RC+^ K^9 Ololumbta Inttitrsity in the (Utty 0f Nem fork E^f^r^nr^ SItbrara w- :'--li»' THE PRACTICE OF MEDICINE A GUIDE TO THE NATURE, DISCRIMINATION AND MANAGEMENT OF DISEASE BY A. O. J. KELLY, A.M., M.D. ASSISTANT PROFESSOR OP MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA AND ASSISTANT PHYSICIAN TO THE UNIVERSITY HOSPITAL, PHILADELPHIA; PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF VERMONT; PROFESSOR OF PATHOLOGY IN THE woman's medical COLLEGE OF PENNSYLVANIA ; PHYSICIAN TO ST. AGNEs' HOSPITAL, PHILADELPHIA; CHIEF OF THE PATHOLOGICAL DEPARTMENT OF THE GERMAN HOSPITAL, PHILADELPHIA; MEMBER OF THE ASSOCIATION OF AMERICAN PHYSICIANS AND OP THE INTERURBAN CLINICAL club; EDITOR OP THE AMERICAN JOURNAL OP THE MEDICAL SCIENCES. ILLUSTRATED LEA & FEBIGEK PHILADELPHIA AND NEW YORK Entered according to Act of Congress, in the year 1910, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights reserved. O O C^X TO MY WIFE Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/practiceofmediciOOkell PREFACE. The following pages represent an effort to prepare for the student and the junior practitioner of medicine a guide to the nature, discrim- ination, and management of disease that should contain the essentials unadorned with great detail. Since the determination of what is really essential must be a matter of individual judgment, the greatest problem encountered was what to exclude, so that the book, without exceeding a convenient limit, should be comprehensive, properly balanced, and in good perspective. An acquaintance with the present development and the trend of medical education, and a teacher's appreciation of the needs of students, make one realize the embarrassment of riches, the large number of facts, too often placed before minds not yet qualified to sort them in their order of importance and grasp their mutual bear- ings. This defect of medical pedagogy violates the physiology of the mind, which is so constituted that the natural stimulus to interest, and therefore to recollection, is the tracing of rational connection. The resulting mental indigestion and lethargy appear at examination time and when the student or junior practitioner is confronted with the necessity of applying at the bedside principles ill understood. A book, of course, cannot replace actual clinical experience, but it should in fairness offer its readers a well-ordered statement of existing knowledge as a basis for training their powers of observation and reasoning, espe- cially in conformity with opportunities presented at the bedside. These considerations determined me to devote most space and atten- tion to the practical aspects of medicine; to the elucidation of those principles exemplified in disease at the bedside, in hospital wards and clinics, and in the consulting room; and to the clinically important and more common disorders rather than to the rarer diseases, however interesting. Such a plan seemed to offer more of value to students in recitations and in hospital-ward and dispensary work, and to practi- tioners desiring to recall elusive facts. A systematic arrangement of the subject matter has been adopted to facilitate comprehension of the mutual relations of different clinical and pathological entities. P^mpha- sis has been laid upon the definition of processes of disease — to impress upon the student the necessity of accuracy in his use of terms and in his clinical descriptions. Inasmuch as the final object of medicine is practice, most space has been devoted to symptomatology, diagnosis, and treatment; and to ensure a rational grasp of these main objectives, they are presented in their natural relationship by means of brief vi PREFACE connecting sections on etiological factors, essential anatomical lesions, and pathological physiology. The sections on pathological physiology might have been considerably expanded; but I venture to hope that, although limited to a statement of the main facts, they may prove serviceable to students in affording them a broad view of disease and of disturbed functions in general. Throughout the book an endeavor has been made to portray the nature and natural history of disease, to correlate disturbed or perverted function with altered structure, to explain the development of symptoms, and to elucidate the sequence of cause and effect. Such knowledge is essential to a correct and intelligent comprehension and interpretation of morbid phenomena (symptomatology and diagnosis), to the ability to forecast and provide against contingencies, to judgment of the course, duration, and termina- tion of disease (prognosis), and to skill in rational treatment and pro- phylaxis. Under the individual diseases, I have, as a rule, emphasized at least one method of treatment that I know to be of value from my own experience; beyond this point, however, I have depended upon the recommendations of acknowledged competent authorities. A few formulse have been included as an aid to the junior practitioner; these with the other instructions mentioned should serve him in times of stress until his experience and judgment warrant his making his own modifications. Intentional limitation of space and the primarily clinical purpose of the book have made it seem desirable to omit discussions of the biological characteristics of the infectious micro- organisms and of the technique of laboratory methods of diagnosis. A book on such a boundless subject as Medicine must be evolved out of the collective experience of the masters of all times and all parts of the world, tinctured by the study, investigation, judgment, and experience of the author. Although this book, in large part, is based upon my own clinical and pathological experience, I must acknowledge my indebtedness to the many writers of many tongues whose contribu- tions to medicine form the basis of my own knowledge. My experience with those disorders known as tropical has been almost limited to the rather few imported cases that an active hospital physician encounters in a large seaport. I have, nevertheless, included a brief account of these diseases, because of the widespread interest recently shown in their investigation, and on account of the increasing number of stu- dents who purpose practising in our tropical possessions; the clinical descriptions, however, are largely a reflection of those of such highly esteemed authorities as Manson, Cantlie, Jackson, and others. The descriptions of the metazoan parasites have been taken, in many instances verbatim, from Stiles — the recognized authority in this country. Elsewhere the attentive reader will note my indebtedness to other authors — to all of whom, I hope, I have given due credit. A. O. J. K. Philadelphia, 1910. CONTENTS SECTION I INFECTIOUS DISEASES General Observations and Pathological Physiology ........ 17 BACTERIAL INFECTIONS Typhoid Fever 32 Paratyphoid Fever 60 Pyogenic Infections 61 Erysipelas 67 Pneumococcic Infections 70 Pneumococcic Infection of the Lung; Pneumonia . 71 Meningococcic Infection; Cerebrospinal Fever 86 Gonococcic Infection 90 Tuberculosis 92 Acute Miliary Tuberculosis 96 Tuberculosis of the Lymphatic System 100 Tuberculosis of the Circulatory System 106 Tuberculosis of the Respiratory System 106 Tuberculosis of the Digestive System 117 Tuberculosis of the Genito-urinary System 120 Tuberculosis of the Nervous System 122 Tuberculosis of the Bones and Joints 124 Diphtheria 131 Influenza 143 Bacillary Dysentery 145 Tetanus 149 Cholera 153 Plague 156 Glanders 159 Anthrax 161 Malta Fever 164 Leprosy '. 166 NON-BACTERIAL FUNGUS INFECTIONS Actinomycosis 169 Mycetoma 170 Nocardiosis 171 Pulmonary Aspergillosis ' 171 Oidiomycosis 172 ZOOPARASITIC INFECTIONS Protozoan Infections Amoebiasis 175 Relapsing Fever 178 Syphihs 180 vm CONTENTS Yaws 193 Trypanosomiasis ■ 194 Kala-azar 195 Oriental Sore 196 Malarial Infections 197 Metazoan Infections Distomatosis . ' 211 Pulmonary Distomatosis 211 Hepatic Distomatosis -. 211 Intestinal Distomatosis 212 Venal Distomatosis 213 Teniasis 214 Intestinal Teniasis ; Tapeworm Infection 214 Somatic Teniasis 217 Nemathelminthiasis 218 Uncinariasis 218 Strongyloidosis 219 Ascariasis 219 Oxyuriasis 220 Trichocephaliasis 221 Acanthocephaliasis 221 Trichinosis _ 221 Dracunculosis 223 Filariasis 223 Acariasis 224 Ixodiasis 224 Sarcoptic Acariasis 224 Parasitic Insects 225 Phthiriasis; Pediculosis 225 Fleas 225 Bed-bugs . . . . \ 225 Myiasis 226 INFECTIONS OF UNKNOWN OR DOUBTFUL ETIOLOGY Variola 226 Vaccinia 233 Varicella 235 Typhus Fever 237 Scarlet Fever 240 Measles 247 Rotheln 250 Glandular Fever 252 Rheumatic Fever 253 Pertussis 257 Infectious Parotitis 260 Yellow Fever 261 Dengue 265 Hydrophobia 266 Rocky Mountain Spotted Fever 269 Epidemic Poliomyelitis 270 Acute Infectious Jaundice . 272 Foot-and-Mouth Disease 273 MiUary Fever 274 Milk Sickness 274 Beriberi 275 Epidemic Dropsy 277 Nasha Fever 278 Japanese River Fever 278 Ponos 279 CONTENTS IX Hill Diarrhoea 280 Sprue • 281 Epidemic Gangrenous Proctitis 281 Tropical Phagedena 282 Tropical Bubo 283 Ulcerating Granuloma of the Genitals 283 Verruga 284 Kubisagari 285 Gangosa 286 Ainhum 287 Goundou 287 Psittacosis ' 287 SECTION II INTOXICATIONS Alcoholism 289 Opium Habit 292 Cocaine Habit 293 Lead Poisoning 294 Arsenical Poisoning 296 Mercurial Poisoning 297 Snake-venom Poisoning . .' 298 Food Poisoning 299 SECTION III DISORDERS OF METABOLISM Pathological Physiology 303 Auto-intoxications 303 Diabetes 305 Diabetes Insipidus 318 Gout 320 Obesity , 327 Rickets 329 Scurvy 331 Amyloidosis . ^ .* 334 Infantihsm •. . . 335 SECTION IV DISEASES OF THE DUCTLESS GLANDS AND OF INTERNAL SECRETION Pathological Physiology 337 CONTENTS DISEASES OF THE THYROID GLAND Pathological Physiology 339 Acute Thyroiditis 340 Goitre 340 Hyperthyroidism and Exophthalmic Goitre 342 Hypothyroidism; Cretinism; Myxcedema . . 346 Tumors and Cysts of the Thyroid 349 DISEASES OF THE PARATHYROID GLANDS Pathological Physiology 349 Tetany 350 DISEASES OF THE ADRENALS AND THE CHROMAFFIN SYSTEM Pathological Physiology 351 Addison's Disease 353 DISEASES OF THE PITUITARY BODY Pathological Physiology 355 Akromegaly 356 SECTION V DISEASES OF THE BLOOD AND HEMOPOIETIC SYSTEM Pathological Physiology . ; 359 Acute Secondary Anemia 365 Chronic Secondary Anemia . 367 Chlorosis 369 Pernicious Anemia 373 Leukemia .... 378 Erythremia 385 THE HEMORRHAGIC DISEASES Hemorrhage in the Newborn 387 Purpura 387 Hemophilia , 390 DISEASES OF THE LYMPH NODES AND LYMPH VESSELS Pathological Physiology 393 Lymphangitis and Lymphadenitis 393 Lymphangiectasis 395 Tumors and Tumor-like Formations 397 Hodgkin's Disease 398 Diseases of the Thoracic Duct 401 DISEASES OF THE THYMUS BODY Pathological Physiology 402 Enlargement of the Thymus • 403 CONTENTS XI DISEASES OF THE SPLEEN Pathological Physiology 405 Anomalies of Form and Position of the Spleen 406 Rupture of the Spleen 406 Thrombosis, EmboHsm, and Abscess of the Spleen 406 Enlargement of the Spleen 407 Splenomegaly; Splenic Anemia 407 Tumors and Cysts of the Spleen 410 SECTION VI DISEASES OF THE CIRCULATORY SYSTEM Pathological Physiology 411 NEUROMUSCULAR DISORDERS OF THE HEART Cardiac Pain 415 Palpitation of the Heart , 416 Arrhythmia 416 Tachycardia 421 Bradycardia 422 DISEASES OF THE MYOCARDIUM The Weak or Insufficient Heart 424 The Overstrained or Irritable Heart 427 The Fatty Heart 430 The Infectious Febrile Heart . 431 The Fibroid Heart 434 Hypertrophy and Dilatation of the Heart 437 Aneurysm of the Heart 443 Rupture of the Heart 444 Tumors and Parasites of the Heart 444 Disease of the Coronary Arteries 444 DISEASES OF THE ENDOCARDIUM Acute Endocarditis 445 Chronic Endocarditis 450 Chronic Valvular ©isease of the Heart 452 Mitral Insufficiency 455 Mitral Stenosis 459 Aortic Insufficiency 462 Aortic Stenosis 466 Tricuspid Insufficiency . , 468 Tricuspid Stenosis 469 Pulmonary Insufficiency 470 Pulmonary Stenosis 470 Combined Valvular Lesions 471 DISEASES OF THE PERICARDIUM Pericarditis 478 Fibrinous Pericarditis 478 xii CONTENTS Serofibrinous Pericarditis 480 Purulent Pericarditis 483 Chronic Pericarditis 484 Hydropericardium 487 Hemopericardium 487 Pneumopericardium; Pyopneumopericardium 488 Chylopericardium 488 DISEASES OF THE ARTERIES Acute Aortitis 489 Arteriosclerosis 489 Angina Pectoris 493 Aneurysm 497 SECTION VII DISEASES OF THE RESPIRATORY SYSTEM Pathological Physiology 505 DISEASES OF THE NOSE Epistaxis 511 Acute Rhinitis 512 Chronic Rhinitis 514 Hay Fgver 515 DISEASES OF THE LARYNX Acute Catarrhal Laryngitis 517 QCdemat ovis Laryngitis 519 Spasmodic L aryngitis 520 Chronic Laryngitis 521 Laryngeal Perichondritis 522 Tumors of the Larynx 523 DISEASES OF THE TRACHEA AND BRONCHI Acute Bronchitis 524 Chronic Bronchitis 527 Fibrinous Bronchitis 530 Bronchiectasis 532 Bronchial Asthma 534 Tracheal and Bronchial Obstruction 537 DISEASES OF THE LUNGS Hemoptysis 539 Congestion of the Lungs 541 CEdema of the Lungs 543 Pulmonary Embolism and Thrombosis 545 Atelectasis and Collapse of the Lung 547 Bronchopneumonia 549 Chronic Interstitial Pneumonitis 552 Pneumonokoniosis ■ • 554 Emphysema • 555 CONTENTS xiii Abscess of the Lung 559 Gangrene of the Lung 561 Tumors of the Lung 562 DISEASES OF THE PLEURA Pleuritis 564 Fibrinous Pleuritis 564 Serofibrinous Pleuritis 566 Purulent Pleuritis 574 Hemorrhagic Pleuritis 576 Chronic Pleuritis 577 Hydrothorax 579 Pneumothorax 580 Chylothorax 583 Tumors of the Pleura 584 DISEASES OF THE MEDIASTINUM Mediastinitis 584 Tumors of.the Mediastinum 585 SECTION VIII DISEASES OF THE DIGESTIVE SYSTEM DISEASES OF THE MOUTH Stomatitis 587 Gangrene of the Cheek; Noma 593 DISEASES OF THE TONGUE Glossitis 594 Eczema 595 Leukoplakia 595 Black Tongue 595 Macroglossia 596 Acute Oedema 596 Ranula 596 ' DISEASES OF THE SALIA'ARY GLANDS Ptyalism 596 Xerostomia 596 Parotitis 596 Gaseous Distention 597 Calculi 597 Ludwig's Angina 597 DISEASES OF THE FAUCES, TONSILS, AND PHARYNX Acute TonsilHtis 598 Chronic TonsilHtis 601 Pharyngitis 603 Ulceration of the Pharynx 603 Acute Infectious Phlegmon of the Ph&rynx; , 604 xiv CONTENTS Retropharyngeal Abscess 604 Elongation of the Uvula . 604 The Lingual Tonsils 604 DISEASES OF THE (ESOPHAGUS Acute (Esophagitis 605 Chronic (Esophagitis 605 Ulceration 605 Varices 606 Rupture 606 Dilatation 606 Diverticula 606 Spasm 606 Paralysis 607 Stenosis 607 Carcinoma 607 DISEASES OF THE STOMACH Pathological Physiology 608 Symptomatic Disorders of the Stomach 610 The Appetite 610 Thirst 611 Nausea and Vomiting 612 Hematemesis 613 -^otor Disorders 614 Sensory Disorders 616 Secretory Disorders 618 Nervous Dyspepsia 621 Acute Catarrhal Gastritis 622 Phlegmonous Gastritis 624 Toxic Gastritis 624 Infectious Gastritis 625 Chronic Gastritis 626 Acute Dilatation of the Stomach 629 Chronic Dilatation of the Stomach 630 Ulcer of the Stomach and Duodenum 632 Carcinoma of Stomach 638 Non-carcinomatous Tumors 643 Hypertrophic Stenosis of the Pylorus 643 DISEASES OF THE INTESTINE Pathological Physiology 643 Symptomatic Disorders of the Intestine 646 Motor Disorders 647 Sensory Disorders 649 Secretory Disorders 650 Intestinal Indigestion 650 Intestinal Hemorrhage 652 Mucous Cohc . 654 Constipation 655 Acute Enteritis ' 657 Chronic Enteritis 659 Diarrhoeal Disorders of Children 661 Croupous or Diphtheritic Enteritis 667 Phlegmonous Enteritis 667 Appendicitis 668 Sigmoid Diverticuhtis . 672 Ulceration of the Intestine 673 Intestinal Obstruction , . . . . , . 674 CONTENTS XV Dilatation of the Colon 682 Infarction of the Mesenteric Vessels 682 Intestinal Sand 683 Hemorrhoids 683 Visceroptosis 685 DISEASES OF THE LIVER Pathological Physiology 687 Jaundice 689 Anomalies of Form and Position of the Liver 695 Diseases of the Bloodvessels of the Liver 696 Fatty Liver 697 Acute Yellow Atrophy of the Liver 698 Active Congestion of the Liver 702 Passive Congestion of the Liver 703 Perihepatitis 704 Acute Perihepatitis . . ... 704 Local Chronic Perihepatitis 705 General Chronic Perihepatitis 705 Acute Hepatitis 705 Acute Non-suppurative Hepatitis 705 Suppurative Hepatitis 707 Chronic Interstitial Hepatitis: the Cirrhoses of the Liver 709 Portal Cirrhosis 710 Biliary Cirrhosis 717 Tumors of the Liver 719 DISEASES OF THE GALL-BLADDER AND BILIARY DUCTS Congenital Obliteration of the Biliary Ducts 721 Acute Catarrhal Cholangitis 722 Suppurative Cholangitis . 724 Chronic Catarrhal Cholangitis 725 Acute Cholecystitis .... 726 Chronic Cholecystitis 728 Cholelithiasis 728 Carcinoma of the Gall-bladder and Biliary Ducts 736 DISEASES OF THE PANCREAS Pathological Physiology 737 Hemorrhages into the Pancreas 737 Acute Pancreatitis 738 Chronic Pancreatitis 741 Cysts of the Pancreas 743 Tumors of the Pancreas 744 Pancreatic Calculi 745 DISEASES OF THE PERITONEUM Ascites 746 Acute Peritonitis 748 Chronic Peritonitis 749 Multiple Serositis 750 XYl CONTENTS SECTION IX DISEASES OF THE URINARY SYSTEM Pathological Physiology 755 Anuria 763 Albuminuria 764 Albumosuria 767 Cylindruria 768 Hematuria 769 PjTiria 769 AnomaUes of Form and Position of the Ividneys 770 Circulatory Disturbances of the Ividneys 770 Nephritis 772 Active Diffuse Xephritis 773 Acute Suppurative Nephritis 779 Chronic Diffuse Non-indurative Nephritis 780 Chronic Diffuse Indurative Nephritis 783 Cj'stitis; Ureteritis; Pj'ehtis; Pyelonephritis; Pyelonephrosis 788 Perinephritis and Paranephritis 792 Hydronephrosis 793 Nephrolithiasis . . . . / 794 CYsts of the Kidney 797 Tumors of the Kidnev 798 Tumors of the Bladder 799 SECTION X DISEASES OF THE NERVOUS SYSTEM Pathological Phj'siology 801 DISEASES OF THE NERVES Neuralgia 808 Neuritis 811 Herpes Zoster 813 Neuromas 814 Diseases of the Cranial Nerves 814 Olfactorj' Nerve 814 Optic Nerve 815 Oculomotor Nerve 816 Trochlear Nerve 816 Abducens Nerve 816 Trigeminal Nerve 817 Facial Nerve 817 Auditor}' Nerve 819 Glossophars-ngeal Nerve 819 Pneumogastric or Vagus Nerve 819 Spinal Accessor}' Nerve 820 Hypoglossal Nerve 820 Diseases of the Spinal Nerves 821 C'er\'ical Plexus 821 Brachial Plexus 821 Lumbar Plexus 824 Sacral Plexus 824 Diseases of the Cervical Sympathetic Nerves 82^ CONTENTS xvii DISEASES OF THE CEREBROSPINAL MENINGES Meningeal Hemorrhage 825 External Pachymeningitis 826 Internal Pachymeningitis 827 Leptomeningitis 828 DISEASES OF THE BRAIN AND SPINAL CORD Cerebrospinal Localization 831 Aphasia , 840 SYSTEM DISEASES OF THE BRAIN AND SPINAL CORD Diseases of the Upper (Central) Motor Neuron Lateral Sclerosis 845 Spastic Paralysis of Infants 846 Hereditary Spastic Spinal Paralysis 847 Amaurotic Family Idiocy 847 Unilateral Ascending and Unilateral Descending Paralysis 848 Diseases op the Lower (Peripheral) Motor Neuron Chronic Anterior Poliomyelitis 848 Progressive Neural Muscular Atrophy . 849 Bulbar Paralysis 850 Ophthalmoplegia 851 Disease of the Upper (Central) and the Lower (Peripheral) Motor Neurons Amyotrophic Lateral Sclerosis 852 Diseases of the Sensory Neuron Tabes DorsaUs 853 Interstitial Hypertrophic Progressive Neuritis of Childhood 856 Combined System Diseases Hereditary or Family Ataxia 857 Hereditary or Family Cerebellar Ataxia 857 Ataxic Paraplegia 858 Toxic Combined Sclerosis 858 NON-SYSTEM DISEASE OF THE BRAIN AND SPINAL CORD Multiple Sclerosis 859 DIFFUSE AND FOCAL DISEASES OF THE BRAIN Hyperemia of the Brain 861 Anemia of the Brain 861 CEdema of the Brain 862 xviii CONTENTS Cerebral Hemorrhage 862 Cerebral Thrombosis 868 Cerebral Embolism 869 Thrombosis of the Cerebral Sinuses 870 Acute Hemorrhagic Encephalitis 871 Abscess of the Brain 871 Tumors of the Brain 873 Hydrocephalus 875 DIFFUSE AND FOCAL DISEASES OF THE SPINAL CORD Vascular Disorders of the Spinal Cord 876 Hemorrhage into the Spinal Cord 876 Caisson Disease 878 MyeUtis 879 Compression of the Spinal Cord 882 Tumors of the Spinal Cord 883 SyringomyeUa 884 . NERVOUS DISEASES OF FUNCTIONAL OR UNKNOWN NATURE Migraine 886 Epilepsy 888 Hysteria 892 Neurasthenia and Psychasthenia 895 Occupation Neuroses 897 Paralysis Agitans 898 Acute Chorea 900 Hereditary Chorea 902 Convulsive Tics 903 Choreiform Disorders 904 Family Periodical Paralysis 904 Heatstroke 905 VASOMOTOR AND TROPHIC DISORDERS Angioneurotic (Edema 907 Erythromelalgia 907 Acroparesthesia 908 Raynaud's Disease 908 SECTION XI DISEASES OF THE MUSCLES Muscular Rheumatism 911 Myositis 912 Progressive Muscular Dystrophy 912 Myoclonus 914 Congenital Myotonia 915 Congenital Amyotonia 916 CONTENTS xix SECTION XII DISEASES OF THE BONES AND JOINTS Acute Arthritis 917 Chronic Atrophic Arthritis 918 Chronic Hypertrophic Osteo-arthritis 920 Osteomalacia 921 Osteitis Deformans 922 Hypertrophic Pulmonary Osteo-arthropathy 923 Osteogenesis Imperfecta 923 Achondroplasia . . . • 923 Facial Hemiatrophy 923 Leontiasis Ossea 924 THE PRACTICE OF MEDICINE. SECTION I. INFECTIOUS DISEASES. The infectious diseases comprise a series of disorders that result from the growth within the hving body of divers pathogenic vegetable and animal parasites. These, the so-called infectious agents (coiitagium vivum), include certain bacteria, certain non-bacterial fungi, and certain zooparasites (protozoa, worms, and arthropods). In consequence, one may divide the known infectious diseases into three classes: (1) The bacterial infections; (2) the non-bacterial fungus infections; and (3) the zooparasitic infections; but to these one must at present add a fourth class, that of infections of unknown or doubtful etiology— which comprise diseases undoubtedly infectious that have not yet yielded up to scientific inquiry their specific etiological factors. Perhaps the causative agents of many of these, as has been demonstrated of some of them (yellow fever, hydrophobia, epidemic poliomyelitis, pleuro- pneumonia of cattle, foot-and-mouth disease, etc.), are certain ultra- microscopic parasites, microorganisms that pass through a fine porous filter impervious to ordinary bacteria, but elude detection by the highest powers of the microscope. Additional reasons, however, for the non- discovery of these organisms are that they may be difficult to stain, difficult or impossible to cultivate in artificial media outside the body, and present in small numbers in the diseases they provoke. Infectious and Contagious Diseases. — In times past the diseases now recognized as infectious were divided into two classes — the miasmatic and the contagious. The miasmatic diseases were those surmised to be due to some cause, a miasm, arising without the body and capable of provoking disease without the intervention of another individual thus affected; the contagious diseases were those caused by some factor, a contagion, developed within the diseased body and capable of transmitting the disease to another individual (man or animal), either directly or indirectly (through the medium of a third person or an 18 INFECTIOUS DISEASES object, or the air). Since a miasm has become a myth of the past, !wly stages of typhoid fever, and occurs usually at the end of the first ami the 44 BACTERIAL INFECTIONS beginning of the second week. A simple laryngitis is not very uneomnion. (Edema, ulceration, perichondritis, and paralysis of the larjmx are quite rare. Bronchitis is a part of the disease, and one of the early manifestations. It is usually slight or moderate in degree only, and revealed by cough, slight expectoration, harsh vesicular breath sounds, and a few sibilant and fine bubbling rales. Rarely the finer tubes are involved — whence bronchopneumonia may supervene. Bronchopneu- monia may also follow oedema and congestion of the lungs, which are by no means uncommon during the second and third weeks ; during the same periods, when the patient is more or less stuporous, an aspiration pneu- monia is not infrequent. True croupous pneumonia may also occur during the later half of the disease, and is a serious complication. Occasion- ally it is an initial manifestation — pneumotyphoid (pneumonia due to the typhoid bacillus, with t^-phoid bacilli in the sputum); in this event the early signs are those of pneumonia, the intestinal and other manifesta- tions of t}^hoid fever only developing later. Pulmonary abscess or gangrene and pneumothorax are rare sequels. Pleurisy may be primary or secondary: secondary to any of the aforementioned pulmonary conditions; primary and due to direct infection with the typhoid bacillus — ^pleurotyphoid. Occurring early, the lesions are usually dry or serous, later often purulent. The bronchial l}Tnph nodes have been known to soften and suppurate. Circulatory System. — ^The pulse is usually increased in frequency, though not proportionately to the fever. During the first week it is less than 100, as a rule; in the second week it commonly fluctuates below 110 and becomes dicrotic (an early and quite characteristic feature). With the progress of the disease the evidences of vasomotor paresis become manifest — low blood pressure, increased frequency of the pulse (130 or more sometimes), which often becomes running or thready, capillary stasis (coldness and lividity of the extremities), overfilling of the splanchnic vessels, anemia of the cerebral vessels, and sometimes vasomotor collapse. As convalescence sets in vasomotor tone is restored, and the pulse becomes slower, fuller, and stronger; during convalescence the pulse is often unusually slow (a characteristic feature). Changes in the heart muscle (parenchymatous degeneration, and acute interstitial myocarditis) are common. Often the only noteworthy clinical manifesta- tion is feebleness of the first sound of the heart. When more marked, however, there is not infrequently gallop rhythm, or embryocardia, or dilatation of the heart (systolic murmur, increase of the dulness, etc.). Endocarditis and pericarditis are uncommon, but not unknown. Venous thrombosis, especially of the lower extremity (femoral, pop- liteal, saphenous, or superficial veins), is not infrequent, particularly during convalescence. It may be due to thrombophlebitis (in which event the typhoid bacillus may be cultivated from the vein and the clot), or to cardiac weakness and slowing of the circulation; the more common occurrence of the thrombosis in tlie left leg may be due to the pressure exerted by the right iliac artery crossing the left TYPHOID FEVER 45 iliac vein, as well as to congenital adhesions, which are ten times as common in the left as in the right iliac vein. The thrombosis is evidenced by swelling and oedema of the leg, and by pain and tender- ness along the course of the involved vein. The process usually subsides without ill effects, but it may require a long time, and embolism of the pulmonary artery, ensuing on dislodgement of the thrombus, has been known to result in death. Infarcts of the internal organs are not very uncommon, and may result from arterial thrombosis or embolism. Gangrene sometimes results from occlusion of one of the larger arteries, and a number of cases of more or less local (though sometimes wide- spread) gangrene unrelated to definite vascular distribution have been reported; they are probably due to secondary infisction of the skin (gangrenous dermatitis). Heart clot is rather unusual. Blood and Hemopoietic System. — Leukopenia is present through- out the disease, except in the event of complications, although a temporary increase in the leukocytes in the peripheral circulation is not infrequently produced by the cold baths. With the leukopenia there is a dispro- portionate increase of the large mononuclear leukocytes and a reduction of the polynuclear neutrophiles (to 60 per cent, or less). An increase of the polynuclear neutrophiles is often an early manifestation of in- flammatory complications (perforation, cholecystitis, etc.) and may be present with little or no increase in the total number of leukocytes. The blood serum agglutinates the typhoid bacillus (Gruber-Widal reaction). During the later half of the disease a rather well-marked anemia usually develops; during convalescence this may assume a high grade and constitute a serious feature (post-typhoidal anemia). The spleen is enlarged and palpable in at least three-fourths of the cases. It may extend two, three, or more finger breadths beyond the free margin of the ribs, and it is not infrequently quite tender. The enlargement is sometimes missed in elderly subjects and in the event of perisplenitis. I have seen infarction and abscess of the spleen ; rupture has been reported. The superficial lymph nodes throughout the body are sometimes palpably enlarged. Nervous System. — Persistent headache (usually temporal and occipital) is a prominent and significant symptom of the first week, and is often associated with severe pains and aching in the back and legs. During this period also restlessness and insomnia are likely to be present, and are often distressing. Sometimes the patient is quite deaf. The pupils are usually markedly dilated. Gradually, in most cases, as the patient succumbs to the toxemia, that is, during the second week, the headache, restlessness, and insomnia are replaced by mental dulness, hebetude, and delirium, which vary considerably in different cases, and in the beginning at least are usually most marked at night. The patient becomes listless and a])athetic, and is more or less unconscious of his surroundings, althougli he may lie for hours at a time with his eyes wide open (coma vigil); he frecpiently mutters constantly, picks at the bed- clothing or at imaginary objects (carphologia), and exhibits general 46 BACTERIAL INFECTIONS muscular twitchings, especially of the tongue, lips, hands, and fingers (subsultus tendinum). Often the undue muscular irritability is quite manifest by the ready production of myoidema. In this, the typhoid state, the urine and feces may be voided involuntarily, and the patient knows not even his wants. Not infrequently he shows a disposition to get out of bed — whence he should not be left alone for even an instant, as not a few patients have thrown themselves from a window during the temporary, though only momentary, absence of the nurse. Occasion- ally, instead of a quiet, muttering delirium, the patient may exhibit a noisy, hysterical (emotional), or maniacal delirium (especially alcoholic subjects, in whom the condition quite resembles delirium tremens). Occasionally typhoid fever is ushered in with unusual nervous symp- toms. The headache and backache may be intense, and there may be also photophobia, pain, tenderness, and rigidity of the muscles of the neck, sometimes even retraction of the head, and rarely convulsions (more common in children than in adults). In other cases, later in the course of the disease, similar symptoms arise. These cases suggest and are only with difficulty distinguished from meningitis; three types may be distinguished: (1) Cases suggesting meningitis, but in which no anatomical lesions can be demonstrated — the so-called meningism of the French, probably due solely to toxemia; (2) cases exhibiting the lesions of serous meningitis and perhaps revealing the typhoid bacillus in the cerebrospinal fluid ; and (3) cases of purulent meningitis from which the typhoid bacillus, either alone or in association with other bacteria, may be isolated. Circumscribed encephalitis, and hemorrhage, embolism, and thrombosis of the brain (hemiplegia with or without aphasia) have been observed. Myelitis or poliomyelitis (spastic or flaccid paralysis) is still more uncommon. Peripheral neuritis is quite frequently observed, of which a well-known manifestation is the rather common tender toes and tender feet — believed to be more common since the use of the cold-bath treatment. The very common painful calves (observed fre- quently during convalescence), as well as the much less common painful muscles in other parts of the body, are not infrequently due to neuritis ; but they are sometimes due to myositis or to thrombosis of a vein. Post- typhoidal insanity (confusional insanity, melancholia, or mere mental dulness) is not uncommon. It is usually attributed to toxemia and impaired nutrition, and in the majority of cases soon subsides. Oculo- motor paralysis, paralysis of accommodation, iritis, keratitis, conjuncti- vitis, and divers other ocular complications have been reported. Genito-urinary System. — ^The urine, as a rule, presents the features of so-called febrile urine (diminished in amount, high colored, of high specific gravity, abundance of urates, etc.). The diazo reaction is usually present. At least three-fourths of the patients exhibit slight albumin- uria — attributable to toxic degeneration of the renal epithelium. Occa- sionally a true nephritis (hemorrhagic or non-hemorrhagic) occurs at the height of the disease. I have observed acute interstitial non- suppurative nephritis (the so-called lymphomatous nephritis of Wagner). TYPHOID FEVER 47 Nephritis during convalescence or as a sequel is quite rare, the lesions developing during the course of the disease usually subsiding in the non-fatal cases. Retention of urine is quite common and often occasions rather severe abdominal pain. Typhoid bacilluria is present in at least one-third of the cases, and sometimes lasts for months after apparent recovery from the disease; because the urine is often not disinfected this bacilluria is answerable for some epidemics. The bacilluria may be due to pyelitis, cystitis, spermatocystitis, prostatitis, or orchitis, or it may occur without noteworthy lesions. Diabetes (or glycosuria), hema- turia, and hemoglobinuria are rarely observed. Menstruation is not infre- quent at the beginning of the disease, and pregnant women usually abort. Other unusual complications comprise osteomyelitis, periostitis, peri- chondritis, synovitis, and arthritis (from which the typhoid bacillus may be cultivated months and even years after the primary infection). Occa- sionally during or after convalescence the patient complains of pain, tenderness, and rigidity in the lumbar and sacral regions, and of certain nervous (sometimes hysterical) phenomena. This condition (so-called typhoid spine) is in some cases a pure neurosis, but it not infrequently has an organic basis — spondylitis or perispondylitis. Perinephritic abscess may simulate the condition. Fever may be an important sign in the differential diagnosis. Typhoid fever is not uncommonly associated with other diseases, especially tuberculosis, malaria, measles, diphtheria, noma, erysipelas, furunculosis, etc. Most of the cases of so-called typho-malarial fever are true typhoid fever; others are remittent malarial fever; in a few cases only do two diseases co-exist. Varieties of Typhoid Fever. — Many different varieties of typhoid fever have been described; but the infection is always with the same typhoid bacillus (which, however, often exhibits variations in certain of its biologi- cal characteristics) ; the clinical differences are dependent, therefore, upon differences in the virulence of the infecting agent, upon unusual localiza- tions of the infection, and upon variations in the resistance of the indi- vidual. Thus, mild (typhus Ifevis sive Isevissimus, Griesinger) and severe forms are readily distinguished. In the mild forms, which are frequently overlooked and especially common in children, the clinical and anatomical manifestations of the disease are ill developed, and although fever, an enlarged spleen, rose-spots, the Gruber-Widal reaction, etc., often occur, convalescence is not infrequently established at or before the end of the second week; but the disease may run the more usual course of three to four weeks. In children the abdominal symptoms are often slight or absent, whereas the nervous, cerebral symptoms are likely to be marked. Unusually acute and rapid cases are sometimes observed. Doubtless an abortive form occurs, but it is very uncommon — more especially since the general use of the (irul)er-Wi(lal reaction. As described, the onset presents nothing unusual, except in some cases rather sudden and marked initial fever; but at the end of the first week the fever falls, and 48 BACTERIAL INFECTIONS convalescence goes on as in the ordinary cases, though relapses may occur. Latent or ambulatory typhoid fever is a form of infection in which the symptoms, at the beginning at least, are so mild that the patient does not feel the necessity of going to bed, and therefore continues about until some unusual phenomenon, such as marked diarrhoea, delirium, intestinal perforation, or hemorrhage, etc., brings him under the atten- tion of the physician. The subsequent course of the disease is often severe and not infrequently fatal. The initial symptoms of typhoid fever sometimes suggest an ordinary "cold," influenza, tonsillitis, or gastritis. An afebrile, exceedingly rare, form of the infection has been described by Liebermeister. The severe cases are characterized, as a rule, by unusual severity of the fever and of the nervous symptoms (delirium, prostration, vasomotor paralysis, etc.) — whence these are sometimes spoken of as the cerebrospinal form. In other cases there is unusual localization of the lesions in different organs — whence the terms pneumo-typhoid, pleuro- typhoid, nephro-typhoid, tonsillo-typhoid, pharyngo-typhoid, meningo-typhoid, etc. A few severe cases have been characterized by petechial spots and hemorrhages from the mucous membranes — so-called hemorrhagic form. The disease often runs a severe course in elderly, alcoholic, and obese subjects. Relapses. — A relapse, a repetition of the anatomical and clinical features of the diease and due to re-infection, is not an uncommon event, occurring in different epidemics in from 3 to 15 per cent, of the cases. It should be distinguished from recrudescence of the fever (spurious relapse, previously alluded to), as well as from complications, such as cholecystitis, pleuritis, etc., for which it is frequently mistaken. It is not always possible to discover the source of re-infection: some- times it may be from without; usually it is from within, and one should always bear in mind the possibility of infection from the gall- bladder which frequently harbors typhoid bacilli without obvious local disease; the urinary tract also may be the source of reinfection; but the real cause of the relapse is most likely to be found amongst the problems of immunity — perhaps in temporary exhaustion or over- powering of the bacteriolytic activities of the blood. As a rule, the relapse comes on within seven days of the beginning of the convalescence; sometimes it develops earlier, even before the temperature has reached normal (intercurrent relapse), in which event it is often severe and protracted; occasionally it may not come on until the temperature has been normal for three weeks or more. The period of apyrexia is usually without noteworthy manifestations. The onset of the relapse, as a rule, is sudden, the temperature rising abruptly, sometimes with a chill or chilliness. Then follow usually the characteristic step-ladder rise of the temperature (for two or three days), new roseolous spots (on the second to the fourth day), and enlargement of the spleen — two of which signs, at least, should be present to warrant the diagnosis of a true relapse. As a rule, the relapse does not last more than ten or fourteen days, and the clinical signs are less severe than in the primary attack; TYPHOID FEVER 49 hut occasionally all the phenomena of the disease are much aggravated during the relapse, and the patient may die of the toxemia or of one of the common accidents, such as hemorrhage or perforation. There may be a second, a third, a fourth, and even a fifth relapse. A recurrence, as contrasted with a relapse, means another attack of the disease occurring after complete restoration to health. Usually, typhoid fever confers lasting immunity, but second and apparently well-authenticated third attacks have been observed — a period of years intervening between the attacks. Diagnosis. — The recognition of typhoid fever is, in the one case, a matter of the greatest ease, and in another, of the greatest uncertainty — for a time at least. No one symptom is conclusive. Of special value in the diagnosis are prodromal symptoms lasting for a week or more, the gradual onset of fever (of characteristic rise, if it has been observed), persistent headache, nose-bleed, roseolous spots, enlarged spleen, early dicrotism of the pulse, leukopenia, and the diazo reaction; the diagnosis is made conclusive by the Gruber-Widal reaction (in dilutions of 1 to 50 or more), and the cultivation of typhoid bacilli from the blood, the rose-spots, the stools, the urine, or the cerebrospinal fluid. In some regions continued fever for seven days without evidence of local disease is quite suggestive. Paratyphoid fever, as a rule, is first suggested by the absence of the Gruber-Widal reaction with the typhoid bacilli. It may be difficult or impossible for some days to exclude cerebrospinal menin- gitis, since typhoid fever sometimes begins with severe nervous mani- festations, but the characteristic course of the fever, the erythematous rose rash (as contrasted with a petechial eruption), the presence of ab- dominal symptoms, the absence of herpes facialis, the presence of the Gruber-Widal reaction, and the negative results of lumbar puncture, serve ultimately to distinguish typhoid fever. The continued types of malarial fever, which much resemble typhoid fever, may be distinguished by the absence of the Gruber-Widal reaction, the presence of the malarial parasite in the blood, and by the administration of quinine. Acute miliary tuberculosis is often differentiated with difficulty, but it is sug- gested by absence of the characteristic fever curve, of abdominal symp- toms, of erythematous rose-spots, of leukopenia, and of the Gruber-Widal reaction, and by the presence of increased pulse-rate, of dyspnoea, of cyanosis, of occasionally bloody expectoration, of choroidal tubercles, and of tubercle bacilli in the cerebrospinal fluid and rarely in the blood. Certain pyemic processes, of which ulcerative endocarditis is an example, are usually diagnosticated typhoid fever, but they may sometimes be differentiated by detecting a source of infection, and by the presence of undue dyspnoea, irregular heart action, a peculiar rough systolic, but more especially a diastolic murmur, irregular and repeated chills or chilly sensations, profuse sweats, the early occurrence of marked prostra- tion, the rapid development of anemia, leukocytosis, embolic phenomena (petechial helnorrhages, infarctions, etc.), and pyococci in the blood, and by the absence of a characteristic fever curve, of persistent headache, 4 .50 BACTERIAL IXFECTIOXS of epistaxis, of abdominal symptoms, and of the Griiber-Widal reaction. Acute leukemia without noteworthy enlargement of the lymph nodes, which usually resembles typhoid fever, may be distinguished by the absence of the Gruber-Widal reaction and the presence of leukocytosis (lymphocytosis). Pneumonia, appendicitis, and tuberculous peritonitis also must be considered in the differential diagnosis in certain instances. Prognosis. — The prognosis is always doubtful, since no one can fore- tell whether or not one of the two accidents (hemorrhage and perforation), responsible for almost two-thirds of the deaths, will occur. The mortality varies much in different epidemics — from 5 to 12 per cent, in private practice to from 7 to 20 per cent, in hospital practice, where the worst cases are encountered. During recent years, in consequence of the general use of the cold-bath treatment, the mortality has certainly been reduced — in some hospital statistics to less than 4 per cent. The prog- nosis in general depends upon the severity of the infection, the resistance of the individual, and the presence or absence of complications. Aside from repeated hemorrhages and perforation (with consecutive peritonitis) answerable for almost two-thirds of the deaths, especially unfavorable symptoms are persistent high fever, persistently rapid pulse (above 1 20), profound toxemia and delirimn, marked t^Tnpanites, and complications, such as pneumonia, meningism, meningitis, etc. Sudden death may occur during the fastigium, as well as during defen^escence or con- valescence, from cardiac collapse, vasomotor paralysis, pulmonary or cerebral embolism or thrombosis, etc. The passage of eighty to one hundred or more ounces of urine daily is one of the most favorable prognostic signs The prognosis of relapses is not essentially different from that of the primary attack. The prognosis in children, as a rule, is good. Treatment. — In t^'phoid fever probably as much as, if not more than, in any other disease, our duty is not to our patient alone, but in a special sense to the community at large Since t}-phoid fever is a preventable disease, it should be prevented; the duty of preventing it falls upon the physician no less than upon the public health authorities. The general measures of prophylaxis set forth on page 29 should be scrupulously followed. AMiether Wright's preventive inoculation will ultimately commend itself to the profession is at least doubtful. According to British armv surgeons, typhoid fever is more than two and a half times as common, and one and a half time as fatal, among the uninoculated as compared with the inoculated troops. Of possible value during times of war, inoculation is not likely soon to attain much vogue in civil practice; it may prove of service among hospital attendants. The serum treatment of the disease, for which Chantemesse and others claim good results, has not commended itself to the profession at large. A satis- factory vaccine (bacterin) treatment has not yet been devised. Since t}-phoid fever is a self-limited infection, the special function of the physician is to assist, never thwart, the well-directed efforts of TYPHOID FEVER 51 nature. This comprises attention to, (1) the general management of the patient, (2) the diet, (3) hydrotherapy, and (4) medicinal and other measures indicated symptomatically. General Maxagemext. — ^Miether the patient shall be treated in his home or in a hospital is a matter to be decided in each individual case ; in general the hospital patient has the advantage, since the nursing, as a rule, is better and the necessary manipulations can be more easily carried out; disinfection is more thoroughly practised; complications are likely to be sooner recognized (since a physician is always at hand) ; and in the event of surgical intervention being necessary, it can be undertaken sooner and under better auspices than in the patient's home. But under proper supervision, the patient may be very well treated at his home. Under all circumstances, he should be isolated — in the hospital, in a ward or room set apart for this purpose; at home, in a room affording abundance of sunlight and fresh air. He should be confined absolutely to bed until he is well along in convalescence, and he must use a bed-pan and a urinal. Special attention should be directed to avoiding creases in the bed-linen so as to promote the comfort of the patient and prevent, as far as possible, the development of bed sores. The patient should be turned on his side from time to time, and his skin, especially of the back, should be frequently sponged with dilute alcohol (50 per cent.) or with equal parts of alcohol and alum water; following this a drying powder may be applied, such as zinc stearate, or equal parts of powdered zinc oxide and boric acid. Should the skin become irritated, one may substitute a mixture consisting of boric acid 10 grains (0.65 gram), zinc oxide 1 to 2 drams (4 to 8 grams), and castor oil 1 ounce (30 grams) . The mouth and throat should be kept clean and sweet by the use of mild antiseptic solutions, such as boric acid (3 per cent.) ; or boric acid (1 dram, 4 grams) , glycerin (6 drams, 25 grams) , and rose water (6 ounces, 200 grams) ; or liquor antisepticus (U. S. P.); or the following: I^ — Carbolic acid 6 minims 40 Oil of eucalyptus 10 minims 60 Sodium borate 1 dram. 4 00 Glycerin 3 drams 12|00 Distilled wat3r, sufficient to make . . . 3 ounces 100 00.— M. The physician should always write his orders in detail, rather than trust to the memory of even a well-trained nurse; in the absence of a trained nurse, this is all the more imperative. The general management of convalescence often demands much tact on the part of the physician — to withstand the importunities of the patient and the usually well-meant, but often ill-advised, endeavors of his solicitous friends. Could solicitous friends be banished for a while, most typhoid-fever patients would fare better; at all events, the visits should be as short as possible, and all matters that may excite the patient 52 BACTERIAL INFECTIONS or disturb his emotions should be scrupulously avoided. On the fifth or the sixth day of normal temperature, in the ordinary case, the patient may be propped up in bed for a while, and on the eighth day or there- abouts he may sit in a chair. A general tonic is usually advantageous, though often not necessary; anemia, however, calls for the administra- tion of iron. Return to ordinary avocations should be postponed as long as possible, especially after severe infections; return to mental work and study, in particular, should be delayed, since a too early return not infrequently results in a prolonged spell of cerebral asthenia. A sea voyage subserves a most useful purpose following convalescence. Diet. — ^The diet should be suited to the individual patient, rather than to the disease. The physician should remember that during typhoid fever the digestive juices are lessened or perverted, and that some at least of the toxemia is due to the poisonous effects of the end- products of destructive katabolism of the body protein; and while he should endeavor as far as possible to supply a sufficiency of calories in foodstuffs to satisfy dynamic needs and to minimize loss of weight, he must be careful to avoid improper food and that excess of food which is certainly productive of digestive disorders. If in the past we have been perhaps too much committed to a diet insufficient in calories and relatively too rich in protein, a diet of too high caloric value may be productive of much harm; certain carbohydrates, under circumstances, may be of value; fats, at least in excess, are not well borne. In many respects the appetite is a good index of the amount, although not of the character of the food that may be permitted. There can be no doubt that at present, as in the past, the majority of patients do best on a diet consisting largely, if not wholly, of milk. To an adult one may give four, six, or eight ounces of milk every two hours during the day, and every four hours at night — nine or ten feedings in the twenty-four hours. This furnishes from 780 to 1750 calories (650 to 700 calories to a quart or liter). The milk may be given hot or cold; it may be diluted with lime water or some carbonated water, such as Vichy; it may be flavored with salt, vanilla, coffee, tea, cocoa, or port or sherry wine; or it may be given as buttermilk, koumiss, matzoon, junket, or in part as ice cream. Twice a day, the white of an egg (20 calories) or the whole egg (80 calories) , if w^ell borne, may be added to the milk. In case of objection on the part of the patient, albumen water (the whites of two eggs added to four to six ounces of water, and flavored with lemon, lime, or orange juice) may be substituted for the milk at every other feeding. In ordinary cases, throughout the febrile period, I commonly adhere to this diet of milk and egg-albumen — the advantage of which is seen in the freedom from intestinal dis- orders, the good general condition of the patient, and the usually prompt convalescence without noteworthy untoward symptoms. However, in the event of very serious objection to milk on the part of the patient, or an obvious poor general condition, I have no hesitation in substituting the milk in whole or in part, or adding to it, cream, milk sugar, eggs, meat and TYPHOID FEVER 53 veo-etable soups^ strained and thickened with flour, powdered rice or barley, cream, egg, etc., or strained oatmeal gruel, cornstarch, arrow-root, potato puree, gelatine flavored with wine, etc. In the event of tympanites or diarrhcea, the milk should be reduced in amount; usually, under these circumstances, too much rather than too little is being given, and curds frequently appear in the stools. Whey, l)oiled milk, peptonized or pancreatized milk, or koumiss may be substi- tuted; but if the unfavorable symptoms do not subside promptly the milk should be entirely withheld for twenty-four to thirty-six hours, and albumen water given instead. Thereafter one may cautiously recommence with peptonized milk in small amounts, or resort to some of the other mentioned foodstufi^s. If the patient has done well on the milk and egg-albumen dietary, toward the end of the third week, in the absence of definite indications to the contrary, two raw eggs daily should be added to the diet; and during the following week, the aforementioned- gruels, broths, soups, cornstarch, etc., as well as very soft-boiled eggs. At the end of four to seven days of normal temperature, soft puddings, milk toast, scraped beef, mashed potato, apple sauce, etc., may be allowed; and a day or two later, sweetbreads, the white meat of chicken, stewed fruit, etc. The return to the ordinary diet should be gradual. Thus, while I incline to liberality in the matter of diet, especially toward the end of the disease, I have yet to see any general good come from the unusually generous dietary, even solid food, sometimes advocated, and I have seen it do positive harm. Of quite as much importance as food is water. A minimum of three or four liters, in stated amounts between the feedings, should be given in the twenty-four hours; often much more can be taken with great advantage to the patient. The daily amount of urine is the best indication of the amount of water that should be given, and we may be sure that that patient who passes eighty, one hundred, or more ounces of urine daily will recover unless he suffers a severe hemor- rhage or a perforation. Hydrotherapy. — Hydrotherapy constitutes an essential part of the treatment of every typhoid-fever patient. Advocated originally by Currie, of England, hydrotherapy was systematized in 1861, and sub- secjuently, by Brand, and is commonly known as the Brand treatment. Its advantages are many, the most important of which is not the reduction in temperature which it effects. Its greatest claim to our attention is that it unquestionably reduces the mortality — large statistics showing undoul)tedly that from five to seven of every one hundred ' Houghton giv'es the following formula for the preparation of a vegetable soup: 00 grams (2 ounces) each of green or canned French peas, white dry beans, potato, rice, and noodles, antl 15 grams (J^ ounce) of carrot, should be boiled in water for at least four hours. Thereupon sufficient water should be added to make one liter (1 quart), which is sufficient for four feedings. This yields 760 calories, of which 6.3 per cent, is protein, 4.3.9 per cent, carbohydrate, and les.s than 0.2 per cent. fat. When ready to use, the sediment should be stirred up, and the patient allowed to eat everytlung except the pea- and bean-skins. Oiuon may be added for flavoring, if