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food thru the intestins at a rate which allows of free absorption. They are taught to avoid over-clothing themselves day or night, to keep the extremities dry and warm, to sleep nine hours out of twenty-four, and to avoid heated assembly rooms. They visit the dispensary at 7 a.m. and 7 p.m. for advice, and to report their condition, and are weighed twice a week, great importance being attacht to gain or loss of flesh. The entire method is that of increasing the patient's resistance by food, air, sunlight, and a minimum of drugs, quite after the manner so successful carried out by Trudeau at Saranac Lake.

The plan at Vanderbilt clinic is really the same, with about the same relativ results. So far, in a period of three years, nearly 50 per cent of all cases treated-incipient, advanced, and far advanced-have had the disease arrested; and 25 percent have been "apparently" cured. The experimenters are very careful not to be over sanguin, and are rather inclined to minimize the results in order not to give a false impression of the efficacy of this

treatment.

Professor Walter B. James has said that he has been surprised to see how very bad cases even will improve under strict surveillance of this sort; for the rules laid down are most rigid, and any departure from them is likely to cause the patient to be "dropt "-a proceeding he very much fears. But the whole matter is one of absolute obedience to the laws of health enforced by intelligent and competent supervision. If a patient has a temperature, spits blood, and refuses to eat, he is put to bed with all the fresh air it is possible to get in a crowded city, and is thus prevented from exercising while under the care of a district nurse, who can see many such patients daily.

The method is not an ideal one, and no special claim is made for it, but it seems to be doing exceedingly well in New York, and ought at least to prove worthy of a trial elsewhere. J. W. VOORHEES.

355 W. 56th St., New York City. [What do our rural friends do for their tuberculous patients? Are they neglected and allowed to die? Here is a voice from the city; now let us hear a voice from the country.-ED.]

We have received quite a number of Pneumonia articles that we are carrying over till next fall. Perhaps now, just after the close of the season, is the best time to write up your experience, while it is fresh in your mind. We will keep the articles over and publish them early next season. Don't forget bronDon't forget bronchitis, too. And also, don't forget the current diseases now and in the near future. Write of them for immediate publication.

Senator Hanna's Case, and the Dietetic Treatment of Typhoid Fever. Editor MEDICAL WORLD:-The following extract from an editorial in the World's Work is of interest to the entire medical profession : "Every man in middle life, who has had the usual experiences and the usual observation of an American, knows how murderously incompetent a very large number of practicians are-it is a public scandal in almost every part of the country."

We must confess that this charge is too well founded; but, that this incompetence is not confined to the humbler members of the profession, to the "rank and file," we need no plainer demonstration than the publisht records of the case of the late Senator Hanna.

The percentage of mortality in typhoid, under the treatment approved by the profession, following the advice of the leading authorities, ranges from 15 to 20 in the various epidemics. I am aware that many physicians in various parts of the country report much more favorable results. There are hundreds of physicians who "never lose a case of typhoid fever "; none, however, have, in a large number of cases, approacht the results attained by the strict Brand method, socalled, viz., 12 deaths in 1,200 cases.

Now, if you were to ask your subscribers what is the Brand method in the treatment of typhoid fever, I will venture the assertion that 75 percent of them would answer, the cold bath; whereas that is only one item, and the least important of Dr. Brand's recommendations. The withholding of food is Dr. Brand's main point, the cold bath being incidental, and rarely required if the former is rigidly enforced.

The

In the March number of the Journal of Advanced Therapeutics there is the second part of a very able article on "Lobar Pneumonia as a Secondary Disease," in which occur the following remarks on diet, which I cordially endorse: "Especially to be avoided are all nitrogenized foods-meat, eggs, fish, cheese, milk; and broths containing them. products of these bodies, when undergoing putrefactiv decomposition, are of a highly poisonous character. Milk especially must be avoided. It is swallowed as a fluid, becomes precipitated as casein, leaving the whey free for absorption. My experience is, that this casein traverses the bowel almost unchanged during impaired digestion; if any change does occur, it is in the direction of putrefaction."

Now, if this be true in pneumonia, it is most emphatically true in typhoid fever, when digestion and assimilation are virtually suspended; where the digestiv secretions, from the salivary glands thruout the entire digestiv

panopepton of the Fairchild's, given at intervals of three or four hours.

tract, are nearly absent. It would seem that, peptonoids of the Arlington Company, or the under these circumstances, common sense would teach the avoidance of food during the continuance of the fever, unless it had been predigested. But, of all foods that the practician should hesitate to force into the disabled digestiv tract of the typhoid patient, milk undigested is the worst.

Once more: "Although typhoid fever is essentially a system disease, its characteristic lesion is the intestinal ulcer, which should, as far as possible, be kept at rest. Milk, which has heretofore been regarded as the only proper exclusiv food, is, as a recent writer, Dr. Inglis, says, 'not a liquid, but a deceptiv solid,' capable of filling the small intestins with dense indigestible curds, which irritate the ulcerated bowel, and, in addition, ferment and cause gaseous distension."

Now, typhoid fever is a conservativ process; it naturally tends to recovery. I believe that Professor Osler is on record that, in typhoid left entirely without medical treatment, 75 percent of them would recover, and 85 percent would get well with very little medical attention. My experience and observation, after mature reflection, teach me that this estimate is even too low; that under intelligent nursing, without medical aid, 90 percent of them would convalesce favorably. That the results do not vary under the many different forms of treatment attests the truth of this statement, the only advantage being, under the strict Brand method, where the intensity of the fever is always greatly modified, and the mortality very close to zero. I have seen cases of typhoid fever protracted three and four months by the use of milk, while others have finally succumbed under its continued administration. The idea that typhoid patients would starve, or that they would lose strength to the danger point without food, is contrary to experience and common sense. The absence of the high temperature, the dry tongue, and other distressing concomitants of the milk-fed patient, the decided shortening of the period of fever, enable the patient to convalesce with comparativly little loss of strength or weight, and with no troublesome sequelae.

But leaving aside all appeals to common sense, how dare our hospitals, and prominent practicians, many of whom guide the opinions of the majority of physicians, continue to feed milk to typhoid patients, and render a mortality record of 15 percent, when Dr. Brand has shown that under the no feeding practise the legitimate mortality is 1 percent?

Before going further, let me say that there may be cases in which, owing to the prejudices of the family, it is impossible to carry out the above advice. In this case you have the liquid

Now, let us consider the case of Senator Hanna. I have taken this case under consideration from no wish to accuse anyone of neglect or wrong-doing, but simply because, by the daily bulletins of the Associated Press, the entire nation was made acquainted with the progress of the case, the daily variations in the condition of the patient, and some glimpses at the treatment. But I have especially chosen this because it illustrates, as I look at it, the disastrous results of feeding milk to a typhoid patient.

The majority of practicians is guided by authority and precedent, and follow the dictum of men like Professor Osler, who advises the use of milk in these cases.

It seems to me, however, not difficult, in following the record in this case, to see how, step by step, day by day, taking a case of mild fever by the acknowledgment of the attending physicians, the administration of milk played havoc with the vitality of the sufferer, culminating in the chill, which banisht all hope.

We get the first intelligible report on February 5, which, it seems, was the fifteenth day of the fever, the first symptoms having shown themselves on January 22. We find a morning temperature of 100°, and an evening temperature of 102.2°. The pulse was regular at

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The reports for the two following days are not important, except that we begin to get some intimation of the irritability of the stomach which naturally follows the ingestion of milk. On the eighth we find the fever accelerated, being 103° in the forenoon, but dropping a degree in the latter part of the day. The pulse has increast, being 92 in the afternoon, and we still find that the irritability of the stomach continues. How much mischief has been done to the gastric and intestinal tract we do not learn; but, as later we are told that the patient is now retaining his nourishment better, we may form some idea. On the tenth the fever is decidedly less, being 100 8° at noon, and a little lower later in the day; but the pulse has increast and the stomach still rebels, tho Professor Osler reports that "all

the vital organs are working well except the stomach." On the eleventh the temperature remains uniform at 102.2° during the greater part of the day, but the pulse has reacht 100 at noon, the temperature running up later to 104, the pulse following it to 112. While again affirming that there are no complications, the attendants are alarmed at this sudden change, tho attributing it to an imaginary crisis. Here I think that they are mistaken; that the sudden increase of fever, reaching 105° that night, was due to septic infection from the undigested and putrid casein in the colon. The attendants seem to have thought so, for we now find them giving saline transfusions to "neutralize the poison in the blood." Still there are no complications, and the vital organs are all right. But the milk diet still continues. The temperature drops to 101.9°, but the pulse climbs up a little to 108. Whether the chill, which occurred at 2 p. m. on the twelfth, was the second I cannot gather from the report, but on the thirteenth at 9 a. m. we find the temperature 104.9°, and the pulse 120, the same continuing with but small variation till the last.

When we consider the sudden rise of fever after a severe chill occurring on the twentysecond day of a mild case of typhoid fever-a man who cannot read septic infection in that, is blind.

The following remarks of Dr. McLane Hamilton may serve to elucidate this point:

con

"That the lower bowel is the seat of infection appears to be very well establisht by the experiments of Baumann, who found that when a fistula was made in the portion which included the lower portion of the small intestin, there was disappearance of the ethereal sulfates of the urin; but that, when the intestinal contents were allowed to pass thru the lower natural outlet, the putrefactiv products were largely increast, and their presence was again detected in this fluid. . . . When we sider that the proteids have passed undigested thru the small intestins and have accumulated below, where they lie infolded in a congested and feeble gut, it is not difficult to appreciate the fact that they form a rich field for bacterial attack, with the resultant introduction into the system of an amount of toxic material sufficient to produce a most serious change. . . . The alcoholic extracts of fecal matter, according to Bouchard, are more toxic than ordinary putrid matter; so it will be appreciated how readily the various alkaloids of the feces may be introduced in such quantities as to do much mischief."

The application of these observations to the case under consideration is obvious. Meriden, Conn.

N. NICKERSON.

Dysmenorrhea.-Coal Tar Remedies. Editor MEDICAL WORLD:-In reply to M.D., regarding dysmenorrhea, page 167, April issue, will say that he will have trouble in such cases. The ordinary remedies and analgesics will most likely be useless. The Editor has recommended gelsemium, which is good if used in very large doses, but he has suggested the combination of belladonna with it, which is its physiological antidote, and would neutralize, if not otherwise more seriously interfere with its action.

Now Doctor, give the lady three 5 gr. capsules of quinin; tell her to take one at 4 a.m., 6 a.m. and 8 a.m., accompanying each with a half cup of very hot water, the morning that she expects the trouble. Tell her that the pain will not come; and I miss my guess if it does. Now I don't want you or anyone else that may succeed under such circumstances to laud this as a cure for dysmenorrhea, for it is not. It is a cure for anything that is periodical, from a toothache to a pain in the big toe. I straightened up the worst case of gastralgia I ever saw with these capsules as here recommended, as soon as I had discovered that the exacerbation came at 2 p.m. every day-i. e., as soon as I recognized its periodicity, when all pain relieveing remedies had failed, as well as any other treatment I had used. A month is a long time (28 days) to consider as periodical, but the 9 o'clock business gives me confidence.

I con

trol a great many cases of ordinary dysmenorrhea with stramonium. I see gelsemium recommended in the Eclectic Med. Jour., January, 1904, in doses starting at 1/4 teaspoonful every hour and increasing to a teaspoonful, in

tetanus.

The Doctor says it is not a poison, and that no bad signs are ever manifest until spasm has been subdued.

There is one good reason for keeping up the price of all coal tar preparations which should not be over-lookt, and that is that the doctor who buys acetanilid by the pound is a dangerous man in a community. He may not know it, but let him look over the list of his deaths in the last year or two. I don't mean immediately after its use, but will say that terminated fatally, or died a few months later from heart trouble. The fatality of wars is not in it with this remedy. It suppresses pain and fever by force, the same as you would subdue an antagonist by choking him with your hand. It is quick and seemingly efficient, but beware. Nature asks for the removal of the cause, and aid to strengthen the heart; then the heart can do its work easily and will work slower and with ease, and the temperature will be reduced. I don't know it to be a fact, but I venture to say that the late Senator Hanna had plenty of coal

MAY, 1904]

Smallpox or Chickenpox-Pemphigus Acutus Contagiosa

tar preparations. In substantiation of this, I will call your attention to the evenness of his temperature at 102°, and of the weakness of his heart, and tendency to such a high range at the last. You may not want to publish this last part; in case you do not I will ask, why?

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I would like to know a sure remedy, outside the use of a shot-gun, for the alcohol habit. Pittsburg, Pa. E. H. MOORE, M.D. [We think you are wrong in your guess that coal tar antipyretics were given to Senator Hanna. Remember that his age, corpulency and a suspicious condition of the kidneys, were all against him.

As to the reason "why" an editor does or does not publish a communication, or certain parts of a communication, is entirely a matter of judgment as to whether or not it will be of interest and value to his readers. This is my standard, and I suppose it is the standard of every other editor. According to that standard, I decided to publish the above as written; however, leaving it to every reader to decide for himself as to its value. In deciding on the admission of communications, perhaps all my errors, if any, are on the side of generosity. I much prefer to err on that side, if at all, for I want these pages to faithfully reflect the rank and file of the profession as it is, its mental grasp, state of progress, etc., and its opinions, resulting from its vast experience and observation.-ED.]

Smallpox or Chickenpox?

Editor MEDICAL WORLD: I note in the April WORLD, pages 158 and 159, an article by Dr. J. D. Groom, on supposed smallpox of a mild type which offers difficulties in points of diagnosis. There have been a number of similar cases in this neighborhood, diagnosed smallpox and rigidly quarantined. I think five families in all. I was called to one of these families some three weeks ago and pronounced the disease chickenpox; and to confirm my opinion I vaccinated four of the children. The vaccination was successful in all four of the

cases.

This I regard as a confirmation of my diagnosis. What have the WORLD readers to say? Will vaccination settle the question? Can anyone who has had smallpox be successfully vaccinated? Let us hear from you. Mr. Editor what have you to say?

Lexington, Ohio. H. H. SMITH, M.D. [We suppose that you vaccinated after recovery from the suspected disease in those four cases, tho you do no say so. Vaccination after an attack of smallpox would not be successful. -ED.]

Terebene in five-drop doses dropt on a lump of sugar makes a cheap and efficient expectorant, especially valuable in bronchitis of the aged.

Pemphigus Acutus Contagiosa.

197

DEAR DOCTOR TAYLOR:-I am greatly interested in a communication from J. D. Groom, M.D., of Maxton, N. C., appearing in April WORLD, pages 158 and 159, entitled "Diagnosis Wanted for Epidemic Eruptiv Disease.' During the past winter the village of Medina, in the western part of this state, has been passing thru an epidemic which has been called "mild smallpox" by some, including, I believe, the health authorities. This diagnosis has been disputed by several competent men ; however, quarantine was maintained, and properly so, if there was any doubt as to the identity of the disease. One of my clients was employed in Medina until December, 1903, when he returned (whether he evaded quarantine or not, I do not know), and within two weeks he presented all the symptoms of a mild "grip," which he did not think needed any treatment. He noticed three or four red spots on his neck. His wife was confined late in December, and ten days later was taken with high fever, headache, pain in back, and complete anorexia. In my absence she was attended by another physician, therefore, this one week's history is second-hand. The doctor diagnosed the condition as "grip"; but on the fourth day, on account of an eruption, he changed it to chickenpox; and later said he did not know what "it" was. A week after the onset I returned and saw the case. Mrs. F. was then covered with a vesicular eruption, discrete in character, and scattered all over the entire integument. The vesicles were situated on a hard, reddened base; they were about marrow fat pea sized and showed no umbilication. There was little itching, but much burning pain. General condition was unsatisfactory; tongue heavily coated (yellowish-white); bowels constipated; partial anuria. dark, with specific gravity of 1,034; no sugar, but a trace of albumin; acidity high. Temperature 103°; pulse 105; was able to take only a little liquid food; lactation absolutely nil; baby artificially fed. Within the next twenty-four hours the vesicles became distended with serum, tending to turbidity, and the temperature fell to almost normal; pulse came down to 80, bowels moved copiously, urin became profuse and, of course, lighter in color and gravity, and there was a desire for food. Next day contents of vesicles increast in turbidity and rapidly became pustules, dried down, and crusting took place. At no time was there any umbilication or reticulation. The woman convalesced without other notable symptom. The skin cleared up gradually, leaving smooth red spots where the pustule and its areola had been, but in no instance was there any pitting.

Urin

The two weeks' old infant presented, in due time, all the mother's symptoms, but in a milder form. In the child only three papules appeared, and they did not pass beyond the papular stage. By January 20 the mother's milk reappeared, and the baby accepted it with joy, and both rapidly regained health.

These cases were the starting point for a small spread of the disease to, perhaps, twelve other persons, male and female, ranging in age from this infant to eighty years, in my practise, while there were three cases from the same source attended by other physicians. Last week three new cases were referred to me, but they are only the shadow of the earlier ones, symptoms and all the phenomena being in every way extremely mild. I believe they are the final struggle of the morbific agent, whatever it is.

The winter here promist, in December last, to be exceptionally hard financially and meteorologically (and it was); therefore, I felt it my duty to make absolutely sure whether or not this was variola. If it were, quarantine would be essential, and that would kill what little business there was in this section, and many individuals would suffer hardship, possibly hunger and starvation. If it were not variola, a little precaution would prevent its spreading much, and every industry need not be paralyzed by the stigma of quarantine for smallpox. After most painstaking study of Mrs. F.'s case in every bearing, and observation of the happy effect of appropriate remedies in her treatment at the end of the first week, I became thoroly convinced that I had neither variola nor varicella to deal with. My final diagnosis was pemphigus acutus contagiosa, based upon my observation of that eruption on sailors from the tropics coming under my care years ago. I have as yet seen no reason to alter my opinion on that point. In this disease, while there are small, hard bodies to be felt under the skin, we do not get that "buried bird-shot" feel so characteristic in variola. The individual lesions are not so small as those of variola, nor do we meet with a secondary fever, as in the latter disease. Smallpox and chickenpox are self-limited pathological entities, not to be aborted by any line of treatment, while this affection seems to be favorably influenced by early and vigorous measures. This eruption, in my experience, is never confluent, and there is no umbilication nor reticulation, nor is there any distinctiv odor connected therewith. Some of these distinctions apply as well to varicella and vaccinia. Furthermore, vaccination has no influence on the disease under discussion. Some of my cases had been vaccinated and some had not. I vaccinated two after the onset, to ascertain whether it would

exert any influence for good. It did not. The eruption and accompanying phenomena were milder the younger the victim; in the elderly they were the most serious, but in no case was there a fatal issue nor any extreme prostration, and convalescence was always rapid. An interesting point, it seems to me, is the apparently progressiv attenuation of the poison in each succeeding case, evidenced by the mildness of the later invasions.

In conclusion, I believe that this disease was brought to us by our soldiers and sailors from the tropics-from our insular possessions; and that much of the socalled smallpox and severe epidemic chickenpox is nothing more nor less than acute pemphigus, contagious in character; therefore, much of the fear, expense, and trouble caused by this supposed variola has been needless; but great care must be exercised not to err on the wrong side, and every precaution should be observed until the diagnosis is certain. T. HAVEN ROss, M.D.

Cato, N. Y.

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My

DR. C. F. TAYLOR.-Dear Doctor: I have been reading your journal for sixteen years, and I don't hesitate to say that I believe you to be one of the ablest champions of the rights of the people that we have in our country today. Therefore, I come to you for aid in a cause that should interest every leading man of our profession. To come at once to the subject of this letter, I have succeeded in interesting our congressman, Hon. E. Y. Webb, in a bill to lessen the secret nostrum evil. idea is to pass a bill requiring the manufacturers of all proprietary medicins to print in plain language the formula of the contents of every package put on the market. Congressman Webb askt me to draft a bill embodying my ideas. I don't feel capable of doing this, as I am not a lawyer. As a representativ of this county in the last Legislature of North Carolina, Í drafted several bills of a local character, but in a matter of so much importance as this I want the aid of wiser and better informed men. Therefore, I come to you and appeal to you to interest yourself in this matter. I want you to get up a bill that you think will best suit the case and send it to me; or send it direct to Mr. Webb. I also want you, if you can endorse this move, to present the case to readers of THE WORLD, and urge each one to write his representativ in Congress in behalf of the measure. Now, Dr. Taylor, if you will aid in this matter I will greatly appreciate the

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