to have the medicine administered by the
physician he had summoned, and who could
not see the justice in having his suffering
needlessly prolonged, while waiting for a
pharmacist to prepare and send his medi-
cine.

Naturally enough, on the part of the pub-
lic there was much opposition to this sys-
tem — a system of unnecessary delay. And
when they came to consider that instead of
paying the doctor $i.oo or $3,00, as the
case might be, for his visit and medicine,
as was the custom once, they now had to
pay him the same amount for a strip of
paper and the pharmacist 50c. for the med-
icine, with the additional annoyance of
having to dispatch a messenger to have the
prescription filled, people soon became im-
pressed with the idea that for all minor ail-
ments they would go direct to the pharma-
cist and thus avoid the intervention of the
physician. But here, too, they occasionally
met with disappointment, for there were
some pharmacists who would not counter-
prescribe, and who were tireless in their



*Read before the North Carolina Medical Society at
Tarboro, N. C, May, 1900.



554



THE CHARLOTTE MEDICAL JOURNAL.



efforts to explain the diflference in the work
of the physician and that of the pharmacist,
endeavoring to show how they could not
prescribe without going beyond their pro-
vince, and beyond their teaching, and vio-
lating a social trust.

But with the rapid increase in number of
the pharmacists, and competition, and a
constant outpouring of patent nostrums, a
great majority of the pharmacists began
business on a larger and more independent
scale. They commenced to refill prescrip-
tions without instruction, and counter-pre-
scribing became a very important part of
their work.

Finally physicians generally were aroused
and began to thmk seriously, and, on real-
izing that when called to relieve the sick
they were armed with no therapeutic agents
other than those contained in a lead pencil
and a pad of blanks, they soon realized their
inefficiency and absolute inability to admin-
ister directly to a sick person's wants.

This condition of things was the cause of
a majority of the more practical medical
men casting their old habits aside and bring-
ing into actual every day practice a more
humane, reliable and satisfactory method of
medication ; and the results have been so
satisfactory to all that now only a small
per cent, cling to that fashion of making
their patients a professional call with no
remedies or means to relieve seffering other
than the pencil and pad of blanks, and
leaving behind him no consolation, but
rather a painful reflection on the uncertain-
ty of the future and what it may bring, if
anything.

There no longer remains a doubt in the
minds of the majority of medical men that
the tremendous outpouring of patent nos-
trums, and the readiness with which they
are consumed by public delusion, ingrafted
in the mind by voluminous advertisements
and countless testimonials, is extremely
harmful to mankind. Not at all from a
business standpoint with the physician, but
from the fact of the unfortunate conversion
of many acute diseases into a more exag-
gerated or even chronic character.

A person who feels a little dull and dis-
inclined to go about his daily pursuits, reads
in a newspaper an extensive essay, written
presumably by a subject suffering in a sim-
ilar manner. The writer pathetically, and
even dramatically, describes his dull fiontal
headache, his complete loss of appetite, an
occasional flush of vertigo, a foul tongue,
and a heavy feeling in the back. He goes
on to state that after consulting several
physicians, each of whom had failed to re-
lieve him, but had expressed doubts as to
his final recovery, he was at last, as a final



resort, induced to try Regulator — it matters
not here what Regulator — and after taking
it for two days was very much relieved,
and on draining a third bottle was entirely
restored and able to perform his usual work.

And there is the needless suffering to
which young children are subjected by the
reckless use by parents and nurses of mix-
tures of unknown power for doing harm,
containing agents of which they know noth-
ing and suggested by some person of utter
ignorance of the fitness of medicinal reme-
dies.

A few months ago my attention was
called to an infant, who having had some
symptoms of malaria, had been drenched
with a teaspoonful of Groves' chill tonic,
every three hours, for several days. And we,
who are familiar with the harshness of that
preparation, can imagine the expression of
bodily suffering manifested by that unfor-
tunate victim.

With the physician supplying the requir-
ed medicines a great deal in the way of ex-
pense, and much more in the way of ease
and comfort, is saved to his patient. This
system, of course, gives the doctor more
work, and enforces upon him a greater ex-
penditure for drugs and general supplies,
thereby subjecting him to more chance for
loss by fraudulent patients.

But even all this should not be considered
any serious obstacle in the way of the phy-
sician supplying directly and personally to
his patient the remedy best calculated to
meet the requirements of the case. When
people find that they can go to the doctor
and get the desired remedy without being
subjected to the annoying delay and addi-
tional expense coincident with the interven-
tion of the pharmacist, they will naturally
have a tendency to refrain from seeking the
grocery, or the general merchandise store,
to find the desired medicinal remedy. The
physicians of this country are better off
that the nostrum-makers live, but the con-
sumers would be better off if they were all
dead.

The medical man of the present day who
cannot easily, pleasantly, and quickly, sup-
ply to his patient any medicine required, is
surely behind the times.

It has been argued from time to time that
carrying medicinal agents and the manipu-
lation necessary in the preparation of pow-
ders and the like for administration, inter-
fered with the dignified bearing a physician
should maintain ; but it seems to me that a
true physician should be so devoted to the
art of supplying remedies to relieve suffer-
ing as to be willing to subordinate all other
things to that.



THE CHARLOTTE MEDICAL JOURNAL.



DISCUSSION.

Dr. Chas. J. O'Hagan.— Dr. Morrill
has written a very good paper and it is
packed full of good sound sense but he
cheated us in the very slipshod way in
which he delivered it. Doubtless however
it will read better than he read it. I be-
lieve the moral of it is that it would be a
great deal better for the medical men to
stick to the old practice instead of buying
synthetic compounds. The physician gets
into a careless habit which demoralizes his
mind. I hope Dr. Morrill's paper will
call your attention to the deleterious effect
of these compounds.



Annual Debate for 1900.*
By James M. Parrott, Kinston, N. C.

In discussing the continued fevers of
North Carolina, I shall exclude of course
the simple or ephemeral fevers of a few
days' duration, as well as the exanthemata,
their complications and sequelae. I shall
also refuse to consider the classical tvphoid
and malarial fevers of the text-books. It
is quite an easy matter to make a clear cut
positive diagnosis of the typical fevers, even
to the casual observer.

In many vicinities of North Carolina,
particularly in its Piedmont and Seaboard
sections, many fever patients are seen an-
nually the exact nature of whose malady it
is very difficult and often impossible to de-
termine. It is about these cases as seen at
the bedside in North Carolina that I wish
to speak. What are these fevers? Are
they really malarial infection, or one of ty-
phoid fever? Or are they manifestations
of an infection of both typhoid and malaria,
or a third form of fever of continued na-
ture which has not yet been recognized and
described?

The symptoms of these continued fevers
vary much. Indeed, it is quite difficult to
describe a difficult case. Many begin with
a rapid rise of temperature, while with
others it is slower ; in some the pulse is
full and bounding, accompanied by severe
headache, congested eyes, flushed face, gen-
eral integumental redness, and many other
evidences of a disease sthenic in character ;
in others the pulse is more or less gaseous
and slow, accompanied by lusterless eyes,
mild headache, skin of dull hue, marked
lasitude, and prostration, giving us a pic-
ture of a malady of an asthenic nature. In
many cases these types merge one into the
other, often the sthenic into the asthenic,



♦Prepared for the N. C. Medical Society, at Tarboro,
N. g. May, 1900.



and even the asthenic into the sthenic, dur-
ing the course of an attack.

Some time ago I was called to see Mr.
J. W., whose illness subsequently beauti-
fully illustrated the sthenic cases. He was
taken rather suddenly with no noticeable
prodromes. When seen on the second
morning of his illness he presented a raw-
beef tongue, (so often seen in these cases,
and generally meaning several weeks of
serious illness), severe frontal headache,
great restlessness, backache, rapid bound-
ing pulse, general hyperemia of the skin,
high temperature, congested conjunctiva,
slight constipation, and rather scanty high-
ly colored urine. For about two weeks
these general synjptoms continued accom-
panied by much nausea, and later by slight
abdominal tenderness, but never by deli-
rium of any consequence even though tem-
perature persisted very high for several
days. His symptoms then began to im-
prove, accompanied by several exacerba-
tions of two or three days' duration. He
was sick six weeks and convalesced slowly.

Another type : Later I was called to see
Mr. P. H., on the loth day of his illness.
His symptoms were almost opposite those
above enumerated. He was weak and de-
pressed, and had been from the beginning.
When examined he had tympany, no pain
over abdomen, occasional free fecal dis-
charge, though generally constipated,
tongue slightly coated with a tendency to
a sharp red edge. No delirium, generally
very quiet and listless, exhibiting a ten-
dency to collapse ; pulse weak and gaseous
and fever ranging low, from loo to loi.
He remained in this condition for two or
three weeks, then began to improve very
slowly. Sick six weeks.

Still another type is often seen. In Oc-
tober I was consulted by C. H. on third
day of sickness. Complained of pain in
limbs, cold chilly sensations, foul odor of
breath and bad taste, and tongue presented
a peculiar condition often seen and always
indicates three or four weeks' illness ; it
was coated white and had the appearance
as though tissue paper was pasted over it,
and was slightly red-edged, though large
and flabby, and presented teeth indenta-
tions as do most all tongues in adults in
Eastern North Carolina when sick. He
complained of very great depression ; pulse
were slow and weak, there was no nausea
and no pain in abdomen, though slightly
tympanitic and constipated. No rose colored
spots appeared during the attack, and at no
time was he delirious. Temperature ranged
for first ten days from 102-103, suddenly
dropped a little, then ran an even down-
ward course, gradually growing less until



556



THE CHARLOTTE MEDICAL JOURNAL.



at the middle of the third week it reached
the normal. Positive widal re-action dil.
1-40, time exposed one hour, no malarial
organism found, quinine had no effect on
temperature.

The following interesting case treated
last fall in Cuba has a counterpart which
is often seen in Eastern North Carolina.
Trooper W. C. gave history of previous
malarial attacks when taken ; temperature
rose rapidly and ranged high, tongue coat-
ed, large and flabby, headache, slightly
nauseated, no delirium, liver and spleen
enlarged, some abdominal typany but no
pain, pulse weak and slow, patient general-
ly quiet and lasitude marked. Crescent and
aestivo-autumal malarial plasmodii found in
blood. Widal test always negative,
thoroughly cinchonized and kept so for some
time, the quinine continuously adminis-
tered, but in smaller doses, itstivo-autumnal
organisms rapidly and promptly disap-
peared, but even after cinchonism could
very often find the crescent organism, es-
pecially in the splenic blood. What caused
this fever to continue.'' Was it the toxiemia
from the a'stivo-autumnal plasmodii, or the
direct result of the crescent organisms them-
selves.'' Very probably the former, for rea-
sons which are obvious and which will be
discussed later.

These four cases illustrate very nicely the
diflFerent types of the continued fever under
discussion, though others not presenting
such marked differences could be mention-
ed, and to these might be added those which
continue for many weeks and are of a very
low grade and resemble case No. 2 above
mentioned except that fever is somewhat
lower and lasts much longer. Now then,
the question is what are these fevers, and
to what are they due.? To answer this in-
telligently many problems must be solved ;
causes which lie behind all fevers consider-
ed, every symptom discussed in detail, the
idiosyncrasy of the subject thoroughly un-
derstood, and the diflFerent methods of
treatment weighed.

In all cases of fever whatever may be the
cause there is oxidation and increased com-
bustion. A certain per cent, of the energy
which should go to form tissue or to repair
Waste cells is diverted from the normal
course ; it manifests itself in obedience to
certain physical laws in the shape of ani-
mal heat, and there is consequent a rise of
temperature. Acids are produced as a re-
sult of this increased oxidation. This com-
bines at once with certain salts to form
bases. These acid and base forming pro-
cesses take place back in the extra capillary
structures, and, of course, there is to a cer-
tain extent a lessening of the normal alka-



linity of the blood. This abnormal condi-
tion stimulates the thermic centres, and as
a result there is again an increase of tem-
perature through physiological reactions.
Once these processes are begun they must
either be checked through nature by medi-
cation or else by nature alone. In many
cases of a long continued fever of a very
'ow temperature, sav from 99 a. m., to loi
p. M. I have no doubt that this is the true
cause, especiatly in those of the so-called
gouty diathesis.

Another point to be considered in dis-
cussing the continued fevers of North Caro-
lina is the idiosyncrasy of the patient. We
are all acquainted with peculiar eflfects of
quinine, morphine and other drugs upon
people. The cinchona alkaloids cause in
some cases asthma, in others, an eruption
with severe nervous symptoms ; in others
still, the most violent congestion of the kid-
neys with accompanying hemoglobinuria
or hematuria and so on. These effects are
denominated the idiosyncrasy of the patient.
May not patients have an idiosyncrasy for
malarial or typhoid paisons.? I have seen
peculiar cases of both these fevers which I
thought might be due to an idiosyncrasy of
the patient for the particular infection.

Again, that quinine is a specific for the
amebic forms of malarial organisms I do
not doubt. So that when a malarial infec-
tion in which only the amebic form of the
parasite is present if it is properly treated
with quinia the temperature should be
markedly affected and the patient promptly
relieved, provided it is an uncomplicated
case and the excretory organs are function-
ing properly. The question is what do you
consider the proper way to administer qui-
nine? It is not my purpose to discuss the
treatment of malarial fever, but a few re-
marks just here may not be out of order. As I
have said before, quinia will promptly and
certainly destroythe amebic forms of malarial
parasites, hence it should be administered
before the paroxysm. The simple giving
of quinine by the mouth without regard to
its digestibility is a practice to be con-
demned. The most scientific and, of course,
the most accurate way to administer it is
by the hypodermic needle. This is not al-
ways desirable, however, and indeed it is
not often necessary. I once saw a case in
which large doses of quinine were given
by the mouth and had been for some time,
and yet it was easy to demonstrate the pres-
ence of the x'stivo-autumnal organisms in
the blood. Hypodermic injections of the
cinchona alkaloid were advised and given.
They acted nicely and the patient was
promptly relieved. In this case the quinia
was not digested and the attending physi-



THE CHARLOTTE MEDICAL JOORNAL.



557



cian evidently thought the nervousness and
its attending manifestations, and a severe
nausea produced by the alkaloid to be the
symptoms of cinchonism, and decided that
he must be dealing with a case of typhoid
fever since the patient grew worse instead
of better. The discovery of the parasite
in the blood and a careful investigation soon
unravelled the mystery, however. Quinia
in this case by the mouth aggravated the
condition of the patient.

Again, there is no doubt in my mind that
many cases of severe malarial and so-called
gastric or ephemeral fever, are continued
and aggravated by errors in the diet. I
have seen one case of typical typhoid made
atypical by such a mistake. I consider the
diet a very important feature in proper
treatment of malaria, and the most impor-
tant by far in the treatment of the so-called
gastric and typhoid fevers. There are a
few facts which I would mention especially.
The most easily digested all-round food is
the one that should be selected. When
carefully prepared, predigested soup and
milk is the best. The patented proprietary
meat extracts, and so-called peptonoid foods
so commonly sold are generally to be con-
demned. In my limited experience I have
always been highly pleased with the results
obtained with good home-made soup and
fresh sweet milk. Many cases of fever, in
which the diet has been neglected, present-
ing the typhoid conditions, viz : muttering
delirium sordes on the teeth, hard dry
brown cracked tongue, feeble pulse, etc.,
are rapidly improved by wholesome food
stuffs properly given ; by this I mean ad-
ministered regularly, and with due regard
for common sense, and generally recognized
physiological laws.

In some cases of continued fever the ex-
cretory organisms do not eliminate the
toxin or germ poison because of their pre-
viously enfeebled condition. The case of
the trooper whose case I have given above
is a splendid illustration of this condi-
tion. In this patient the excretory organs
had been enfeebled by several previous at-
tacks of malaria, and after the quinia had
destroyed the a^stivo-autumnal organisms
the fever was very probably continued by
the persistent presence of the toxin, should
there be such, of the parasite. I am not
prepared to say that in this and other simi-
lar cases that crescent form of the organism
produces the continued temperature.

Manson and other prominent observers
have taught us that the crescent organism
is a regenerative type of the parasite. If
this be true, very probably a careful daily
examination of the blood of these patients
after quinine has been discontinued would



demonstrate the presence of the organism
more fully developed, and the long con-
tinued use of the cinchona alkaloids should
eventually free the patient of the crescents
by destroying their source. This might be
equally true should the crescent prove to be
a degenerative form of the parasite. There
is one thing, however, about which we are
all positive, and that is that in all cases of
remittent malarial infection the fever con-
tinues more or less for a longer or shorter
period after the organisms have disappeared.
If it be true that in one otherwise healthy and
whose organs were normal before the at-
tack the temperature persists for a short
time after the destruction of the parasite
because of malarial toxin, why is it not
equally true that it might continue a longer
time in one previously debilitated and whose
organism were functionating below normal
prior to the infection causing their inability
to throw off the poison?

To the student of medicine, one of the
most striking features of disease is the
marked difference along certain lines of the
same disease in different sections, and of
the close resemblances of those differences
in certain other sections. There are char-
acteristic and striking symptoms which are
common to many infections in localities of
the same general hygienic condition.
To illustrate : the peculiar action of the
pulse in yellow fever is seen very often in
other diseases in the tropics, especially in
fevers.

Last summer while in Cuba I noticed
quite often that on the third day of a re-
mittent malarial attack, instead of the pulse
continuing rapid as it should in a typical
case, it would fall in frequency very often
as low as fifty per minute, and after a few
days regain its former ratio to the tempera-
ture. I have made the same observation
concerning the temperature. All of us who
live in a malarial district are familiar with
the phenomenon of the third-day aggrava-
tion of symptoms, and also that in all these
cases of whatever nature, that quinine to a
more or less degree will prevent more or
less this periodical exacerbation. This is a
common everyday experience. Why are
not other symptoms of other fevers affected
by the same cause whatever that iTiay
be.^ From these and other observations I
am led to believe that the environment of
germ and patient has much to do with the
symptoms of any fever infection for this .
reason : those of us who live in the Pied-
mont and Seaboard sections of North Caro-
lina may expect to see typhoid fever mani-
fest itself in a very different manner in
many instances from that of the mountain
districts. Improved sanitation because of



558



THE CHARLOTTE MEDICAL JOURNAL.



better drainage, and other accompaniments
of progress have changed the environments
of germs, especially of typhoid fever, and
of man ; hence those of us who live in Eas-
tern Carolina no longer so often see the old
time typhoid fever with its classical symp-
toms, but in its stead there has developed
another fever which, in my opinion is, in
the majority of cases, typhoid being marked
by many symptoms not met with before.

In closing the consideration of the causes
of the atypical continued fevers, I might
add here that there is no doubt that many
cases of continued fever are not really con-
tinued fever in the common acceptation of
the terrii, but sometimes there is an error in
diagnosis. I recall the case of a gentleman
whose disease was diagnosed typhoid of an
atypical type, and yet which on close ex-
amination proved to be an abscess of the
liver. We cannot be too careful in diag-
nosing any atypical fever as continued fever,
for after all close conscientious work at the
bedside will prove that they are less fre-
quently seen than the careless observer
would suppose.

Diagnosis : So much for the causes of
the atypical fevers seen in North Carolina.
To us as active practitioners, the most im-
portant question except the treatment is
the diagnosis. Every conscientious physi-
cian is frequently non-plussed by this ques-
tion. He is undecided as to whether this
case is typhoid or malarial, or a third form
of fever neither typhoid nor malarial. So
far as I am concerned, I have not seen
enough of these fevers to convince me that
they are anything else than either typhoid
or malaria. Oxidation and the consequent
diminution of the normal alkalinity of the
blood, the idiosyncrasy of patient to the in-
fection, the faultiness in the administration
of quinine, and possibly, its inability to
effect the crescent organism, together with
the fault in diet, the effect of environment
on the germ and its toxic manifestations as
well as on patient, added to improved or
changed sanitary conditions and the errors
made in diagnosis can and do account for
all of the atypical types of malarial or ty-
phoid fevers seen in North Carolina. The
elimination of the so-called third form of
fever from the discussion narrows the ques-
tion to a consideration of the differential
diagnosis between the typhoid and malarial
fevers of the atypical type. In an attack
of atypical fever it is seldom that one can
derive any benefit from a study of the out-
set. In either typhoid or malarial fever it
may be slow or sudden. A close study of
the temperature for four or five days assists