CELERINA.

W. P. England, M. D., White Pine, Pa., says: I have used Celerina and am pleased to say that in all cases of nervous prostration, such as follows the use of alcohol, and for all cases of nervous debility, I find it without an equal. After the experience I have had with it I do not hesitate in recommending it to the profession as one of our best nerve tonics.

The action of Celerina on the brain and nervous system is that of an exhilarant and slight narcotic, relieving depressions and lessens irritable nerve conditions. In cases of organic and functional lesions of the heart, an increased steadiness of pulse-beat and diminution of pulse irritation is apparent.

A. J. Wesco, M. D., Seven Mile, O., says: I have tested Celerina and got good results. Man, aged sixty-five years, mechanic, habits very intemperate, will spree for weeks, came to me with nervous system in bad fix; could not eat or sleep. Gave him eight ounces Celerina, teaspoonful three times a day, which placed him on his feet again, and for that I think it par excellence.

Convulsions may frequently be cut short, like magic, by teaspoonful doses of Celerina repeated at short intervals. The nausea as an aftereffect of chloroform or other narcosis, may generally be controlled in the same manner.

T. J. Haile, M. D., Atlanta, Ga., says: Celerina has always acted finely in all cases where I have tried it, especially in those troublesome cases of hysteria, nervous depression and feebleness, and prostration resulting from alcoholic excess. Have found its effects very exhilarating and nourishing. In fact, it is my main dependence in all nervous diseases.

The psychological depressions and neuralgias, so common in the period following a debauch, are lessened or disappear altogether by the use of Celerina.

J. B. Johnson, M. D., 920 N St., Washington, D. C., says: I used Celerina not only as a nervine and tonic, but also found it most excellent, in two drachm doses, in sobering persons who were made drunk by alcoholic drink, and such patients informed me that they were greatly assisted in recovering from a spree by the use of Celerina.

After the removal of alcohol, Celerina, given in doses of from onehalf to one ounce every four hours, is speedily followed by the most characteristic symptoms of improvement.

Dr. Bramwell, Whitley, Northumberland, England, says: I have found Celerina valuable as a nerve stimulant and restorative in a patient suffering from the effects of a severe drinking bout.

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NORTH CAROLINA

MEDICAL JOURNAL.

A SEMI-MONTHLY JOURNAL OF MEDICINE AND SURGERY

[Entered at the Post-office at Wilmington, N. C., as second-class matter.]

VOL. XXXVIII.

WILMINGTON, AUGUST 20, 1896.

No. 4.

Original Communications.

"IS THERE IN NORTH CAROLINA A CONTINUED FEVER WHICH IS NEITHER TYPHOID NOR MALARIAL ?”*

By H. A. ROYSTER, A. B., M.D., Raleigh, N. C.

The subject which I have chosen for debate on this occasion was suggested by a discussion, having a similar title, before the Raleigh Academy of Medicine, at its regular meeting in August, 1895. In that discussion the question had only a local significance, being confined to the City of Raleigh and vicinity. On account of its great importance, I have deemed it profitable to submit the query to this larger body of North Carolina's representative medical men, thus giving it a wider range of application, and obtaining lessons of experience from all parts of the State. My own limited experience and my short residence here, would not justify me in expressing any dogmatic opinion concerning this question. My object in bringing it before you is rather to direct attention to the points at issue, especially in the light of modern research, and to foster the interest already manifested.

Whether there is or is not in North Carolina a specific continued fever which is not typhoid and not malarial, there is a fever which resembles both, but about which there is a difference of opinion. You have all seen it—a continued fever, moderately severe in type, of two to four weeks' duration, characterized by morning remissions or intermissions, uninfluenced in its general course by the action of quinine, and yet presenting none of the distinguishing features of typhoid fever. The history is usually vague; there may be a period of malaise lasting a week or two, or the attack may come on suddenly with a chill during apparently perfect health. The associated *Subject for Annual Discussion, North Carolina Medical Society, Winston, May 12, 1896.

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symptoms of the developed disease are not distinctive. The mental condition is unaffected; catarrhal processes form no part of the disorder; the abdominal symptoms of typhoid are absent; no typical rash appears; as a rule, there are no distinct chills, though chilly sensations may show themselves. The subjective symptoms are merely those of the fever itself.

Now to the question before us: What is this fever? Is it a distinct entity, a specific disease? or is it an atypical manifestation of either malarial or typhoid fever? We might conclude it was malarial, but its duration is not shortened by quinine, the acknowledged therapeutic test for this infection; we might call it typhoid, but the specific elements of that disease are not present. There are three conclusions to which we may come: that it is either (1) a malarial fever, unmodified by the administration of quinine; (2) a mild typhoid fever; or (3) a separate and distinct disease hitherto unrecognized. The first conclusion is justified by those who do not accept quinine as the infallible test for malarial fevers. Personally, I have never. believed that all continued fevers which yielded to quinine were malarial; nor that those which refused to respond to its influence necessarily did not partake of malarial characteristics. The fact that there occur numbers of cases of typhoid fever so mild as not to be recognized during life, but revealed in the intestinal lesions on the autopsy table, shows that there is some ground for the second alternative. Long experience and extensive observation have led many to accept the last proposition, viz: that this affection which I have tried to describe is a specific fever, neither typhoid nor malarial.

So far as my knowledge goes, these cases have not been thoroughly investigated or subjected to scientific inquiry. They are rarely fatal, and, therefore, have not been submitted to careful post mortem examinations. Clinical experience has furnished the only real basis for differential diagnosis. No systematic study of the blood in these cases has been made in North Carolina, so far as I know. I had hoped in this connection to present the results of some original investigations which I began during the latter part of the summer, upon my arrival in Raleigh, but which I was prevented from com. pleting by the disappearance of the proper material with the approach of autumn and the cold weather. It is my intention to pursue these investigations, as far as I can, and to report at some future time; so that, this may be regarded s a preliminary paper. The number of examinations made was not sufficiently large to serve as the ground-work for any positive statements. Enough was done, however, to prove conclusively to my mind that his whole question of continued fevers cannot be settled by clinical observation alone. In former times it was considered wise and philosophical to present long arguments and dissertations on medical matters; but now-a-days a simple little scientific fact will floor all argument, all dissertation. Every method which modern science can afford must be brought to our aid before

we can be justified in giving an opinion, much less in deciding absolutely upon any question. I know that there are men to-day who assert that they are able from clinical symptoms to diagnosticate these cases of fever accurately, call them either one thing or the other, off-hand, and satisfying perfectly their own minds. Thus far, in my brief career, this power of tuition has never been granted me. Many of these obscure cases of continued fever have puzzled me, and, in regard to some of them, I have remained still in doubt.

It is now generally conceded, I believe, that the exciting cause of malarial fever is the plasmodium malaria, an animal organism, discovered by Laveran in 1880. True, some observers have never admitted this fact. But the number of those who have studied and verified the Frenchman's theory by actual demonstration is sufficiently large and authoritative to give weight to the affirmative side of the question. It will not be necessary here to review the subject of malarial pathology from its real beginning up to the present time. For our immediate purposes it is necessary to know that the plasmodium inhabits the blood of a patient affected with malarial fever and that its detection by the microscope confirms the diagnosis beyond controversy. we can determine the existence of the plasmodium of malaria in the blood of these doubtful cases of fever, their nature is settled at once. Whether quinine influences them or not, they are surely malarial. With possible faulty methods and careless observation, the absence of the plasmodium would prove nothing; but, barring this, the failure to find the organism would exclude malaria.

In the case of typhoid fever the recognition of Eberth's bacillus is not such an easy matter. Examination of the intestinal discharges generally gives negative results, except in the hands of the most competent bacteriologists. This want of a ready method of demonstrating the presence of the germ leaves an element of uncertainty in these cases where the symptoms of typhoid fever are not well marked. The fully developed clinical picture of typhoid is unmistakable.

With these considerations, let us look into the differential diagnosis of these obscure cases of continued fever. To repeat: We may regard them as malarial fevers, as mild typhoid cases or as instances of a distinct affection, of which the most constant and characteristic symptom is the fever. I doubt not that among them are to be found cases of each variety—some being typhoid, some malaria and some, possibly a third, unknown fever. We know that the first two fevers do occur, to a greater or less degree, in all sections of the State. Have we at the present time sufficient evidence to say that at least some of these atypical cases are neither typhoid nor malarial, but a specific fever, which has not as yet been described? If so, what is this fever-its origin, its symptomatology and the indications for its treatment? If we can exclude malaria and typhoid, then the existence of a distinct