1

lescence, because there are no lesions to repair. The spleen, in
some cases may be somewhat enlarged, but not markedly so, and
there may
be traces of albumen in the urine. In fatal cases of
the ardent type of the tropics, the autopsy reveals no causes,
although the Peyer's glands may be a little swollen. There is
no lesion of the solids; the changes, whatever they are, take
place in the blood and nervous system. The process is due to a
chemical, not a microbic poison.

It is noted that the symptoms begin without any marked prodromata. There may be lassitude, headache, disturbed sleep, and malaise for a day or so, but these symptoms have not the severity or the pertinacity of commencing typhoid fever. Then develops the stadium of the disease. The temperature goes up quite rapidly, and often to a high degree, reaching possibly to 103° on the second day; in the severer type of the tropics it may reach to 105°. It is a curious fact that the initial rise may be the highest point reached in the entire fever, but the elevated temperature remains with moderate daily fluctuations, a possibility of a degree and a half in twenty-four hours. This condi

in a

tion of affairs will last for about ten to fourteen days, and then
be terminated by a rather abrupt fall. There is copious sweat-
ing, urination, or diarrhoea, and the temperature goes to normal
couple of days. During the continuance of the disease the
nervous symptoms are mild, although there may be headache as
marked and as violent as in typhoid fever. But the patient is
not so drowsy as in typhoid fever, nor does he display any
tendency to stupor, picking at the bed clothes, tremor, or other
severe nervous symptoms. There is a curious absence of any
functional disturbance. The tongue is moist, yellowish in the
centre, but reddish at the edges. The appetite will probably
disappear, but diarrhoea or vomiting is rather rare. As a rule,
the bowels are quiet, and the abdomen not particularly painful,
nor is it depressed or distended. The urine is febrile and scanty,
high colored and strong in odor, containing phosphates and
urates, and possibly a little albumen. Nose bleed is rare; there
is
no eruption, although there may be bluish, slate-colored spots
of conjestion under the epidermis. When sweating appears
there may appear water blisters upon the epigastrium or folds of
the groin. There may also exist herpes about the mouth, but it

is not common, and is slight in character. There are no complications, and there is prompt and complete convalescence. In many patients there does not exist a tendency to subsequent attack.

When we come to the question of diagnosis we are placed at once in an embarrassing position. For a week it is well to display caution, and delay treating the case with the same rigidity, as if it were typhoid fever. As the case progresses, we must treat it with deliberate indecision, endeavoring at each examination to eliminate every disease which might cause such a condition. Tests on typhoid cultures should be made, but, unfortunately, the toxine does not develop in typhoid fever until the end of the first week, at which time the typhoid eruption usually makes its appearance. So, unfortunately, at the very time that the diagnosis is wanted this test is most uncertain.

Again, we have to consider the fact that of all irregular diseases, changeable, uncertain and deceptive, typhoid fever is one of the worst. If it presented a definite clinical picture, if we could put our finger upon certain symptoms which we knew to be invariably present, we might be able to be more outspoken in our opinions. But there is not a symptom of typhoid fever which may not be wholly absent; in fact, almost every symptom may be almost in abeyance, and yet the case be one of typhoid fever.

It is better to keep the patient in bed indefinitely, than that carelessness may lead to perforation or relapse. I had a case recently in my own practice who had an obscure case of fever, but who was apparently well on the sixteenth day. He was an intelligent man, and so I went to him frankly and told him my fears and uncertainty in his case, that probably he did not have typhoid fever, but if we were mistaken it would be a pretty serious matter for him, and so voluntarily he stayed in bed until the thirty-fifth day. We will never know whether this time was wasted or not, but certainly it is safe to err invariably on the safe side.

As to the treatment, it should be of the simplest. As long as there is fever present in the patient, absolute rest in bed is imperatively demanded, with the use of the bed-pan and urinal. Many patients claim that they cannot use a bed-pan, but, as a

rule, if patiently persisted in they can usually overcome their predjudices, but in case this is absolutely impossible, then enemas should be employed. The diet should be liquid; the tongue, the abdomen, the urine and the stools should be carefully watched. The temperature, as a rule, is high enough to be brought down by the use of sponging. If it gets above 1031° it is well to try cautiously one or two doses of some antipyretic, but if the temperature is disposed to stay up, bathing should be resorted to. It is well, even if malaria has been excluded from your diagnosis, to give quinine, administering it by the rectum, if the stomach is irritable. I am a great believer in the use of codeia in these cases, in one-quarter-grain doses, for the sleeplessness and irritability which come with fever. As there are no complications, this is about all the treatment that these cases demand.

or a

ANEMIA AND ITS TREATMENT.

BY DEERING J. ROBERTS, M.D., OF NASHVILLE, TENN.

There are few practitioners of any experience who have not from time to time had to contend with anemia in some of its forms, either as a Primary or Essential Anemia, Chlorosis, etc.; Secondary or Symptomatic. This pathological condition characterized by a diminution or deterioration in the quantity or quality of the blood or one or more of its constituents, either as a result of no known pathological condition of other tissues or organs than the blood itself; or as a result of (a), hemorrhage; (b), inanition or want of assimilation; (c), excessive albuminuria, prolonged suppuration, long-continued lactation, chronic dysentery, etc.; or (d), toxic agents, as the absorption of lead, arsenic, mercury and phosphorus, and the toxic influence of acute and chronic infectious diseases, as typhoid and yellow fever, diphtheria, acute inflammatory rheumatism, chronic malaria, tuberculosis and syphilis. The general practitioner, the surgeon, the obstetrician, the gynecologist, and other specialists, all will continue to meet with it from day to day, and it will often prove, unless promptly and efficiently met and combatted, "the last straw that break's the camel's back." After other serious involve

ments of regions or viscera have been safely tided over, and the original danger is well and satisfactorily out of the way, anemia may still bar our progress in establishing a successful restoration to health.

The pallor of skin and mucosa as indicated by the general surface and livid lips, the languor, debility and extreme fatigue under the slightest exertion, occasional palpitations, dyspuma, headaches, anorexia, or possibly perverted and unnatural appetite, the visible undulating pulsations of the carotids, the pulsation of the peripheral veins, the occasional heart murmurs, the "bruit de diable" or venous hum over the large cervical veins, both muscular and mental weakness, loss of or impaired nerve function, neuralgia, coolness of surface, the weak, thready or compressible pulse, together with constipation or occasionally its opposite, make up as a whole, or in part, a clinical picture that is usually readily recognized by any careful observer.

Should the diagnosis, however, be in any doubt whatever, a proper laboratory examination will show a diminution of (1), the total quantity of blood in the body, oligamia; (2), of the red corpuscles, oligocythemia; (3), of the hæmaglobin, oliggochromemia; (4), of the albumen, anhydræmia; (5), or changes in the shape of the red corpuscles, poikilocytosis; (6), or in their size, micro, macro, or megalocytosis. It is rare, however, that so thorough an examination is necessary; and many of us, especially those engaged in active practice have neither time nor opportunity for such an investigation, and rely on the general characteristic features presented, together with the previous, clinical history.

In the treatment of this condition iron in some form has long been a recognized essential remedy, and a most excellent one it has proved on many occasions; yet, sometimes it brings only disappointment, either from the inability to get the patient to take it in sufficient quantity, or from failure to secure its entrance into the circulation by the absorbents, or from bringing about other symptoms that add to the discomfort and danger impending, as irritability of the bowels, diarrhoea or its opposite, or from its astringent effect on the mucous lining of the alimentary tract interfering with the proper digestion and assimilation of the limited food supply that is tolerated by the patient.

More than half a century ago M. Burin-Duboisson demonstrated by chemical analysis the recognized fact, that the red corpuscles of the blood contain about one-twentieth as much manganese as iron. Nature never doing anything uselessly or unnecessarily we can but recognize it as one of the essential constituents of the blood; and when its preparation is lessened by hemorrhages and other conditions that impair the blood, its restoration through natural channels is but slow and uncertain; so that it is quite a natural suggestion to take steps to secure its re-establishment in proper proportion. Soon after its demonstration as existing in the blood, M. Hannon and others used it with satisfactory success in chlorosis, syphilis, scrofula and other similar conditions. Kugler, in 1838, noticing that individuals employed in bleaching establishments where chlorine was largely used, and in those who handle large quantities of the salts or oxides of manganese were free from diseases of the skin, bones and glands, made a successful trial of it in scrofula. various salts or oxides of manganese used from time to time being deficient in stability or difficult of assimilation, its use has not been altogether satisfactory until quite recently.

The

A little over a year ago, I received from Messrs. M. J. Breitenbach Co., of New York, a preparation new to me, bearing the name of "Liquor ferri Peptonatus, Gude," or "PeptoMangam, Gude," prepared by Dr. Gude, of Leipsic; Germany. The claim being made that it was a combination of iron and manganese with peptones, having decided advantages over the preparations of iron, even the albuminate in both permanency and ease of assimilation. It is clear, of a rich sherry-wine color, neutral in reaction, free from astringency, and of a pleasant aromatic taste. It is also claimed for this preparation that "it is a powerful blood-forming agent; a genuine hæmoglobinogenetic; feeding the red corpuscles with organic iron and manganese which are quickly and completely absorbed in cases of anemia from any cause, such as chlorosis, amenorrhoea, dysmenorrhoea, chorea, Bright's disease, etc."

Dr. A. P. Loomis, of New York, in a paper read before the Section on General Medicine of the New York Academy of Medicine. speaks of it most favorably and reports a series of eight cases, in which anemia had resulted from various causes,