicago Homeopathic Medical
College; Attending Physician Cook County Hospital
2.959 W A SHING TO N B O U L E V A. R. D.
c Hºc A G O L L No is









THE MANAGEMENT OF THE ORDINARY HEART
- CASES.
In reading the United States vital statistics, one is
astonished at the great increase in the number of deaths
from organic disease of the heart.
Strange as it may seem, the greater increase is in
the farming and rural districts. When we stop to con-
sider that it is the general practitioner who has the care
of these cases in their beginning and for the greater
part, if not all the time of their illness, we believe that
a discussion of the management of such cases will be
of general interest.
Doctors are but little, if any, different in their lives
from men and women in other walks of life. We all get
into habits more or less. In the hurry and rush of our
general work, we are prone to become more and more
routine. And while we know that the physician is less
inclined to be routine than his brothers in other walks
of life, yet we feel that, to a large extent, all cases of
organic heart disease look alike to the general prac-
titioner. -
If we can bring out in this paper, or its discussion, a
few points that will tend to increase and encourage the
study of such cases individually, our aim has been ac-
complished. -
Believing as we do that in order to understand or.
ganic heart disease we must not only have a fairly good
anatomical knowledge of the heart as well as a fairly
good physiological knowledge of its action, but we must
3
also have a fairly good knowledge of the pathology of
heart diseases as well as a knowledge of the pathological
conditions producing changes in the heart muscle, its
valves or their appendices. We therefore beg your in-
dulgence while we recapitulate some of the salient patho-
logical facts to be remembered. First, diseases of the
heart are structural, valvular and functional. Func-
tional conditions we shall not consider at this time. Dis-
eases of the valves are usually called organic heart dis-
eases and very often, after a diagnosis of the valvular
condition has been made, no further study is given to
the case. -
Primary disease of the valves of the heart is confined
to the left side. A few cases of congenital valvular
disease of the right side are found. The result of an
intro uterine endocarditis and are not to be discussed
at this time.
The order of frequency of valvular lesions of the left
side of the heart are: first, mitral regurgitation; second,
aortic regurgitation; third, mitrel stenosis; fourth,
aortic stenosis. In order to study these conditions in-
telligently, we must ascertain first, the valve or valves
affected; second, how badly diseased; third, the condi-
tion of the heart muscle; fourth, the state of the general
nutrition.
Diagnosis.
It is not our intention to discuss at any length the
diagnosis or the diagnostic points of valvular lesions.
You all have, more or less, the ability to correctly diag-
nose such conditions. We shall, however, briefly review
some of the important points. First, the location of the
murmur; second, the direction in which it travels; third,
its time—whether systolic, presystolic, diastolic, pre-
diastolic or late systolic or diastolic—; fourth, the pres-
4
ence of cardiac hypertrophy and of what portion of the
heart as indicated by the position of the apex and the
cardiac dullness.
Heart murmurs are described in various ways—loud,
soft, blowing, harsh, musical, etc.;-but the more impor-
tant ones are the loud and soft sounds. A loud murmur
may be good or bad. It may be good at one time and
bad at another. A soft murmur may be good or bad.
As a rule, a loud murmur means less than a soft murmur.
When a murmur that has been loud and distinct becomes
soft it means beginning or ruptured compensation. When
a murmur that has been soft and blowing in character
in the course of an acute illness of any kind becomes
harsh it indicates additional valvular involvement.
When the heart sound is distinctly heard with the mur-
mur, the lesion is slight. When the murmur replaces
the heart sound, the lesion is severe.
The study of the pulmonic second sound is of vital
importance in forming a correct conclusion of an organic
heart disease. In youth and up to 29 years of age, the
pulmonic second is more distinct than the aortic second.
From 29 years of age to 45 or 50, the pulmonic second
and the aortic second become more and more equal.
The pulmonic second is most distinct during the first
half of this period and the aortic most distinct during
the latter half of that time. If one is to train his ear
to the proper appreciation of the value of the pulmonic
second sound, he must take every opportunity of com-
paring it with the aortic second in cases where no cardiac
lesion exists. It will be remembered that the pulmonic
second sound in health is caused by the recoil of the
blood in the pulmonary veins and that the aortic second
is caused by the recoil of blood in the aorta, supple-
mented by the contraction of the muscular coats of the
5
aorta. Therefore, any accentuation of the pulmonic
second sound means increased pressure in the pulmonary
circulation. *
In valvular lesion the pulmonic second sound shows
first, the amount of obstruction to the pulmonary cir-
culation, caused by the mitral disease; second, the con-
dition of the right ventricle.
If a mitral disease exists and the pulmonic second is
distinct, it means some lesion of the valve and hyper-
trophy of the right ventricle. If the pulmonic second
has been distinct and begins to lose its snap, it means
loss of tone of the right ventricle.
As the greater number of organic heart diseases are
lesions of the mitral valve, let us at this time consider
these conditions and their management.
In the course of an acute illness—such as rheumatism,
chorea, pneumonia, typhoid fever, etc.—the pulse should
begin to be out of proportion to the temperature, soft
and of low tension, some slight cough be present with
slight dyspnoea, on lying down. The indications are
endocarditis to a greater or less extent. A murmur
may or may not be heard. The treatment is first, for
the acute condition present; second, general nutritional
treatment; third, absolute rest in bed until the pulse is
normal, no dyspnoea is present and the pulmonic second
sound has assumed its normal tone, or until compensa-
tion has taken place, if a mitral lesion has occurred.
But, while all cases of mitral lesion—the result of endo-
carditis—have such a beginning but few are recognized
and by far the greater number of the cases have become
chronic when the doctor sees them. .
When a mitral lesion has been recognized, there are
two questions to be answered. First, is it a chronic
lesion the result of a pre-existing endocarditis? Second,
6
is it due to dilation of the mitral orifice or a rela-
tive lesion? If the patient has known for some time
that he has an organic heart disease, or if there is
a history of rheumatism or other acute condition, fol-
lowed by a period of dyspnoena and cough with a gradual
improvement, it would assist in concluding that the case
is a valvular lesion; but if the apex is well to the left of
the nipple line and down in the sixth Space, or under
the sixth rib, and the pulmonic second sound is accentu-
ated, you may be sure it is a chronic lesion. But if the
case is from 55 to 70 years old and there is no history
of an endocarditis, the apex is only a little to the left
of the normal line, the pulse is weak, soft and irregular
and the history of the dyspnoea is recent, you may con-
clude that the case is one of chronic myocarditis—the
result of degenerative changes in the heart muscle. If
the apex is to the right of the nipple line or in the nipple
line in the sixth or seventh space the impulse heaving
in character the pulse water hammered, the mitral lesion
is relative secondary to aortic regurgitation whether you
hear a diastolic murmur or not.
If the case is a chronic valvular lesion, the first ques-
tion to solve is in what stage is it? Is it in the stage
of compensation or is compensation partly or altogether
broken? If the pulse is fairly full of fair volume, fairly
regular, there is no cough or dyspnoea—except on ex-
traordinary exertion—the pulmonic second is distinct
and no edema of the feet or ankles exist, you may say
that compensation is good.
The next question to answer is what is the extent of
the lesion? Or how badly is the heart crippled? If the
murmur is well defined and the first sound of the heart
as heard at the apex, not replaced by the murmur, and
the apex is only a little to the left of the nipple line and
7
the pulmonic second is litle accentuated, no dyspoena
is present and the pulse fair, the lesion is slight. If the
murmur is soft and blowing in character and wholly, or
to a great part, replaces the first sound at the apex, and
the apex is well to the left of the nipple line or even in
or beyond the axillary line, the pulmonic second dis-
tinctly snappy, the lesion is a severe one. If the murmur
is soft, the pulse small and irregular, the finger nails,
and often the fingers, blue and cold, the apex impulse
tappy, and the second sound at the apex lost and dyspnoea
present on slight exertion, the case is one of combined
regurgitation and mitral stenosis, whether the presystolic
murmur or roll of the stenosis is heard or not.
It is to be borne in mind that it is not the amount of
hypertrophy present that means perfect compensation,
but how well is the normal standing of the circulation
being maintained. As a rule, a great amount of hyper-
trophy means a severe lesion and a small amount a lesion
of less extent and gravity. The management of this
particular class of cases is first, forbidding overtaxing
of the heart. His watchword is “Go slow. Take things
easy.” Avoid excesses of all kinds. Look after the
digestion and bowels, regular habits of life. Such cases
should be impressed with the importance of reporting to
their medical adviser every so often where the condi-
tion of pulse, heart’s action and pulmonic second, is to
be noted. If the patient is complaining of cough, in-
ability to lie down and dyspnoea on exertion with or
without edema of the feet and legs and scanty urine,
compensation is ruptured to a greater or less degree and
the questions to answer are: first, what is the extent of
the lesion? Second, what is the condition of the heart
muscle? In estimating the extent of the lesion, it must
be distinctly determined whether the mitral lesion is
regurgitation alone, stenosis alone or a combination of
8
the two. The diagnostic points for stenosis, and regur-
gitation combined have been pointed out—if the hands
are blue and cold, the pulse small, irregular and weak,
the apex not so far to the left, the apex impulse tappy
and the aortic second Sound absent at the apex and no
mitral murmur present—the case is one of mitral stenosis
whether the presystolic murmur or roll is heard or not.
If the pulse is of fair volume, but of low tension and
irregular, apex well over or in the axillary line, the apex
impulse inclined to be wavy under the hand with now
and then a distinct impulse and the murmur is soft and
blowing and not heard so well far away from the mitral
area and the pulmonic second is not at all accentuated,
the heart has dilated to considerable extent. If there is
edema of the feet and legs, it has dilated enough to
stretch the right auriculoventricular opening.
The correct management of such a case is of vital im-
portance to the future of that heart. Usually the first
thing done is to give some heart tonic or stimulant which
very often only increases the dilation, when we remember
that the dyspnoea, cough, scanty urine, edema of the feet
and legs is due to venous engorgement. Is it better to
take the whip to the lagging horse or to first lighten his
load? We cannot relieve the pulmonary venous engorge-
ment without bleeding, but we can the systemic by re-
lieving the overloaded liver and bowels—1 to 1% grains
of calomel in broken doses, followed by some saline.
Then one every hour until 5 or 6-1/6 grain podophyllin
granules have been given, will empty the liver and bowels
and often stimulate the kidneys and do wonders for the
dyspnoea and pulse when it is combined with absolute
rest in the semi-prone position. Now, we may give some
heart tonic. Arcenicum Alb, arcenicum iode, strophan-
thus, spartine, giving 2 or 3-1/6 podophyllin granules
each day enough to keep the liver well emptied with light,
9
easily digested food. After a few days, chelidonia may
be stubstituted for the podophyllin. If the heart does
not respond to these tonics, then the alkaloid caffein may
be used. If these remedies do not bring relief from the
dyspnoea, edema, irregular pulse, etc., digitalis should
be tried. But the writer is convinced that more harm
has been done from the use of this drug than good, that
it is one of the best, if not the best, heart tonic we have,
he believes. But it acts upon the muscle of the heart,
producing increased muscular activity. It also acts upon
the muscular coats of the aorta and arterial system, pro-
ducing contraction of the arteries. Therefore, the blood
pressure is raised and the work, required by the heart, is
increased. To whip up such a heart that is more or less
dilated is dangerous. True, if the heart muscle will
stand it, the results are all that can be expected. But
the liver and bowels must be relieved first and the reme.
dies, spoken of, tried.
Then digitalis may be given, watching its effects care-
fully and remembering that it requires 24 hours to ob-
tain the full physiological effect of digitalis and that,
after this time, it continues to act for 24 to 36 hours.
In using digitalis we believe one should learn to rely
upon one or two preparations and know how to get the
best results from them, often failure is due to too small
a dose, at other times from too long intervals between
doses. If digitalis is used in this class of cases, the fat
free, preparation may be given in from 5 to 8 drop
doses every 2 to 4 hours. If, after 24 to 36 hours, the
urine has increased some in amount, the pulse has slowed
down to an extent and the cough and dyspnoea are re-
lieved even a little bit, then the drug may be continued
and the dose increased to from 8 to 10 drops. If the
improvement continues, the dose may be lessened or
held, as the case requires.
10
If you are convinced that you have a case of mitral
regurgitation and mitral stenosis, it is a grave question
whether digitalis ought ever to be used. If it is, it
should be in small doses and under careful watching;
and on the first symptoms of a thready pulse, or any in-
crease in the dyspnoea, it should be stopped. If the .
feet and legs are edematous and the abdomen more or
less dropsical, the urine very scanty, the pulse small,
soft and irregular, the impulse wavy in character, the
murmur soft or almost inaudible, the pulmonic second
indistinct, the cough and dyspnoea severe, the heart has
dilated and compensation is ruptured. It is one of the
marvels of the experience of the physician to see the
improvement that follows careful and scientific treat-
ment of such apparently desperate cases. The manage-
ment is first, absolute rest, not in bed until the symptoms
are relieved, but in a morris chair or some such chair;
second, relief of the hypatic and abdominal venous en-
gorgement as much as possible and our experience has
been that it is wonderful what can be done, the active
principle of eleaterium in 1/20 grain doses every hour
until free catharsis occurs; then 2 to 4 doses each day,
enough to be given to produce 2 or 3 good, full
watery movements in the 24 hours. The medi-
cation for the heart requires great care. We
are sure that we have obtained the best re-
sults by giving these cases strychnine, 1/60, 1/40
or 1/30 of a grain to a dose combined with nitro
glycerine; 1/250 to 1/150 of a grain every 2 to 6 hours,
with a fair amount of Rhein or Tokay wine or whiskey.
Alcohol is not in any sense a heart remedy. It acts upon
the vaso motor nerves, dilating the perferal arterials,
thus relieving the work on the heart. The nitroglycerine
acts in the same way while the strychnine stimulates the
heart through the pneumo-gastric. After the pulse has
11
become somewhat more regular, the impulse Iess wavy
and the dyspnoea relieved even a little, then some heart
tonic may be given—strophanthus 2 to 4 tincture tablets
every 2 to 4 hours. If improvement follows after a few
days then digitalis may be used with care, for, if the
heart will stand digitalis, it is the remedy par excellent—
give the preparation you know best and give enough to
produce results, watching it closely. But, if the urine is
not increased, the pulse better and the dyspnoea relieved
some in 36 to 48 hours, the digitalis had better be stopped.
The strychnine and the nitro glycerine are to be con-
tinued with it. If the heart takes up and the dropsy
disappears, the drugs may be gradually withdrawn and
the iode of arsenic 2x substituted or the citrate of iron,
quinia and stryc 2x given. If no improvement occurs and
the dyspnoea becomes severe, even amounting to cardiac
asthma with more or less pulmonary edema, then the
case is desperate and desperate means must be resorted
to. We have seen wonderful relief and beginning im-
provement follow bleeding if 8 to 16 ounces of blood is
withdrawn from the arm. The results of such a pro-
cedure are marvelous and improvement begins at once.
Insomnia is one of the most troublesome symptoms in
these cases of ruptured compensation and rest becomes
imperative. Bell chamomilla, coffee crude, or if this fail,
codeine + to $ grain at bed time in broken doses often
gives several hours of sleep. If this will not suffice,
morphia, 1/6 of a grain hypodermically at bed time,
will produce several hours of much needed sleep. The
diet in these cases should be very light and easily di-
gested. Attention should be given to ventilation, and
the skin and everything should be done possible to keep
the patient’s mind at ease. -
Not all these cases will recover, but many of them
will under such management and live for several years.
12
If, however, the case is 55 or older, the feet and legs
are edematous, inability to lie down, dyspnoea and cough
pulse soft, small and irregular, the impulse under the
hand wavy but at times distinct, the apex only slightly
downward and to the left of the nipple line, the murmur
soft and blowing in character, the pulmonic second dis-
tinct but not accentuated, the case is one of mitral regur-
gitation, due to chronic endocarditis or endocarditis
and myocarditis. The management of such cases is not
very satisfactory and the mortality rate high. The liver
and bowels should be relieved by the podophyllin or
eleaterium 1/20 grain doses, care being taken not to ex-
haust the patient; whiskey in liberal quantities, nitro
glycerine 1/250 of a grain every 4 to 6 hours, strychnia
1/60 of a grain combined with it. The best remedy for
the greater number of these cases is crataegus tinc-
ture, giving from 10 to 20 drops every 2 to 4 hours. If
it fail to give results, digitalis may be tried (the infusion
being the better preparation). It should be used with
extreme care. The general nutrition in these cases is
always poor and must receive special care. The in-
somnia is one of the most troublesome symptoms and
must be met in some way; codeine or morphine as has
been advised at bed time. The urine often contains a
plain trace of albumin, but no casts, no kidney lesion is
present, the albuminuria being due to the passive con-
gestion of the kidneys and the deficient alcolinity of the
blood and should receive no special attention.
The management of mitral regurgitation and mitral
stenosis in children is often a hard proposition, owing
to the difficulty of obtaining absolute rest.
One of the grave questions to answer in the manage-
ment of mitral lesion is how much exercise can be taken
when the patient is apparently in good health? We often
13
hear it said that a well compensated heart is as good as
one in which no lesion exists. Such is not the case. If
it were true why do such hearts give way? Every per-
son with a mitral lesion has a crippled heart and his first
duty in life ought to be to see that compensation does not
become unbalanced. Therefore, how much exercise these
cases can take is a grave question. The rule is often
given that when dyspnoea occurs it is time to stop. That
is going too far. When dyspnoea occurs even to a slight
degree, the right heart is overworked. The best way is
that when a person with a mitral lesion begins to get
tired, it is time to rest. The amount of exercise must be
according to the extent of the lesion. The greater the
amount of hypertrophy of the right ventricle, the more
care should be exercised in putting any strain upon the
heart. In mitral stenosis, the exercise must be very
limited. Attention to the general state of nutrition is
important. Limiting the amount of liquids taken, is
often of great service. See that the liver is active, the
digestion good. Iron of some form is usually of great
service. If individuals, suffering with mitral lesions,
would make it a rule to stay in bed one day a week or go
to bed at least two nights a week at 7:30 or 8 and live
a moderate life, free from excesses of all kinds, we would
have many less cases of ruptured compensation.
14
THE TREATMENT OF PULIMONARY
TUBERCULOSIS.
Ever since Robert Koch in 1882 established the
etiology of tuberculosis, physicians, chemists and lay-
men have been endeavoring to discover a remedy or a
combination of remedies that will destroy the tubercular
bacilli and their ptomaines without destroying living
tissue. Kings, princes, individuals and governments
have offered large rewards to the successful discoverer
of such a remedy, but up to the present time no one has
been able to prove his claim to the prize.
That tuberculosis should be the cause for such wide-
spread research work and the expenditure of so much
money in an endeavor to master the Great White Plague
is not surprising. In 1900, 111,059 deaths occurred in
the United States from tuberculosis, or about one-ninth
of the deaths from all known causes—costing the United
States in money from a hundred and fifty million to two
hundred million dollars. Millions are spent each year
on secret cures, nostrums, and so-called specific treat-
ment for this disease. Men and women of wealth have
spent and are spending vast sums in exploiting cures
that were thought to solve the problem. Men promi-
nent in the profession have thought several times that
the solution was at hand, but the serums, the lymphs, the
tuberculin extracts, have all been tried and found want-
ing; yet when one makes a careful study of this dreaded
disease he is astonished at the results obtained by Nature
in her own way. For example, Naget in a study of five
hundred bodies dead from all causes, found that tuber-
15
culosis had existed in 97 per cent of the cases. In one
year of our own experience in Cook County Hospital, 97
cases were followed to the Morgue, of persons who had
died from various causes, and 68 were found to have had
tuberculosis at some time in their life. That thousands
of cases of tuberculosis, pneumonia, streptococcus, diph-
theria, typhoid fever, tetanus and other septic blood dis-
eases do recover by Nature’s own process, leads us to
hope that some day some one will unlock her secret, and
discover what it is that she in her wonderful laboratory,
the human body, uses and how she uses it to bring about
cures in these diseases. -
That there is something that we take into our bodies
that can be and is made into a wonderful germicide ca-
pable of destroying germ life, and of overcoming the
destructiveness of toxins without destroying human tis-
sues, we know; and some day the glass that is now dark
will become clear. -
It would require volumes to report all the so-called
cures investigated by us during the past twenty-nine
years. It would take much time to discuss the results
obtained by different men and different methods of treat-
ment, so we shall confine our report to methods that have
produced known results. Before discussing the treat-
ment, there are a few diagnostic and prognostic points
we wish to call attention to, born of experience.
There are three principal ways of tubercular invasion.
First, the insidious; second, that following a cold, pneu-
monia, or bronchitis; third, as a storm.
The insidious form comes on with a feeling of general
malaise; tired, loss of ambition, poor appetite, restless
sleep, irritable, moody. In these cases the early morn-
ing temperature is subnormal, 97, 964, 96. This condi-
tion may last for several weeks before cough begins.
16
The cough is dry, hacking in character, with little or no
expectoration. Careful examination of the chest will
show a spot or two in one or the other apices or under
the clavicle, most often at the junction of the outer with
the middle third or under the lower angle of the scapula.
No pronounced dullness is present on percussion; no
positive bronchial breathing is to be found, but a posi-
tive increased whispered fremitus will be found. The
progress of such a case is: Morning temperature sub-
normal, evening temperature 99, 99% to 100; morning
temperature normal, evening temperature 100 to 101;
if the morning temperature remains at or near normal—
98 to 98%—no extension has occurred and no new spots
have become infected, and breaking down of the tubercle
will occur, with discharge through the bronchi, encapsula-
tion and ultimate calcification. If the evening tempera-
ture becomes normal for a time and the morning tem-
perature is 98 or normal, then the evening temperature
again increased to 100 or 101, secondary infection has
occurred, streptococcus, pneumococcus, etc. If the early
morning temperature again becomes subnormal, a new
spot of invasion has occurred.
The second form of invasion (that following a so-called
cold, bronchitis, or pneumonia): Whenever a supposed
cold or bronchitis becomes unilateral, tubercular infec-
tion can be strongly suspected, and the whispered fremi-
tus will locate the invading spots. An unresolved pneu-
monia offers a splendid media for a tubercular infection.
The return of a dry, hacking cough with a subnormal
morning temperature and an increased evening tempera-
ture points to tubercular infection, if there be no effusion.
The third form of invasion (the storm) comes on very
much like typhoid fever. After several weeks of poor
appetite, headache, some cough, the morning tempera-
17
ture is 100 to 102, the evening 102 to 104. The abdomen
is distended, the stools are apt to be loose, Sweating
often occurs and some mild delirium, and the case is often
mistaken for typhoid. But in spite of liquid food and
general typhoid treatment the fever persists. The cough
is not bad, but is present and most often loose. The
Wiedal reaction is negative. But the whispered fremi-
tus will positively locate the spots of infection in the
chest. In a few weeks the fever subsides to a great ex-
tent, and the case runs the typical course of pulmonary
tuberculosis.
The prognosis of a case of pulmonary tuberculosis de-
pends upon the number of points of infection. The
greater the number of spots, the poorer the chances are
of recovery; yet personal resistance plays a great part
in the prognosis. t
The three cardinal principles in the treatment of pul-
monary tuberculosis are, first, fresh air; second, good
food; and third, rest.
Fresh Air. So much has been written and said re-
garding fresh air in the treatment of this disease, that
any additional remarks would seem superfluous, yet a few
valuable points gleaned from observation: First, in a
dry, comparatively pure air outdoor living gives the
best results in most cases, but not in all. If a tuber-
cular patient living and sleeping out of doors awakens
in the morning tired and languid, try him indoors. Re-
member that it is far better to live indoors with open
windows screened with cheesecloth to filter out dust,
smoke, soot, etc., than to live outdoors in a damp place or
breathing dirty, smoky, dusty air. Also remember that
a sleeping porch on the second floor or on the roof is
much better than a tent on the ground, unless it be in a
dry, clear, pure air. Outdoor sleeping on the ground
18
has been and is being overdone; better progress can be
made on the porch or in a room with windows open. No
case of pulmonary tuberculosis can expect to improve in
impure air. That Nature does cure many cases without
their sleeping in the open, we know.
Food. Here we touch a mooted question. That every
patient suffering from pulmonary tuberculosis requires
not only good food sufficient to meet the daily expendi-
tures of bodily energy, all will admit; and that they re-
quire an excess of easily digested and assimilable foods,
we all know. The routine egg and milk diet offers the
greatest amount of food in the simplest form; but all
patients cannot properly digest and assimilate quantities
of milk and eggs. Many can manage very good quan-
tities if the bowels and liver are well looked after.
Others can care for only small quantities. Some can
take cream without milk, some can take raw eggs in
sherry, in grape juice, lemon juice, malted milk, etc.;
but he who orders milk and eggs to all of his tubercular
patients will fail. Each case is a law unto itself. We
have had good results, even better results, with scraped
raw meat in place of too many eggs; rare cooked meats
of all kinds; fruits in abundance, especially grapes,
oranges and apples. Too much stress cannot be put
upon the fact that all tubercular patients have more or
less impaired digestion, and special attention must be
given to this condition, and that large quantities of un-
digested food is harmful, and that no digestive organs
will work well unless the waste is properly carried away.
Occasional colonic flushings have done much good.
There is much difference of opinion regarding the use of
wine, whiskey, etc. Where a certain amount of wine or
whiskey aids digestion and does not increase tempera-
ature or pulse, they do good; they should, however, be
19
taken with the meals only. Oatmeal in any form is a
most nutritious food for these cases; it can be taken in
large quantities, with milk, in cakes, fried in butter, in
bread, crackers, etc. Cornmeal, as hominy with milk
or fried in cakes with butter, or as cornbread, and cheese
of any kind if acceptable, usually is beneficial.
Rest. As fresh air is necessary for the improvement
of a tubercular patient, and good food required to fur-
nish the energy to combat the disease, so rest is im-
perative to conserve tissue waste. We have known many
good men, careful, painstaking, who have given their
most careful attention to the air and the food their tuber-
cular patients received, but failed to obtain results be-
cause they neglected the matter of rest. Rest for the
tubercular patient does not only mean sitting quietly
in the tent or on the porch, getting up to attend to this
little need, or that requirement, seeing company, sew-
ing, writing letters, and so forth. It means that so long
as the evening temperature is above normal, absolute rest
is imperative. Sitting in a chair in the tent, well pro-
tected from the weather, is all right if the temperature
is not above 100 in the evening. If it is, the recumbent
posture is imperative; if the best results are to be ob-
tained, rest in the recumbent or semi-recumbent posture
is to be insisted upon so long as the temperature is above
normal. You may have good air, good food and care,
in fact every possible adjunct to the treatment, but you
will not obtain the best results unless absolute rest is
secured.
When to permit a tubercular patient to exercise is a
Question for thought. Usually when the temperature has
been 98 to 99 in the evening for a week or more, some
exercise may be permitted, say a walk of one-half to one
block. If the temperature goes above 100 after a walk,
20
quiet should be insisted upon for two or three days. If
the temperature does not go above a hundred, the walk
may be increased a few yards each day, watching the
temperature. Should the temperature go above a hun-
dred after a walk, too much exercise has been taken.
Complications. The most common complications of
pulmonary tuberculosis are, first, cough; second, hemor-
rhage; third, mixed infection.
Often in the early stages of the disease, the cough is
the only troublesome symptom, and the doctor is im-
portuned to stop the dry, hacking, annoying cough that
prevents sleep, racks the body and often results in
vomiting. The temptation to use some opiate or cough
syrup containing various and Sundry sedatives is strong.
We all know that no remedy has been proven that can
produce tuberculosis. But we do know that he who
carefully studies his Materia Medica and selects his
remedy according to the totality of the symptoms in each
case will obtain for his tubercular patient the greatest
relief for the cough. For instance, a dry, hacking, teas-
ing cough with little expectoration, accompanied by rest-
lessness, calls for aconite; an explosive Cough in parox-
ysms with dilated pupils, for belladonna; a hacking cough
with tickling in the throat or trachea, for bryonia; a
harsh hoarse cough, for phosphorus; a croupy spasmodic
cough, for spongia; a loose cough with a tendency to
nausea, for ipecac ; a dry cough worse on lying down, for
Hyos; waking up with a croupy cough resulting in a
little ropy expectoration, for Kali bichromicum. In the
severe cases when the coexisting bronchitis is extensive
and the alveolar inflammation large, with large quan-
tities of expectoration, some sedative may be required.
In these cases we have often found atropine, 1/250 to
1/150 of a grain, one dose at bedtime, gives sleep.
Codeine, to 4 of a grain at bedtime; Hyos 1/400;
heroin 1/12 at bedtime; steaming, as we will speak of
later, often gives results.
Hemorrhage. When the tubercle breaks down a small
hemorrhage often occurs, from a drachm to an ounce.
It usually has ceased to be active before the physician
arrives. Ipecac, hamamelis, are usually all that are re-
quired, but in those cases where a number of tubercles
coalesce and a large blood vessel is destroyed, extensive
hemorrhage may occur. The use of from 15 to 30 minims
of sterile ergot hypodermically, or one-half an ampule
of pituitary extract, will usually control it. The ice
bag is not to be forgotten.
Mia!ed Infection. We believe that but few of the
people who die each year supposedly from tuberculosis
do die of tubercular infection, but that the breaking down
of the tubercle and the secondary infection with strepto-
coccus, staphylococcus, pneumococcus, and so forth, and
the resulting septic conditions, is responsible for the fatal
termination.
It is impossible to prevent secondary infection. The
tubercular cavity communicating with the bronchi forms
the best possible breeding ground for all kinds of micro-
organisms. Therefore the question is how to manage
the results of a secondary infection. Pure air helps.
Good food assists. In fact these with rest are Nature’s
methods. Some considerable experimental work is being
done in these cases by artifically collapsing the affected
lung by nitrogen injections into the pleural cavity; the
results as yet are not very satisfactory owing to many
reasons. We believe that inhalations of steam or warm
air laden with various sedative mild germicides, as oil
of eucalyptus, oil of tar, oil of pine needles, iodine, mer.
cury in solution, acetic acid, hydrochloric acid: offers
22
the best method of combating the mixed infections and
of relieving the coexisting bronchitis.
Personal Ea:perimental Work. For over twenty-five
years the writer has been conducting personal experi-
ments in the treatment of tuberculosis. After many
trials and tribulations he hit upon a preparation of mer-
cury made by dissolving bichloride of mercury in beech-
wood creosote and treating it with hydrated calcium
chloride and powdered albumin, making a peculiar mer-
curous mercury. With this preparation, which he called
Albumasine, used as a spray douche, and by steam in-
halations, we have succeeded in Guring a number of cases
of tuberculosis of the nose, throat and larynx. Quite a
good many cases of pulmonary tuberculosis also were
given this remedy and recovered, but with it was used
the best adjunctive treatment known. When cavities
exist and mixed infection is present, steaming with this
peculiar mercury does much good, but while it can be
used hypodermically and intravenous, it does not possess
the power of destroying tubercular bacilli unless it comes
in direct contact with them. -
For several years past we have been experimenting
with an iodine preparation made in much the same way.
The iodine has given some good results, and we hope to
be able to perfect an iodine compound that will be of
great service in tuberculosis. It is a well-established
physiological fact that the secretions of the suprarenal
capsules represent the key to tissue respiration; that
they control to a large degree the action of the heart,
lungs, liver and so forth; that the oxygen carrying prop-
erties of the red blood cells as well as that of the blood
plasma depend upon the suprarenal secretion. The
suprarenal capsules are controlled by the anterior pitui-
tary body through the solar plexus, the splanchnic nerves,
23
and the cerebral, thoracic, ganglia of the sympathetic.
The anterior pituitary body governs the suprarenals.
Therefore it controls oxidation, and the standard of
health is maintained by the pituitary body.
The thyroid gland sustains the functional activity of
the anterior pituitary. The thyroid secretion is iodine
in organic combination. These being facts, iodine is the
most important element in the human body; therefore we
believe that there is a strong probability that Nature’s
unrivaled antitoxin or germicide is some form of organic
iodine. For many years it has been known that a sea
voyage is very beneficial to a tubercular case. From
time immemorial, cod liver oil has been used for these
cases, often resulting in cures. High pure air, dry air,
and even excessive feeding, mean more iodine. Iodine
also favors calcification in the tissue, assists elimination,
stimulates absorption; so that we believe that when the
secret of Nature’s laboratory is unlocked, iodine will be
found to be the normal body germicide.
24
DIAGNOSIS AND TREATMENT OF TYPHOID
FEVER.
There are but few subjects in medicine more common
or more frequently discussed by medical men than
Typhoid Fever and there is, perhaps, no acute disease
that the physician is called upon to treat that he permits
himself to get into so routine a method as he does in
treating this disease.
The results of the present day methods of treating
typhoid fever are so uniformly good and the mortality
so far below that of but a few years ago that the physician
allows himself to believe that, as his results have been
so good for so many years, and his routine treatment so
successful he may rest upon his experience rather than
study each individual case; but, unfortunately, once in a
while a mistake is made in the diagnosis, or what ought
to be plain indications for a change in remedies are over-
looked, and a life that should have been saved, passes
away.
Our only excuse for presenting this paper to this
society is that typhoid fever still ranks with pneumonia
as one of the two most common acute inflammatory dis-
eases the human race is at present subject to.
Diagnosis.
We do not intend to discuss the diagnosis of those
typical cases with the characteristic prodromatic symp-
toms, or temperature, or epistaxis or diarrhea, rose
spots, etc. These are the cases where the novice will
rarely fail to make a correct diagnosis even without the
25 3 ->
laboratory findings. But it is those atypical cases, that
come on in an irregular way without any or but few
prodrome, run an irregular course and often become
seriously ill because of our failure to make a correct
diagnosis.
If one will keep in mind the fact that the diagnosis of
typhoid fever, except in rare cases, can seldom be made
with any degree of certainty before the end of the first
week, and often not before the middle of the second week
and every suspected case treated as a typhoid, the mor-
tality rate of thirty-four and eight-tenths per cent will
be materially reduced.
Without going into an extensive differential diagnosis
of the diseases, let us describe some of the more common
affections from which it must be differentiated and per-
haps, one or two rare conditions.
First. The intestinal form of la grippe. We have
all seen many cases of la grippe, which by the end of the
first week presented an almost typical picture of typhoid
fever. The laboratory findings show the diazo reaction
as negative, the wedal reaction not positive, but some
clumping of the bacilli are seen; or, perhaps the technique
has been faulty and a negative report obtained. Still
the clinical picture is so much like typhoid fever that we
are loath to abandon our diagnosis. If by the end of
the second week the temperature touches the normal in
the morning and the skin has remained more or less moist
during the course of the disease, the case is one of acute
intestinal la grippe; but if the temperature persists after
the second week, even if the skin is moist, and the diazo
reaction absent and the wedal not positive, a diagnosis
of typhoid fever is, in all probability correct, for it should
be borne in mind that la grippe and typhoid are often co-
existing in the same patient. We do not wish to be mis-
26
understood: we expect to find the wedal reaction present
in typical typhoid, but our experience has been that in
the exceptional case it is not and, while we appreciate
the value of the laboratory findings not only in this dis-
ease, but in many others, yet we believe that the labora-
tory findings must fit the clinical picture to be confirma-
tory evidence. In other words, we hold that in the
greater number of the cases laboratory findings should
be confirmatory evidence rather than diagnostic.
It has been our privilege to see, during the past four
years, in consultation, four cases, and one in our own
practice of what proved to appendicular abscess mistaken
for typhoid fever. In three of these five cases the wedal
was reported not positive, but suspicious; in two it was
reported as positive. In four of these cases no leukocyte
count was made until after three, four and six weeks had
elapsed. In the remaining case the white count was
made within the first week. It has also been our priv-
ilege to see, within the past four years, two cases which
had been treated as typhoid fever and perforation was
supposed to have occurred; one case was posted and a
large appendicular abscess found; the other operated
upon for perforation and a large appendicular abscess
that had ruptured into the general peritoneal cavity
found, drained and recovery occurred.
The results of these experiences have taught us that
if a case presents any of the ear marks of typhoid fever
and the diazo is absent, the wedal negative or not posi-
tive, a white blood count must be made. *
We have also seen two cases of acute trichinosis within
the last four years, diagnosed and treated as typhoid
fever for several weeks. Aside from the fact that the
spleen is rarely enlarged in trichinosis, and the muscular
pains are, as a rule, more pronounced, the two diseases
might often be confounded. At present the evidence
seems to show that in trichinosis the eosinophales are
largely increased.
We shall omit considering the differential diagnosis
between typhoid fever, septaemia, endocarditis, pneu-
monia, empyema and puerperal fever, although we might
spend some very valuable time in the consideration,
particularly of septic endocarditis; but we will speak
of one more class of cases, namely para typhoid. These
cases are very much like typhoid fever, but, as a rule
much milder and less fatal. A reaction similar to the
wedal is obtained with the para colon bacilli.
Treatment.
The United States Government statistics for 1900 to
1904 show that the average death rate in thirty-eight
cities in this country in typhoid was thirty-four and
eight-tenths per cent, and that it costs the United States
each year $200,000,000.00, yet, when the mortality of the
last twenty years is compared with the mortality rate
of forty to fifty years ago it shows a marked improve-
ment. If Homeopathy had done nothing else in the
world but lower the death rate in typhoid fever, Samuel
Hahnemann and his followers did not live in vain. We
do not mean that all the lives that have been saved have
been saved by Homeopathic medicine, but homeopathic
physicians have taught and are teaching the medical
world that heroic dosing is not only unnecessary in the
treatment of typhoid fever, but that the mortality rate
is much lower under other treatment.
It is in prescribing for our typhoid fever patients that
we are apt to become routine and treat the disease rather
than the patient. To our mind if the Homeopathic law
means anything, it means that we treat the case and not
28
the disease. We have known one most excellent prac-
titioner who treated all his typhoids with baptisia, and
during one fall lost four cases that ought to have been
saved; another who believed for several years that he
had a sovereign remedy in echinacea for all cases of
typhoid fever, but who had his confidence badly shaken.
We have heard many physicians of the dominant school
and not a few so-called Homeopaths say that typhoid
fever is a toxin and that they did not believe that any
medication was of avail in the disease. After nearly
twenty-five years of active practice, in which we have
had our share of typhoids to treat, and after four years
on the Cook County Hospital staff, with a large number
to treat, not under the best circumstances possible, we
unhesitatingly say that, while typhoid fever is a toxemia,
the course of the disease can be often cut short and with-
out any doubt the severity can be materially lessened
and convalescence shortened. -
We believe that it is good practice when called to see a
case of typhoid for the first time, if the intestinal tract
has not been thoroughly cleansed it should be. We are
in the habit of giving one grain of calomel in broken
doses, one-fifth of a grain for five doses; then a half an
ounce of castor oil. After this is done we may select
our remedy. g
If the patient is restless, the skin dry and hot, the pulse
hard and rapid, the headache tense, ACONITE is the
remedy, and we have known a number of cases where the
wedal reaction was positive that we felt sure the remedy
cut the disease short in two weeks, before suppuration of
the intestinal glands occurred.
Perhaps no homeopathic remedy is as commonly used
in typhoid fever as Arsenicum Alb, yet our experience
has been that it is not so often indicated as some others.
29 .
If the patient is restless, thirsty for small quantities of
liquids, diarrhea serious and often involuntary with a
very strong odor, delirium of the negative type, wants to
get out of bed—then ARSENIC is the drug.
If the tongue is moist, the bowels loose, the patient
complains of pain, is sore and complains on being moved
and of the muscles and body being sore, ARNICA is the
drug.
If the lips are cracked and bleeding, the tongue, teeth
and gums covered with bloody sordes, AURUM TRIFOLIUM
is the remedy.
If the pupils are well dilated, the headache frontal,
the Sclerotic coats of the eyes injected, the skin dry,
backache persistent and delirium marked, BELLADONNA
is the remedy.
If the tongue is dry, the thirst great and for large
quantities of water, the delirium early and about one’s
work with a constant desire to go home, frontal head-
ache, wants to lie still, diarrhea early and often epis-
taxis, BRYONIA is the remedy.
If the tongue is brown with a dark red streak down
the middle or the whole tongue is red and as if it had
been skinned, the delirium of the low muttering type,
with a constant inclination to slip down in the bed,
BAPTISIA is the remedy. -
If the headache is in the occipital region, the skin
moist, the pulse full and soft, the temperature not run-
ning very high, the backache severe, GELSEMIUM is the
remedy.
If the tongue is a dirty yellow with red tip and edges,
marked, PROTo ToD MURC will do good work.
When the delirium is pronounced and the case passes
into stupor, with the pupils either contracted or dilated,
30
the jaw dropped, the bowel movements involuntary,
OPIUM is the drug.
When hemorrhage occurs with a gush of bright red
blood PHOSPHORUs has done good work.
When the case has reached the third or fourth week
and the diarrhea is persistent, two to six movements in
an hour, yet the patient seems to be strong, PHOSPHORIC
ACID has done good work.
If the tongue has the characteristic triangular tip, the
abdomen is distended, the rose spots abundant, RHUs
Tox. is indicated.
If the urine is thick, the tongue smooth and glazed,
the backache pronounced ATROPINE is the drug.
We do not mean that these are the only remedies indi-
cated in typhoid fever, but that they have been the ones
most often indicated in our experience and have given us
good results. The indications, as given, have been many
times proven and are from our own observations.
We do not believe in the use of combination tablets of
any kind and can see no place for them in typhoid fever.
We recognize the trend of the times toward poly-phar-
macy and fully appreciate the fact that the Homeopathic
physician who can conscientiously use combination
tablets will save himself much time and materially as-
sist the dominant school of medicine in absorbing us.
The two most common and dangerous complications of
typhoid fever are, first hemorrhage, and second, per-
foration. We will consider the latter first.
The mortality rate in perforation is very high. Sur-
gical interference may be of service; otherwise every ef-
fort possible to sustain the patient is to be resorted to
until recovery can be obtained.
The treatment of hemorrhage must be prompt and the
remedy well chosen. Phosphorus has been spoken of.
31
UNNERs. OF McHIGAN
Our own best results have been from hamamelis; we usu-
ally give Pond's Extract, one dram every half hour and
have seen wonderful results following its use. The use
of the ice coil, elevating the foot of the bed and the ad-
ministration of strychnine, 30th, hypodermically as often
as every two hours for six or eight doses to keep up the
heart, either alone or in combination with 120th of
atropine (not using more than one or two doses of the
atropine).
Diet.
If we are apt to become routine in our prescribing for
typhoid fever, we are more apt to become routine in our
directions as to diet. In Cook County Hospital as well
as in our own practice, we have learned that a routine
diet is not best for all cases of typhoid fever. We per-
mit all kinds of strained fruit juices—Orange, lemon,
grape fruit, pineapple, grapes, strawberries, cherries,
etc.; broths of all kinds, bouillons, plain tomato soups,
oyster broth, buttermilk, lactonized milk, koumiss, with
plenty of distilled water and an abundance of chipped
dried beef and chewing gum to chew. We do not use
sweet milk in any quantity.
As to the temperature; it is kept as low as possible by
sponging or the abdominal coil. If the bowels are con-
stipated, enemas of normal salt are used every other day,
with a dose of castor oil every four or five days or, if
necessary, every day. The so-called stimulants, whiskey,
brandy, wine, etc., we have never seen do any good.
32