A RIP VAN WINKLE 
IN THE 
Pracbice o < Med icipe 
The Efficacy of Venesection, Cold Water, Starvation 
and Some Other of the Older Means of Cure 
in Certain Diseases. 
A re.urn swing of the pendulum from the modern 
plans of exclusively drug treatment, from forced or over- 
feeding and from "expectancy" '(irujTnrg'tonztHTef:;- 
CLIYTON ILLINOIS: 
18 p. NOTICE 
Whatever the presentation of so small a volume, as 
a medical treatise, may suggest, the author feels that it 
will be found sufficiently voluminous, considering the 
subjects treated of. 
For the work considers but three diseases, and is 
confined principally to their treatment. 
Medical books usually abound in the history, eti- 
ology, diagnosis and prognosis of diseases, but are short 
on treatment, while in this volume the rule is reversed. 
The author believes, that a knowledge of the treat- 
ment of disease is the main consideration and the 
element of real weakness with the practitioner ; and 
here the average volume is characterized by a striking 
indefiniteness and uncertainty. 
Indeed, the average volume on "Practice," while 
well suited to the needs of the student and as a text 
book, is of little help to the practitioner so far as the 
treatment of disease is concerned. It is well worth con- 
sulting, of course, but it is not sufficiently clear and 
voluminous on treatment. 
The average volume is again deficient, as it appears 
to the author, in what may be designated as the phi- 
losophy of medicine, or the reason for treatment. 
It will tell us that this, that and the other remedy 
is and has been used, but it says less about the reasons 
why-the rationale. 
The present volume, it is thought (and whether the 
author's position is regarded as true or erroneous), will 
be found sufficiently voluminous, and more so than PRE PACE. 
the average work, on the philosophic aspect of the sub- 
jects discussed. 
And, therefore, whatever of merit attaches to the 
author's effort on general grounds, he feels that he will 
at any rate be credited for giving, at sufficient length, the 
reasons for the faith within him. 
Because more convenient, the author asks the privi- 
lege to use the pronoun Z, intercbangable with "the 
author" and "the writer." 
The Author. CHAPTER I. 
Prefatory and General Introductory Statement. 
"Let me wipe oft'this honorable dew 
That silverly doth progress on thy cheeks."-S/iak.\ 
I have chosen as a title for this little book "A Rip 
VanWinkle in the Practice of Medicine," the reason for 
which is that many years ago I learned of certain 
methods of treatment for some diseases herein to be con- 
sidered, and, after following to some extent and experi- 
menting with other, and what has been called "im- 
proved," plans for a time, have been forced back to an 
"early love," as it were. Not only have I been forced 
back, by experience and observation, to the adoption of 
some ancient methods and means of cure, but I am also 
persuaded to believe that I now stand on grounds that 
will bear the test of rational and scientific criticism. 
As it appears to me, indeed, I have, in a sense, 
aroused from a slumber of medical insanity into which 
the profession have been plunged by a too radical spirit 
of progress which has characterized modern medical 
thought. 
As I view it, the desire to improve and to move for- 
ward has led men to cut loose from the past and to lay 
aside old methods, more because old than because irra- 
tional, and thus to make departures that hy claim to 
merit only because new. 
Medicine is what is called an inexact science, by 
which is meant that it is an ever varying or a progres- 
sive or developing science. This is not so much true A Rip Van Winkle in the Practice of Medicine. 
5 
with relation to the practice of surgery and obstetrics as 
in the treatment of general diseases. 
As to whether, in this state of inexactness, the pro- 
fession are advancing or retrograding is a question to be 
answered by saying that there is general advance, but 
possibly retrogression in some particulars, and tem- 
porarily. 
That something approaching chaos reigns, however, 
in the professional mind is seen in the fact that no two 
physicians treat the same disease nor the same kind of a 
case alike. This is more so now under modern rational- 
ism than it was formerly under empiricism; and because, 
under empiricism (which means according to authority), 
the physician followed more after rules laid down by 
others, while under rationalism (which means reasoning 
out your case), the physician adopts his own methods 
and is free to do so. 
Thus the practice of medicine, or the science of 
medicine (more correctly, the art of therapeutics), is less 
exact under rationalism than under empiricism. 
Yet most all physicians are empirics-that is, they 
follow some authority ; and when you find a man who 
ignores all authority, and who is so extreme a rationalist 
that he consults only himself, you will find very gener- 
ally the most irrational physician. 
Established principles do not change so rapidly, in- 
deed, that one generation can lay aside all that has been 
learned in the past generations. 
A man should be very slow to condemn a method of 
treating disease simply because it is gray with years. 
The fogy is not the one who adheres to old methods, 
but it is he who follows more in his own routine. 
A man's methods may be all new and yet he may be 
deeper in the rut than the conservative who considers 6 
A Rip Van Winkle in the Practice of Medicine. 
both the old and the new ; and the greatest of all fogys 
and cranks is the routinist. 
Men speak very glibly about being behind, or up 
with, the times, but I don't know about this. 
As in politics, in religion, and in many other things, 
perhaps the profession of medicine is getting too fast, and 
to be too fast is sometimes equal to retrogression. It is 
a very good idea to go slow, sometimes, and I think I 
shall be able to point out herein that an occasional halt 
should be called, in order to survey the ground over 
which we have passed, as well as to guard carefully our 
future steps. 
I have come to believe, in the first place, that the 
profession rely too much on drug treatment, or internal 
medication, and not enough on other means, herein to 
be considered, and in this very departure will be seen 
the possibility of exactness; for, when drug treatment is 
adopted and relied on, an infinite variety of drugs are 
used, no two cases are treated alike, new remedies are 
being offered continu-ally, each doctor settles upon the 
use of his special favorite remedies, and, while each is 
in a rut of his own creation, there is infinite confusion 
over drugs and therapeutics grows more and more in- 
exact ; while, if the means and methods herein advocated 
are correct, it will be seen at a glance that, in the main, 
the art of healing approaches exactness and, as I claim, 
becomes more scientific. 
For if, for instance, water is better than drugs, we 
all use the same remedy, instead of a great variety of 
remedies. 
So, too, if blood-letting is better than drugs in a 
given variety of cases, we have a means of relief, simple 
in its nature, free from the unknown quantity of variety 
and from the dangers incident to the use of powerful A Rip Van Winkle in the Practice of Medicine. 
7 
drugs which alone could relieve desperate cases", and 
thus when we are enabled to depart from drug treat- 
ment, and so far as able, the art of therapeutics becomes 
more simple and therefore more exact- 
But there is a second fundamental error into which 
the profession have fallen, as it appears to me, more seri- 
ous, probably, than that of exclusive drug treatment, and 
that is "expectancy" (expecting the patient to recover 
naturally). The expectant theory dominates medical 
thought in all schools, and I believe it is the greatest foe 
to science and exactness. 
This theory has taken the field so completely that it 
is at once and always like pulling against the current to 
advocate and to practice heroic measures, and it is here, 
more particularly, that my divergence from prevailing 
methods will meet opposition. 
"Expectancy" is based on a scientific principle, ex- 
pressed in the technical phrase "vis medicatrix naturae" 
(the power of nature to cure), and springs from the 
common observation that most diseases tend to spon- 
taneous cure, as a wound does to heal naturally; but, 
like most departures in thought, it goes to extremes in 
practical application. It is the beginning of what 
"Christian Science" is the end of, or a scientific princi- 
ple tending to evolve into a superstition. 
"Expectancy " is the real genius that has to so great 
an extent supplanted "heroism" in the practice of medi- 
cine, and there is a gulf between the two which is 
bridged only by an exact scientific knowledge not yet 
attained. 
"Heroism" was based in the theory that bodily dis- 
eases must be combated vigorously, and its most worthy 
exponent was he who attacked the " materies morbi" 
most energetically; while "expectancy" is based in the 8 
A Rip Van Winkle in the Practice of Medicine. 
belief that most diseased conditions tend to vanish 
naturally and therefore only require to be guided by care- 
ful and persuasive means. 
Generally speaking, practically, expectancy is cor- 
rect, but it, too, has been carried to irrational extremes 
and has served as a cloak for ignorance, as an instru- 
ment for imposition and as an excuse for the play of 
superstition. 
Its first legitimate offspring was "Homeopathy," its 
second "Infinitessimalism," and its third "Christian 
Science" or nothingness, idealism, God. 
All of these children of "expectancy" that thrive on 
the "vis medicatrix naturae " have served, and are serv- 
ing a good purpose by holding in check the radical ten' 
deucy and spirit of ' 'Heroism," so supposed, but the bet- 
ter opinion probably is that, by opposing some well-es- 
tablished principles, expectancy has converted the hero 
into the coward and the genius into the ignoramus. 
For, in all cases, it says, "you need not attempt much, 
only trust to nature." When the physician would in- 
cline to heroic treatment, it says, "do not interfere too 
much with nature," and he inclines to conservatism and 
perhaps to forego a very necessary means of relief. 
And, once falling into the embrace of expectancy 
practically and succeeding on that theory as he will in 
all mild forms of disease, the physician inclines to neg- 
ligence and therefore to ignorance- He says, "I can 
only assist nature a little and, since I can not do much, 
it is not necessary to know much or to look up informa- 
tion," and thus he scarcely examines the authorities or 
reads the journals, much less to listen to counsel. 
I have met many physicians who have, in rather a 
boastful spirit, told me that they never consulted the A Rip Van Winkle in the Practice of Medicine. 
9 
books, but relied altogether on their own judgement and 
trusted to nature. 
Three years ago a physician of 20 years' practice at- 
tended a lady in confinement under my observation, left 
the placenta in the uterus, returned the next day and, 
when asked to remove it, said, "O, it will come away in 
time; nature will attend to that." He returned yet again 
the second day to find that another physician had been 
there and removed it, barely in time to save the woman's 
life. 
This extreme case serves to show the general tenden- 
cy of expectancy, and I could recite numerous cases of 
a similar nature. 
Especially is this disposition to trust to nature and 
its effects on the professional mind seen in relation to 
the practice of venesection. 
I think I have met in consultation at different times 
and places mere than a hundred physicians. This is a 
great many, but I believe I have not overstated the num- 
ber. If I have ever seen a physician bleed a person I 
can't call it to mind, where I have suggested it they have 
generally been inclined to oppose it. I don't know of a 
physician who practices it generally and I know of many 
who would actually not know how to proceed with the 
simple operation. 
The bad effects of the expectant theory is reflected 
often from the professional mind to that of the laity. 
The druggist is led to substitute, in the belief that medi- 
cines do but little good, and the housewife is opposed to 
"strong medicines" and frightened out of her wits at any 
attempt at heroic treatment. 
Once, when I reprimanded a druggist for substitut- 
ing, he replied, "Why I did'nt think it made much dif- 
ference. When I have'nt the article prescribed I am in 10 
A Rip Van Winkle in the Pract'ce of Medicine. 
the habit of using something else that will not hurt, as 
medicines can't do much any way." 
And so it will continue to go so long as mere expect- 
ancy holds the fort and until something nearer exactness 
is arrived at in the treatment of disease. 
The diseases to be treated of especially in this work 
are the three great internal inflammations, Pneumonia, 
Cerebr spinal Meningitis and Typhoid Fever, and mY 
reasons for offering a treatise on these three ailments are 
that, after early childhood, more persons die from these 
affections than from all other acute diseases; that I be- 
lieve these diseases are generally being treated irration- 
ally, and that in their treatment something near exact 
and definite methods of treatment and wonderfully suc- 
cessful results may be arrived at. 
With meningitis is included, with cerebrospinal 
meningitis, all those cases of meningitis occurring in 
typhoid fever, pneumonia, cholera infantum, etc., thus 
giving us a great many more cases than comes to the 
notice of physicians in the occasional epidemics of cere- 
brospinal meningitis alone, and making the mortality 
from it equal perhaps to that from typhoid fever or 
pneumonia. 
I present the work in the following order and a little 
differently from the suggestion of my motto, "Facts are 
before theories." 
I rather begin with theory or the fundamental the- 
ories, and, after this introductory statement, take up the 
"bloodletting controversy of 1857 8," supplementing it 
with the rationale oj phlebotomy. 
From this wre pass to the consideration of pneumonia, 
cerebrospinal meningitis and typhoid fever in the order 
named, concluding with a supplemental article on the 
absurdity of "foiced-feeding A Rip Van Winkle in the Practice of Medicine. 
11 
I also add an appendix with an article on "some pe- 
culiar theorizing" and on ''the effect on the average 
medical mind of modern bacteriological research," which 
I especially request the reader to not overlook. 
THE IMPULSE. 
During the first two years of my practice it happened 
that I was called to treat a great many cases of pneumo- 
nia, typhoid fever and cerebrospinal meningitis, and in 
my own practice and in that of other physicians around 
me many persons died from these ailments, especially 
from the latter. 
This experience caused me to reflect that these three 
diseases required special consideration and to think that 
possibly the profession was a little lame in methods of 
treatment. 
Consequently I began to look up treatment for these 
ailments, to watch current literature on the subject and 
to note the treatment adopted by members of the pro- 
fession here and there, as I came in contact with them, 
as I read reports from them in the journals and in the 
public press' and as I would hear, from time to time, 
from people who had lost friends from these diseases in 
various parts of the country, or who had noted methods 
of treatment with results of same. 
The most forcible suggestion which has been brought 
to my mind, in this connection, is that persons dying 
with the diseases mentioned, do not all die from the dis- 
ease proper, but from a given symptom or condition that 
may or may not occur during the progress of these ail- 
ments, except that we exclude cerebrospinal meningitis, 
which consists of one special symptom or condition 
which causes death. 12 
A Rip Van Winkle in the Practice of Medicine. 
In typhoid fever, for instance, if the patient suc- 
cumbs it is generally from bowel hemorrhage or from 
head symptoms either of which may occur in other dis- 
eases or not all in typhoid. 
In pneumonia death very generally, or often at any 
rate, occurs from a head complication or heart paralysis 
and not from the disease itself. 
So that I was impressed more with the desire to know 
how to prevent and control given symptoms than to cure 
the disease, and the burden of this work is in the main 
to point out how to prevent and to relieve these symp 
toms. CHAPTER II. 
THE BLOODLETTING CONTROVERSY OF 1857 8 AS APPLIED 
TO INTERNAL INFLAMMATIONS. 
When a student of medicine I read with interest the 
"bloodletting controversy of 1857 8," as reflected by 
Prof. J. H. Bennett, of Edinburgh, Scotland. 
It was-mainly from this controversy that sprang the 
antipblebotomy movement, resulting in the general 
abandonment and condemnation of venesection by the 
profession and the medical authorities. 
It is this controversy that the author desires here to 
reopen, and, having become convinced that the dispute 
has been decided wrongly, it is proposed to first examine 
critically the fundamental allegations upon which the 
antiphlebotomists base their reasoning and their con- 
clusions. 
These allegations are: 
First--That "the materies morbi in the blood can not 
be reduced by venesection." 
Second-That "venesection does not lessen the flow 
of blood to the inflamed part." 
Third-That "inflammation, once established, can 
not be cut short." 
Fourth-That "venesection renders the blood more 
watery and so changes its composition that the physio- 
logical processes are impaired and natural cure retarded." 
If these four propositions are true then we may ad- 
mit that Bennett has succeeded in upsetting the theories 
of Hyppocrates. Galen, Sydenham and Cullen; if not 14 
A Rip Van Winkle in the Practice of Medicise 
true, then we must recognize the ancient sages as be- 
longing yet to the immortelles. 
Let us briefly and in order examine them. 
1. The ancient writers drew no distinction between 
eruptive fevers and inflammations, and bled alike for 
small pox and pneumonia, supposing that, in each case, 
they accomplished good by decreasing the morbid ma- 
terial in the blood, and, while Bennett justly criticises 
them here, he falls into a like error of affirming that the 
"same principles'' should guide us in each case. He 
reasons that in such cases as small pox no good could be 
expected to follow venesection, so far as influencing the 
morbid material in the blood isconcerned, and concludes 
that in inflammations we should expect no more from it 
than in eruptive fevers. 
Pneumonia is the one disease in which good is ex- 
pected to follow venesection, because it decreases the 
materies morbi in the blood, but Mr. Bennett exhibits a 
serious weakness in not pointing out nor realizing, as it 
appears, the difference between the nature of the mate- 
ries morbi of pneumonia and that of eruptive fevers. An 
eruptive fever might require venesection, on account of 
a complication or a severe symptom, but we would not 
expect to exert much, if any, influence on the materies 
morbi, by that means, in such a case. 
It is true, as Bennett affirms, that Hyppocrates and 
even Sydenham had a very crude notion of inflammatory 
processes, and it is doubtless true that they practiced 
venesection from the force of the observed effects regard- 
less of correct theory, but Bennett's position, that vene- 
section should be abandoned because "the same prin- 
ciples govern'' in eruptive fevers and in inflammations, 
is not tenable and because the same principles do not 
govern in the two conditions. A Rip Van Winkle in the Practice of Medicine. 
15 
The materies morbi in eruptive fevers is a specific 
poison, while the condition in pneumonia is a circulation 
surcharged with carbonic acid poison and with effete 
matters not eliminated, (which condition, together with 
its indications for treatment, will be more fully explained 
in the next chapter), and Mr. Bennett's first proposition 
1S negatived, in part at any rate, by the fact that the two 
conditions are vastly different. 
2. Mr. Bennett's position that "venesection does 
not lessen the flow of blood to the inflamed part" is ab- 
solutely negatived by the observed facts, afrd "facts are 
before theories.'' This is demonstrated in venesection 
for meningitis. 
I am called to see a case of meningitis or head con- 
gestion and, in addition to the severe pain, I observe 
that the veins in the whites of the eyes are engorged I 
bleed the patient and immediately the eyes clear up and 
the symptoms subside. Htre I absolutely see the blood 
leave the part and Bennett's assertion is disproved. 
On this point see also, a further explanation in next 
chapter, but I add here the strange declaration of Bennett 
that, in all inflammations, "more blood, rather than less, 
should be sent to the diseased part,'' (which assertion is 
perhaps in part responsible for the modern craze for 
forced-feeding in acute febrile diseases), and this asser- 
tion just following his attempt to reason that venesection 
did no good, because it "does not decrease the flow of 
blood to the inflamed part"-a direct and palpable con- 
tradiction in theories. 
For, to affirm that venesection "does not decrease the 
flow of blood to the inflamed pait," is ecpial to affirming 
that the flow of blood to the part should be lessened 
(and that it is lessened is the claim of the phlebotom- 
st); yet he next turns and argues that more blood should 16 
A Kip Van Winkle in the Practice of Medicine. 
be sent to the diseased part, and thus admitting that, at 
any rate, venesection could do no harm, since it does 
not decrease the flow of blood to the inflamed part." 
3. To Bennett's assertion that inflammations can 
not be cut short and that therefore are to be allowed to 
run unmolested, every informed physician replies that it 
is erroneous. 
While many diseases are self-limited, the eruptive 
fev<rs, for instance, and while many inflammations, let 
alone, seem to run a definite course, it is nevertheless 
true that abortive measures succeed in an infinite num- 
ber of cases. Typhoid fever, until quite recently, has 
been regarded as a self limited disease and Bennett so 
classes it, but, under the cold bath and starvation treat- 
ment the majority of cases terminate in from fourteen to 
seventeen days, instead of twenty-eight to thirty-two 
days. 
In threatened meningitis accompanying typhoid fever 
water-pouring aborts the congestion on the spot, and I 
have seen the same sypmtom yield to venesection so of- 
ten in pneumonia that there ceases to be any question in 
my mind about it- 
Congestion and inflammation of the lungs (and, for 
practical purposes, we need not draw a distinction be- 
tween the two) abort under venesection in an infinite 
number of cases, and I have witnessed the same thing 
in cerebrospinal meningitis. 
Indeed in the latter ailment if the patient recovers at 
all the case aborts or is aborted, because the disease 
consists of a symptom and condition running regularly 
and progressively from its inception to a fatal termina- 
tion. It is not so much a disease per sc, that, like 
typhoid fever and pneumonia, generally tends to run a A Rip Van Winkle in the Practice of Medicine. 
17 
definite period, if unmolested, but is simply a local in- 
flammation having no definite period of duration. 
Numerous cases of pneumonia and pleurisy abort at 
once under a heavy dose of opium, yet it is hardly a safe 
remedy in pneumonia so administered. I know one 
physician, however, who has so treated pneumonia for 
forty years and his success is so general that he has seen 
no cause to change his treatment, so he states. 
(I am quite sure that I have aborted some cases by the 
same means, but I repeat here that it is not a safe pro- 
cedure as a rule. I have seen cases much injured in 
the attempt. In a case characterized with much conges- 
tion about the chest and head, it is, I think, very haz- 
ardous, and only quite recently I saw a young man die 
from opium poisoning in the attempt to aboit pneumonia 
with the drug.) 
Venesection is practiced in pneumonia both as an 
abortive measure and with a view of rendering the 
disease less severe, and every experienced phlebotom- 
ist knows that a timely venesection in this ailment 
gets the patient on his feet sooner, in the great ma- 
jority of cases, than any other method of treatment. 
Indeed many cases of pneumonia are of a progress- 
ive nature; that is, the infl animation begins in a small 
area of lung tissue and tends to extend to the entire 
lung, (and in fact to the other lung often,) and, in 
such cases, venesection is the absolute and reliable 
abortive measure. 
On the proposition that venesection renders the 
blood more watery and unfit for building up purposes, 
Mr. Bennett presents a contradiction in argument and 
I think shows the error of his contention. 
It is a fact that venesection makes the blood more 
watery, and it is a fact that in inflammations the 18 
A Rip Van Winkle in the Practice of Medicine. 
blood is deficient in water, and Mr. Bennett brings 
forward the commendable practice of administering 
alkalies in inflammatory affections with the view of 
reducing the viscosity of the tyood. 
He thus admits that the blood is deficient in water 
and advocates its dilution with medical agents that 
are supposed to accomplish just what venesection ac- 
complishes. 
Mr. Bennett is forced to the position he takes, 
however, because it is in keeping with his contention 
that inflammations need active support. 
It is here that we may draw a distinction between 
the nature of, and requirements for, eruptive fevers 
and inflammations, and it is here again that we may 
note that Bennett places them in the same category. 
It is doubtless true that many diseases that were 
starved under ancient modes of treatment should hav 
been supported, but, that acute inflammations do bet- 
ter on a spare than on a full regimen, is getting to be 
recognized with wonderful rapidity. There is no 
longer any question but that, in most active inflam- 
mations, digestion and assimilation ate absolutely 
suspended and that the disease must be gotten under 
control before we can think about support, and that 
getting control consists largely in eliminating effete 
products with which the system becomes surcharged , 
often from overeating. 
To urge nourishment and support from the start 
in a case of meningitis, where the stomach is foul and 
rejects everything ; in a robust subject with pneumo- 
nia with a torpid liver, or in a case of typhoid fever, 
when secondary digestion and assimilation are abso- 
lutely suspended, is to talk very carelessly and con- A Rip Van Winkle in the Practice of Medicine. 
19 
trary to science and common sense. 
Yet this is Bennett's logic, and leading lights in 
the profession today are, from the force of habit, re- 
flecting the same sentiments. 
I was inclined for a time to follow the fine-spun 
theories of Bennett, yet only in a kind ol half- 
hearted way; but more mature reflection and a wider 
observation, supplemented by the demonstrations of 
experience, have forced from my mind every one of 
his fundamental postulates. 
Bennett's theoretical conclusion is that internal 
inflammations should be encouraged to a natural issue 
by supporting the system rather than to interfere with 
attempts at abortion, and he gives an illustration 
to support his theory. 
He here starts with a correct' assumption, but 
draws irrational conclusions from it, as I shall at- 
tempt to show. 
He correctly affirms that in all inflammations it is 
the local disease that causes the disturbed condition 
of the circulation, just as a thorn stuck i i the foot or 
any part of the body creates first a local irritation and 
secondly throbbing, pain and fever. He correctly says 
that it is the 'Ws a jrontce" (cause or power in 
front) that causes the accelerated circulation, and not 
the "rzs a tergo" (or power behind) or the condition 
of the system or blood that causes the local lesion. 
But he makes a very awkward comparison, as it 
appears to me, in attempting to put the case of an 
internal inflammation and that of an injury, as from 
a thorn stuck in the foot, in the same category. 
His comparison is good in showing a similar 
pathological condition as a cause of systemic disturb- 20 
A Rip Van Winkle in the Practice of Medicine. 
ance, but his deductions as to treatment are erroneous, 
because the same treatment is not applicable in the 
two cases. 
The thorn must be removed or the parts poulticed 
to suppuration, but the former is impossible and the 
latter irrational in the case of internal inflammation. 
The treatment which would be successful in the case 
of the thorn injury would be universally fatal in in- 
ternal inflammations such as typhoid fever, pneu- 
monia or meningitis. It would be nonsensical in 
these ailments. 
Bennett admits, however, that the two cases must 
be treated differently, the injury by removing the 
thorn or by encouraging suppuration, and the inflam- 
mation by encouraging it to its natural termination 
and the absorption and elimination, through the 
emunctories, of the exudation. 
But, as he would admit that it would not be ra- 
tional practice to attempt the removal of the thorn 
by simply encouraging the natural processes of tissue 
change, so may we, with equal reason, claim that in- 
flammations cannot always be trusted to nature. 
Now when we reflect that the trend of medical 
thought and practice has followed the lead of Bennett 
during the past thirty or forty years, and that his 
theory has been the basis of a reckless or rather neg- 
ligent expectancy, and if we now perceive that his 
main theory is wrong, we should be ready and willing 
to question critically the prevailing methods of treat- 
ment for inflammatory affections and to reconsider 
"the blood-letting controversy.'' 
More especially should we be impelled to this re- 
consideration, when, after all his theorizing, Mr. A Rip Vin Winkle in the Practice of Medicine. 
21 
Bennett affirms that he would yet bleed "in some 
cases." 
And again, Bennett opposed antiphlogisticism 
generally-all heroic tearing down remedies-and, 
while tartar emetic is one of the most potent anti- 
phlogistics, it seemed to be his chief reliance in 
pneumonia, so that, after all, he condemns venesec- 
tion, yet holds slightly to it, and continues to use its 
chief ally-tartar emetic. 
Thus, after all, Bennett, the great leading expo- 
nent and propagandist of the theory that acute 
febrile diseases require support rather than depression 
in the active stage, has proclaimed one theory and 
continued to practice on another. 
That the profession have followed his theory 
rather than his practice is seen in the universal dis- 
carding of venesection and tartar emetic in late years, 
and, if any reader doubts the position of the profes- 
sion here, let him make an effort to find a physician 
(or any number) who practices venesection, or to find 
prescriptions filled for tartar emetic, in the treatment 
of pneumonia; or let him examine the authorities- 
Quain, Reynolds, DaCosta, Hare, Bartholow and the 
whole host of modern writers. 
Bartholow, however, has swung back to venesec- 
tion and calomel in the treatment of pneumonia. 
The college professors all reflect the theory pro- 
mulgated by Bennett, and it is thoroughly grounded 
in the minds of the rank and file of the profession. 
While writing this I get the information that some 
of the college professors on practice have, during the 
past winter, taught that blood-letting is again 
gradually coming to the front. 22 
A Rip Van Winkle in the Practice of Medicine. 
While I have, in a great measure, followed the 
professional trend, I am frank to say that I did so in 
a half-hearted way, and more because I lacked the 
boldness to dissent from current notions entertained 
by older men around me than because I was convinced 
by Bennett's reasoning-. 
On one hand the departure seemed progressive, but 
on the other hand it seemed too radical a departure 
from established principles. 
That which particularly caused me to doubt the 
propriety of relegating venesection was the fact that 
Bennett failed to disprove the main scientific theory 
on which it is based, namely, that in inflammations 
the blood becomes viscous (or thicker) and that vene- 
section renders it less so. 
In other words, Bennett failed to banish from my 
mind a fundamental principle of pathology that had 
been well grounded. 
But having now presented, and replied to, the 
theories on which Bennett bases his departure, and 
being convinced from experience and observation that 
they will not hold good in practice, I shall attempt in 
the next chapter to present the theory upon which 
venesection is based ; and if I add anything, in either 
form or substance, to principles long established, they 
are offered in a spirit of modesty. CHAPTER III. 
THE RATIONALE OF PHLEBOTOMY. 
perhaps the only thing- in this chapter that may 
appear as new is the way it is presented. I have 
simply chosen a method or course of reasoning- which 
will make my arg-ument easily understood by every- 
one who presumes to an understanding of the ele- 
mentary principles of physiological law. 
First and foremost the rational practice of medi- 
cine depends on a correct understanding of physi- 
ology, and, when we follow a line of procedure in 
harmony with this science, we may expect to meet 
with the best possible results. 
I have come to realize, however, and the longer I 
live the more thoroughly, that there are few physiolo- 
gists engaged in the practice of medicine. 
The average college graduate is deficient here, and 
after a physician puts up his sign he seldom devotes 
time to anything more than practice and the making 
of money. He reads works yet on practice, surgery 
and obstetrics and is often compelled to refer to his 
anatomy, but physiology, the most scientific branch 
of medical study, he seldom further considers. 
I am inclined to the opinion that many of the pre- 
vailing methods of treating disease originated in the 
minds of tliDse who, if they understood physiology, 
have had but little regard for her laws. 
For, as it appears to me, the abandonment of 
venesection was an ignoring of physiology, and the 24 
A Rip Van Winkle in the Practice of Medicine. 
methods of treating disease that have taken the place 
of venesection clear violations of physiological prin- 
ciples ; and if this proposition appears true on the 
presentation of the argument, the author has made 
out his case in favor of phlebotomy. 
When venesection was in vogue authors on "Prac- 
tice" used to give its rationale, but modern writers 
have very naturally ignored the subject. 
It is only through the practice of a given system 
or means of cure that we become familiar with its 
rationale. Having quit the practice of venesection, 
the profession have ceased to consider its laws. The 
authorities advise against it, and therefore they do 
not explain it, and hence we become ignorant of it. 
The art having been lost, its rationale has been 
forgotten, and therefore the necessity for its re- 
statement. 
The headings under which the author's theory is 
presented are: 
First-The physical principle involved. 
Second-The physico-physiological principle. 
Third-The physiological principle. 
Fourth-The physiologico-pathological princi- 
ple. 
1. The physical principle, or that where physi- 
cal laws are taken specially into the account. 
Maxim-The human organism, whether in health or 
disease, is governed by physical-, as well as by physio- 
logical and pathological laws. 
There is, in all congestions, what is* called a de- 
termination of blood to the parts affected, tending to 
engorgement and inflammation. 
The circulation is full and the arteries are beating A Rip Van Winkle in the Practice of Medicine. 
25 
plump, plump, plump, forcibly and often rapidly, 
against the diseased part, as against an inflamed 
member when held downward. If, now, we deplete 
the circulation by means of venesection, the arterioles 
tap, tap, tap, softly against the diseased parts, as 
against an inflamed member when held upwards. 
To deny that this change from a full to a de- 
pleted circulation would lessen determination and 
congestion is to deny a simple law of physics, 
hydraulics, or, we may say, of mathematics ; for, 
plainly, if we take away all the blood, determination 
would cease, and with equal reason may we affirm 
that the removal of a part of it would have some effect 
on the force of the circulating current, and thus lessen 
the determination. The stream would be less full and 
flow with less force and persistence. 
• I think that this proposition admits of no denial ; 
yet Bennett has denied it in the assertion that vene- 
section does not lessen the flow of blood to inflamed 
parts. 
And in some forms of congestion there exists a 
peculiar form of circulation pressure, not altogether 
the result of an overflowing current, but the result of 
a change of the current in a sense, or of abnormal 
distribution. There occurs a dam, as it were, over 
which the current cannot readily pass, or on account 
of which it passes more slowly, when the circulation 
becomes sluggish, requiring more force to throw it, 
yet not moving smoothly through natural channels. 
In pneumonia, for instance, the lung being con- 
gested the blood ceases to flow through it readily, 
when there results a backward pressure upon the 26 
A Rip Van Winkle in the Practice of Medicine. 
heart and over to the systemic circulation seeking an 
outlet through venesection. 
And something similar, in a sense, occurs when, 
through overfeeding or a retarded excrementitious 
process, one or both (and the two are one), the circu- 
lation becomes too full and demands artificial relief. 
In such cases venesection not only performs a 
vicarious function of assisting excrementitious organs, 
but it also acts mechanically by relieving an over- 
burdened heart. 
The instant relief afforded by venesection in many 
cases goes to show that a mere overflowing current 
requires attention, and not pathological conditions. 
Take a case of commencing meningitis : In the short 
space of time required for venesection there could be 
no change in the pathological condition of the parts, 
yet the relief is instantaneous. 
Clearly, in such a case, it is only physical or me- 
chanical laws that need to be taken into considera- 
tion. 
In performing venesection in such cases we relieve 
the part affected of pressure, and we relieve the heart 
of the burden of throwing an overflowing current. 
Phlebotomy seems to weaken the heart for the mo- 
ment, but it soon begins again to perform its function 
smoothly and with less burden to perform. Leave the 
circulation too full and the heart struggles vigorously 
for a time, but finally yields to an extra burden and we 
have paralysis of the organ or other serious complica- 
tions, to which the patient succumbs, even after the 
primary ailment has abated-a demonstration again from 
the simplest laws of physics. A Rip Van Winkle in the Practice of Medicine. 
27 
Again, when we apply ice to the bowels in typhoid 
fever, to arrest a hemorrhage or to prevent it, we are 
stimulating a capillary contraction, the object of which 
is to drive the blood away from the congested glands; 
and to deny that venesection would do the same thing, in 
a measure, if done before the hemorrhage occurs, is to 
deny a simple law of physics. 
How many have asserted that a hemorrhage has 
often acted well in relieving congested parts ? If so, 
what is the difference between hemorrhage and venesec- 
tion. 
Is it not, in each case, the reduction of the circulation 
pressure ? 
If the application of ice tends to check hemorrhage, 
would it not also tend to prevent it ? If venesection 
would have a similar effect on the circulation, should it 
not be resorted to at an early stage in robust subjects, in 
order to prevent hemorrhage from the bowels in typhoid 
fever (which is difficult to confrol and often fatal), and 
in order to prevent extensive extravasation in pneumonia 
and meningitis ? 
2. The physico-physiological principle. 
Maxim-Physical and physiological laws arc inti- 
mately connected. 
The second principle upon which phlebotomy is 
based is what may be termed the physico-physiological 
principle, because in its consideration both physical and 
physiological laws must be taken into the account. 
The great central organ of vitality, and the one which 
is especially called on to perform extra labor in acute 
febrile diseases, is the heart; and it is a well-demon- 
strated fact, recognized by every informed physician, 
that this organ often gives way (peculiarly so in pneu- 28 
A Rip Van Winkle in the Practice of Medicine. 
monia) or becomes seriously diseased or burdened in 
the progress of serious febrile ailments, even when or 
after all other organs are performiqg their functions nor- 
mally and easily and recovery has been expected. 
The action of the heart is governed by two well- 
recognized fo ces, the vis a jrontef, or power in front, 
and the v/5 a tergo, or power from behind, the former 
dependent upon physiological processes, the latter gov- 
erned by a law of physics or mechanics. 
The living process of metamorphosis, the life process 
going on in the remote cells of the body, is and consti- 
tutes the physiological process of the living organism, 
and consists in chemical changes whereby the dead or 
effete products are thrown off into the venous circulation 
through an excretory process and on through the excre- 
mentitious organs-the skin, kidneys and the bowels- 
and whereby, or the result of which, fresh material is 
drawn from the arterial circulation. This constitutes 
the vis a front#, or power in front, which draws upon 
the heart and gives it strength. It is the physiological 
pump, as it were-the vacuum which nature abhors and 
attempts to fill and thus keeps the heart at work. De- 
stroy this process and the heart ceases to act; impede it 
and the heart becomes enervated and weak. 
When the system becomes surcharged, as we say, 
from overfeeding and from a sluggish condition of the 
excrementitious organs, this tissue metamorphosis be- 
comes burdened and the vis a front# lessened, resulting 
in fever and a manifestation of heart weakness. The 
heart is warning us of an obstruction in front, beating 
vigorously against that obstruction and asking for either 
a clearing of the track through the emunctories or a 
lessening of the load by means of phlebotomy. A Rip Van Winkle in the Practice of Medicine. 
29 
To leave the system in statu quo here and resort to 
heart sedatives as a means of relief is about as rational a 
procedure as would be that of a man who would add his 
weight to a load already too heavy instead of putting his 
shoulder to the wheel. Nature might struggle through 
under the burden, but the number of failures that are 
seen evidence the irrationality of the plan, to say nothing 
of its theoretical absurdity. 
When we speak of the vis a tergo we mean the power 
of the heart itself to throw the circulating fluid ; and, 
while we may admit that this power from behind is de- 
pendent on the vis a front#, or the physiological cell 
metamorphosis, which is proven by the fact that the 
heart becomes weaker or fails as the cell metamorphosis 
is lessened or suspended, so must it be admitted that 
there is also an individual heart.life force, as proven in 
the fact that the organ may become paralyzed and cease 
to act even when the physiological processes in the re- 
mote cells of the system are all in perfect order. 
The two forces, vis a jront# and vis a tergo, are, 
from the nature of the case, interdependent; and here we 
see the connection between physical and physiological 
laws ; and thus, while we must always guard and keep 
in order the vis a front#, we must also remember that the 
vis a tergo also needs attention. 
In many diseased 'conditions, the interruption of the 
physiological life processes necessarily weakens the vis 
a front#,'when at once we observe that the heart be- 
comes weaker, yet acting more vigorously- This of 
itself will finally overcome the heart, even though the 
burden of a full circulation was partially relieved by 
venesection; but it cannot be denied that, while the dis- 
eased process is at work, the physical burden of the 30 
A Rip Van Winkle in the Practice of Medicine. 
heart is much greater by virtue of its increased activity 
alone, and that the extra force necessary to throw a 
given volume of blood must tend to weaken the heart, 
just as extra work tends to overcome any part of the 
muscular system. 
3. The physiological principle. 
Maxim-Health depends on normal Physiological 
conditions, and therefore the first object to be sought in the 
relief of disease is to re-establish those conditions. 
The third principle upon which phlebotomy is based, 
is that it takes directly from the circulation a portion of 
the blood which h diseased and surcharged with effete 
matter that has not been eliminated by the emunctories 
and the presence of which retards the healthy physiolog- 
ical processes and thus tends to weaken the vital forces. 
Its argument is that a depleted circulation, contain- 
ing less effete matter, is more conducive to health and 
strength than a too full circulation containing more; to 
which is added the theory that the nerve centers are 
shocked and oppressed by a full diseased circulation, 
while they are relieved and refreshed by a depleted one. 
It is a well recognized fact, and one established by 
scientific research, that, in internal inflammations, the 
blood is more viscous or fibrinous and deficient in watery 
elements than in health, and it is another fact similarly 
established that venesection makes the blood more 
watery. 
It is an established fact again that in pneumonia the 
blood becomes surcharged with carbonic acid and deficient 
in oxygen, and common sense and arithmatical law teach 
us that an abstraction of a portion of the blood leaves 
less carbonic acid in the circulation. A Rip Van Winkle in the Practice of Medicine. 
31 
It matters not how that venesection makes the blood 
more watery, whether the water is at once absorbed from 
the tissues or whether exhibited by mouth (for both 
amount to the same thing, the former following the lat- 
ter), and that the lungs can supply oxygen more readily 
and sufficiently to a depleted, than to a full, circulation 
is readily seen. 
By taking on water the blood is washed of its more 
solid elements through the skin, kidneys and general 
emunctories, and by taking on proportionally more 
oxygen through the lungs more poisonous matter is 
eliminated. 
So that venesection tends to re-establish physiological 
conditions, to encourage normal tissue metamorphosis, 
and thus to promote health. 
That venesection would act somewhat differently in 
health need not be considered, for it is diseased condi- 
tions that we are considering. 
Many antiphlebotomists advocate the administration 
of alkalies in internal inflammations, with the view of 
lessening the viscosity of the blood and thereby abating 
the pathological condition-the disease. Thus they are 
attempting, in a roundabout and uncertain way, to get 
results such as venesection brings directly or at once; 
and thus, while they condemn phlebotomy, they are 
attempting to create a chemical change in the blood 
similar to that produced by it- 
Representing current opinion, generally, though not 
universally accepted, Prof. Hare condemns the use of 
aconite, veratrum, antipyretics and blood-letting, on the 
ground that they only mask the symptoms and give a 
deceptive promise of relief, while they lower the vital 
forces and thus lessen the prospects of recovery. 32 
A Rip Van Winkle in the Practice of Medicine. 
Of the drugs mentioned I accept as true that they 
only mask the symptoms and retard the real physiologi- 
cal processes (are only poisonous), butthat the lowering 
of the strength of the patient merely is harmful in the 
acute stage of fevers is not supported by sound reason- 
ing, and that the effect of blood letting is in any way 
similar to that of depressing drugs cannot for a moment 
be admitted. 
If the reduction of the strength of the patient tends 
to prevent or lessen the chances of recovery, how is it 
that the patient becomes convalescent and starts on a 
sure road to health, often, only after being reduced to a 
mere skeleton from the ravages of disease? 
The physiological processes proceed just the same in 
the weak as in the strong subj ?ct, and often better, be- 
cause in the overfed the system is surcharged with foul 
matter, while in the reduced subject often the system is 
hungry, as it.were, and thevital processes acting vigor- 
ously. 
Likewise, when the blood is surcharged with dele- 
terious products an abstraction of a part of it leaves less 
effete matter to be eliminated by the excrementitious 
processes-less work system to'perfcrm-and 
hence blood-letting conduces to strength by taking off 
the strain, and the sooner enabling the 
processes to proceed naturally and free from the burden 
of effete products* 
To those who have learned the evils of the modern 
and prevailing habit of over and forced feeding in fevers, 
and who have come to realize the wonderfully rational 
and successful plan of starvation (excepting water), I 
desire to put the question: Should we not, from a 
scientific standpoint, expect similar results from starvation A Rip Van Winkle in the Practice of Medicine. 
33 
and venesection? Starvation decreases blood; so does 
venesection. 
And this is all primarily that venesection does. 
The claim that venesection is injurious by reducing 
the strength is equal to the assumption that patients with 
little blood naturally would succumb to fever more gen- 
erally than full-blooded ones, while the reverse is the 
rule. 
In typhoid fever, pneumonia or meningitis it is in 
the plethoric subject where we meet danger. 
Must not the patient be reduced at any rate before 
convalescence? Yes. Then what form of reduction of 
strength is the quicker and the more easily overcome? 
Every physiologist knows that persons soon rally 
from the loss of blood in any reasonable amount, whether 
in sickness or in health. Every physiologist knows 
that the system can not so easily rally, or is likely not to 
rally, while under the influence of poisonous drugs and 
especially heart depressants. Every physiologist knows 
that the system can not rally while it is burdened with a 
surcharged circulation and with effete products that re- 
quire to be eliminated. 
What physician has not wondered at that peculiar 
condition that often supervenes in the later stage of 
pneumonia, where, although the patient seems so strong 
generally and where he coughs strong and expectorates 
easily, there is yet a heart depression which carries 
him off? 
And what physician does not know, without wonder, 
that, however much reduced a patient may be from long 
continued sickness or from mere loss of blood, he will 
yet survive and regain his strength rapidly ? 34 
A Rip Van Winkle in the Practice of Medicine. 
What is the difference between the two forms of 
weakness-that from venesection and that from heart 
sedation with drug depressants or heart paralysis from 
the retention in the circulation of effete matter, both of 
which latter are virtually the same? The former is a 
simple natural weakness, from which the patient soon 
rallies, because the physiological processes are proceed- 
ing with less interruption and burden. The latter is a 
diseased or artificial weakness, caused by a suspension 
of the physiological processes, and therefore necessarily 
followed by dissolution. 
Take a case of severe pneumonia from the start. We 
treat it on a mild expectant plan or on heart sedatives, 
and, as it seems, are getting along nicely until about 
the seventh or eighth day, when we expect a favorable 
crisis, but instead we have an unfavorable one; the 
temperature rises a little, the heart becomes weak and, 
although the lung has cleared up and the patient seems 
strong, and although we have hedged and yet continue 
to hedge against the condition with ammonia, quinine, 
digitalis, strychnia or stimulants, the termination is 
often fatal. It is because the system, and especially the 
heart, has been overtaxed in an effort to eliminate effete 
matter which might have been removed, to a great ex- 
tent, at the outset by the timely use of the lancet. 
It is not known just what the effect of poisonous 
drugs, such as aconite and veratrum, is on the physio- 
logical processes, but reason teaches me that it is the 
same as that produced by accumulation of effete matter. 
At any rate they mask without eliminating, and the 
vital forces give way the same under the continued pres- 
ence of effete matter and under the use of drug depress- 
ants. The general admission is that depressing drugs A Rip Van Winkle in the Practice of Medicine. 
35 
weaken the heart and really retard tissue metamorphosis. 
If so, they not only mask, but they prevent the system 
from throwing off effete matter, and thus add fuel to fire. 
It is only eliminants that could possibly assist the 
natural processes, and as the greatest eliminants are 
venesection, which removes surcharged blood directly, 
and calomel, which eliminates indirectly, without mask- 
ing or suppressing physiological tissue change, it follows 
that, from a scientific point of view, the old treatment of 
antiphlogisticism is the more rational system, and that 
the modern system of drug depression is to be con- 
demned as unscientific and irrational. 
Be it remembered that drug depression by means of 
heart sedatives has taken the place of venesection and is 
the prevailing plan of treatment for acute febrile diseases, 
but Prof. Hare makes a great slip of the pen when he 
confounds them as similar in their effects on the human 
organism. 
Drug depression and venesection, I repeat, have lit- 
tle in common. The former acts upon the nerve centers 
and from there the circulation and physiological pro- 
cesses are depressed. The latter acts in a manner 
mechanically and chemically, and, by lessening the 
pressure of the circulation and abstracting a portion of 
the surcharged blood only reduces physical strength, 
but at the same time takes determination away from dis- 
eased parts and leaves the physiological process, not 
only normal, but better conditioned to proceed. Acon- 
ite, antipyrene, and such powerful drugs, mask poison 
and deceive, depress vital power and retard tissue meta- 
morphosis, while venesection is free from all these. 
When you take acetanelid you congeal the blood in the 
capillaries, but the loss of blood by epistaxis, a wound 36 
A Rip Van Winkle in the Practice of Medicine. 
or venesection only invigorates healthy tissue action by 
creating a circulation hunger. 
4. The physiologico pathological principle. 
Maxim-Physiological and Pathological Processes 
Have Nothing in Common- 
If the foregoing maxim is true, then the antiphlebot- 
omists, Bennett and his coadjutors, and all who have 
followed the same lead, present their case on the anomo- 
lous and absurb premises of attempting to harmonize two 
antagonistic principles. For they contend that, when a 
pathological condition is set up, it cannot be cut short, 
but may, and should be, pushed to its natural issue by 
the physiological process. 
If, for instance, an extravasation of liquor sanguinis 
occurs or begins to occur, as, say, in pleurisy (or it is at 
any rate the logic of their theory), that no attempt is to 
be made toward checking it independently of physiologi- 
cal tissue change, or that it is best checked or cured 
through physiological processes. 
It is well agreed that an exudation once poured out 
must be absorbed by physiological action, but that this 
action is the reversal of the process now going on is, I 
think, clearly established. 
The pathological condition is an exasmotic one, the 
pouring out of liquor sanguinus from the capillaries, 
while the physiological one is an endasmotic process, 
whereby the exudation is absorbed back into the capil- 
lary circulation and on through the excretory channels. 
Just where the former process stops the latter one be- 
gins. 
That some inflammations seem to run a definite 
course, when let alone, is true, but it is equally true that A Rip Van Winkle in the Practice of Medicine. 
37 
the natural termination of others is the destruction of 
life, and thus, while it might be good policy to only en- 
courage the former one in its career, such a course would, 
at any rate, be reprehensible in the latter. 
Besides, the genius has not yet arrived who could, 
in advance, distinguish between the two. 
It may be reasonably contended that pneumonia and 
typhoid fever, if let alone, have something near a defi- 
nite period to run, and then tend to spontaneous cure; 
but the tendency in pleurisy and cerebrospinal meningi- 
tis is an uninterrupted progression, and I am quite sure 
that many cases of typhoid fever and pneumonia also as- 
sume this progressive form. 
And, whatever the tendency, in this respect, to en- 
courage physiological processes only, would be but equal 
to letting the pathological ones alone. 
While the physiological processes are the reverse of 
pathological ones, the former does not counteract the 
latter, but only correct the result. The pathological 
process pours out, the physiological process takes up. 
Both may proceed and do proceed together, nature al- 
ways repairing, but, to affirm that, by encouraging physi- 
ological tissue change, we push a pathological process to 
its natural issue, is to make the diseased and the healthy 
processes identical. 
After all is said, the position of the antiphlebotomists 
is simply to let inflammations alone, that the diseased 
process is a natural one tending to self cure. 
But, as experience and reason have taught us that 
physiological processes may be artificially suspended, so 
has experience (if nothing more) taught us that patho- 
logical processes are subject to therapeutic art. A Rip Van Winkle in the Practice of Medicine. 
38 
And now, as we proceed, let the reader reflect that, 
if I have offered a correct rationale, then venesection is 
the proper treatment for internal inflammations and pre- 
vailing methods wrong, because other and prevailing 
treatments do not fulfill the indications and can therefore 
be no more than attempting to perform a given work 
with tools other than those most suitable for the purpose. 
Besides, the prevailing methods of drug treatment, 
for the most part, have no settled and definite rationale. 
They could not have, because they are so various, and it 
may be noted that authors who recommend them say lit- 
tle in the way of reasoning out the principles upon which 
they act as related to physiological laws. 
Phlebotomy as practiced in the olden times was per- 
haps justly condemned, because it was carried to ex- 
tremes. 
But modern medical thought and practice has gone to 
the other extreme. From bleeding for everything we 
have gone to bleeding for nothing, from bleeding to' ex- 
tremes and oft repeating we have gone to bleeding not at 
all. 
It remains for the genius of the present and the future 
to get on rational grounds between these extremes, and, 
when that is accomplished, we may expect to have done 
much in the direction of substantial medical progress. 
A HABIT OF PROFESSIONAL NEGLIGENCE, OR PERHAPS 
TIMIDITY, OR STUPIDITY, OR INDIFFERENCE, OR 
CRIMINAL CARELESSNESS, OR WHAT NOT. 
The most radical opponents of phlebotomy must ad- 
mit that it has yet a place in therapeutics, even though 
that place be small. In an urgent case of puerperal con- 
vulsions, for instance, nothing else can take its place. A Rip Van Winkle in the Practice of Medicin*. 
39 
-I remember some thirty years ago, before the St. 
Louis Medical Society, Prof. Pallan condemned in se- 
vere terms the growing habit, with the members of the 
profession, of going without a lance in the pocket. 
He cited a case where three passing doctors were 
called in to see a lady who needed immediate bleeding, 
and not one of them was prepared to do it. 
Venesection is of course an emergency remedy, and 
such above all are the remedies which the physician 
should know how to use. Most cases of sickness get 
well as readily without, as with a doctor, especially all 
the milder cases of pneumonia, and here we have the 
doctor making bills when he renders no aid and abso- 
lutely unprepared to render assistance should it be 
necessary. 
The greatest recommendation for a physician should 
be that he knows what to do in emergencies. When one 
needs a doctor surely is when he needs him badly. 
I believe, however, that it has been timidity and a 
false pride, to a certain extent, that have caused the 
profession to get out of the habit of performing venesec- 
tion, and, getting out of the habit, they dispense with it 
often when they know that it should be resorted to. 
And especially are we slow to hurt a delicate patient 
and to besmear, with blood, the persons, the linen and 
the tapestry of the exquisite-the elite of our patrons. 
It is said that when Napoleon once called a physician 
to attend his wife, knowing the timidity of the generality 
of men when dealing with the aristocratic and the great, 
said to him, "Take hold and treat her as you would a 
peasant. " 
The doctor who has practiced some years knows how 
much there is in the sentence quoted. 40 
A Rip Van Winkle in the Practice of Medicine. 
Or it may be, after all, that supine laziness and in- 
difference on the part of members of the profession was 
and has been the initiative cause of the antiphlebotomy 
movement. I have observed that lethargic, careless and 
indifferent men seldom resort to heroic measures requir- 
ing work, unless forced to them. 
Next the sloth breeds the coward, and the coward 
the ignoramus. The lazy man does not want to practice 
blood-letting. When he gets out of the habit he be- 
comes timid about it; timidity causes him to forego the 
practice, and he then forgets all he may have known 
about it and becomes ignorant of one of the greatest arts 
in therapeutics. 
And, naturally, when men do not want to do a thing, 
or do not know howto do it, they conjure up all manner 
of theories against it- These theories, supported and 
encouraged by a persistence of the disposition which 
hatched them, finally become standard and authoritative, 
are passed along the channel of medical education and 
dogmatically asserted in the face of and against science, 
history and experience. And thus phlebotomy has be- 
come almost a lost art. 
The object of this work is to revive it and to assign 
it to its proper place in the healing art. 
Another thing that has operated against the practice 
of venesection is an honest reliance on the expectant 
theory, on the belief that nature is first and the physician 
only second in the therapeutic effort. 
Still another element to be considered is the com- 
mercial spirit of the times. Innumerable remedies are 
discovered, invented and manufactured and thrown on 
the market, where they are eagerly sought by a profes- 
sion equally as gullible as the general public, A Rip Van Winkle in the Practice of Medicine. 
41 
The physician who grabs at every new remedy and 
puts it in the place of long-established means of relief 
has no reason to laugh at a public that are gulled by 
venders of patent nostrums. One is duped by subsi- 
dized medical journals; the other by a less culpable 
public press. 
And now, after all we have said on the subject of 
venesection, who is the best authority-the man who 
has practiced it or the man who has only theorized on it? 
"Facts are before theories," and when such great 
minds as Hypocrates, Galen, in the ancient world, and 
Sydenham, Cullen, Paget, Andral, etc., following the 
reformation, and down to the present century-men of 
wide experience in the practice of the art and of wide 
general learning, and men as capable to judge of facts as 
the greatest men of today-when they have asserted so 
positively the merits of venesection; and when the dis- 
senters, such as Bennett, condemn it in theory and hold 
to it in practice; and when we know that modern au- 
thors who have opposed it are not men who have prac- 
ticed it, but who speak only on theory; and when we 
see such men as Bartholow admit his former error and 
proclaim that venesection cannot be abandoned, may we 
not conclude that the subject demands our most earnest 
consideration ? CHAPTER IV, 
PNEUMONIA. 
I shall present the subject of pneumonia in my own 
way and according to my experience and observation. 
No attempt will be made at minute differential diagnosis, 
nor will I devote any time to the histological aspect of 
the disease nor to the various chemical blood changes 
that science reveals in pneumonia, but handle it in a way 
that the average physician, and indeed, the laity, may 
understand me. 
Pneumonia is met in mild or severe form, according 
to the severity of the winter, or according to the number 
of succeeding cold snaps. In mild winters and in the 
early part of the season it is generally of a mild form, 
while, during severe winters and toward spring, it is 
more severe. 
Not always so, but as a general rule. 
In this first fact there is something that should put 
the doctor on his guard, for it is a tricky and deceptive 
disease, and often, a case which at outset seems mild, 
may turn out to be severe, and mild and expectant treat- 
ment, which will do for mild cases, will be found inade- 
quate for severe ones. 
Another distinction to be drawn in cases, and that 
should put the physician on his guard, is that the sever- 
ity of the first symptoms does not- determine the gravity 
of the case. 
Bartholow says that pneumonia comes on suddenly 
with a rigor, or preceded by a day or two of malaise, A Rip Van Winkle in the Practice of Medicine. 
43 
followed by a rigor-one variety coming on suddenly, as 
after getting too warm and cooling off suddenly, the 
other covering two or three days in its initial approach. 
In my experience, the variety coming on slowly may 
consume a few days or a great many in its approach. A 
person may have a cold for a month, or, through expo- 
sure for a long period, may get gradually sore about the 
chest, and finally, after some weeks, take down with 
pneumonia, and, so insidiously may the case pass from 
a mere indisposition to severe pneumonia, that the pri- 
mary requirements of treatment will be lost sight of. 
Rather than approach suddenly and with severe symp- 
toms, these cases develop into deep-seated and widely - 
spread pneumonia, without any one of the symptoms 
that usually warn us of danger. 
As it seems to me, the difference between these two 
variety of cases is so great that they reflect two distinct 
diseases, and I am sure that they often require a differ- 
ent treatment in some respects. In one variety there is 
a sudden attack upon the lung, usually on the outer sur- 
face or involving the pleura, and thus characterized with 
much pain. In the other variety the lung becomes sore 
and slowly congested and the exudation begins in the 
center more generally and extends perhaps rapidly with- 
out any pain and with less cough than in the other 
variety. The nerves seem to be obtunded in these cases, 
and a dull heavy pain develops slowly in place of a sud- 
den and more severe pain peculiar to the other variety. 
(It is useless to draw a distinction between pneumo- 
nia proper and pleuropneumonia, because the average 
physician can not differentiate and the treatment need 
not be much different-must treat symptoms anyway as 
they develop.) 44 
A Rip Van Winkle in the Practice of Medicine. 
A distinction usually drawn between these two varie- 
ties is that the first is unmasked, the second, masked 
pneumonia. It is a good differential designation and, in 
remembering it, we should remember that the masked 
enemy is the or e to be the most feared, as much here as 
anywhere else, for it is the enemy that robs you (if not 
well on guard) of your patients, your mental equipoise 
and your reputation. It will steal upon you unawares, 
it will get a deeper hold than you think it has, even after 
you detect it, and it will laugh at the remedies you are 
likely to apply for a case seemingly so mild. 
In the winter of 1869-70,'and again a year or two 
later, I treated a great deal of pneumonia of a severe 
type, and, while I was inclined to follow the tide that 
had then well set in against venesection, I adhered very 
strongly to calomel, the blister and other of the anti- 
phlogistic methods. Indeed I pushed calomel so strongly 
that many of my patients were severely salivated. 
So that, while I bled only when forced to do so, the 
other heroic means resorted to perhaps compensated 
for it. 
I, however, resorted to venesection in some of the 
more desperate cases and, to consider the treatment gen- 
erally adopted by me, I may say that it was decidedly 
antiphlogistic. I also and always expected to get control 
of the disease before I thought about supporting the pa- 
tient. In fine, I tore down from start to finish, for the first 
few days at any rate, and met with good success so long 
as I followed this line. 
At the same time. I practiced in a community where 
there existed a strong prejudice in favor of heroic treat- 
ment, especially blood-letting. Often, when called to A Rip Van Winkle in the Practice of Medicine. 
45 
see a case of pneumonia, the patient would insiston vene- 
section, even when I was not disposed to resort to it. 
Making some inquiry as to thecause of this prejudice 
I was told by an old citizen that some years previous 
there had been a severe epidemic of pneumonia and that 
in that epidemic a Dr. had bled his patients and 
they recovered, while those that were not bled died. 
There was at this time especially a growing preju- 
dice in the professional mind against venesection, grow- 
ing out of the controversy of ten years previous. The 
antiphlebotomists had won in this controversy, for the 
time, and it seemed that the profession rather gladly 
seized a theory so much calculated to relieve them from 
the inconvenience of blood-letting. 
Then came along, of course, 'and in proper order, 
various theories as to what should take the place of vene- 
section and num rous drug sedatives, depressents and 
antipyretics clamored for recognition; and, following the 
general cuirent of modern thought, more perhaps from 
habit and imitation than from real scientific enquiry, I 
drifted away from ancient moorings. 
But occasionally the ghost of antiphlogisticism, re- 
surrected by experience and observation, would rise be- 
fore me. I would see the drug treatment fail in that 
class of cases where formerly venesection was regarded 
as the "sheet anchor," and occasionally I would see or 
hear of venesection coming to the rescue successfully in 
similar cases. I would see, as it seemed, aconite and 
veretrum .paralyze the heart, antipyretics mask the 
symptoms, only to deceive, and I would see cases pulled 
through only with herculean efforts, that, under vene- 
section, would have aborted in a few days, according to 
the pretentions of the ancient school of thought, until I 46 
A Rip Van Winkle in the Practice of Medicine. 
came to seriously question the virtue of prevailing modes 
of treatment and to doubt the rationalism of the departure 
from older notions. 
The expectant plan of treatment has, however, 
been my reliance generally, until more recently, or, I 
may say, more so after my first few years of practice 
and until up to the present time. 
The prevailing plan of heart sedation with aconite, 
veratrum as primary treatment, I have not adopted, 
except that I have used veratrum quite frequently. 
I have always regarded aconite as too powerful a heart 
depressent to be used as a medicine at all, and, after 
careful investigation and repeated experimentation, 
have come to the same conclusion with reference to 
veratrum. 
All along, during thirty years of observation, it 
has been noted that certain epidemics of pneumonia 
have been exceedingly fatal, but the writer has noticed 
that, in the desert of destruction, an occasional oasis 
has appeared, and in that oasis has been found the 
lancet, calomel in heroic doses and general antiphlo- 
gisticism in timely use. 
I have observed that in the general run of cases 
and in most seasons, the expectant treatment has been 
successful, but that in severe cases and severe epi- 
demics it fails utterly. Indeed, the difference in cases 
is so great that one, who has been successful with ex- 
pectant or with any of the modern plans of treatment, 
wakes up as though he had met a new disorder, when 
he comes in contact with a severe form of the disease. 
And one may run along for fifteen or twenty years, 
treat numerous cases and never encounter the disease 
in its more severe form. A Rip Van Winkle in the Practice of Medicine. 
47 
For this very reason many physicians abandon 
heroic treatment, rely on the expectant plan, and are 
very much inclined to ridicule, and look with con- 
tempt on venesection and on antiphlogisticism gen- 
erally, until they encounter one of these severe epi- 
demics, when they lose most all their cases and are 
driven to mysterious explanations for causes of a mor- 
tality exceeding that of the balmiest days of phle- 
botomy. 
Then they have learned something from experi- 
ence, if they are perceptive, but they say little about it. 
Right here it may be remarked that, in his on- 
slaught on venesection, the experiments and statisti- 
cal collections of Bennett were confined to a period of 
only a few years, and that one of his strongest sup- 
porters had practiced but eleven years and treated but 
seventeen cases of pneumonia. An experience cover- 
ing so short a period as that to which Bennett's in- 
vestigations were confined is entirely unreliable. The 
author treated something near fifty cases, mostly on 
the expectant plan, from 1884 to 1899,without a single 
fatality. 
During this period I bled very few cases and even 
those might have gotten along without it. I really 
fiad none of the more severe variety of cases, and 
from this experience alone could have given strong 
endorsement to Mr. Bennett's side of the controversy 
and to expectancy, if not indeed to the prevailing plan 
of heart sedation, but I had learned something before 
that had created a suspicion, and something since 
that has confirmed the correctness of my suspicion, 
that Bennett's observations did not extend over suf- 
ficient grounds. 48 
A Rip Van Winkle in the Practice of Medicine. 
Furthermore, I treated cases in 1869-70 and again 
in 1884 on heroic measures, excepting venesection, 
and succeeded, but in 1899 treated apparently the 
same kind of cases on the same plan with universal 
failure and some similar cases by timely venesection 
with magical success. 
During this epidemic of severe pneumonia in the 
winter of 1899, and when many died of the disease, 
which was called by the doctors "typhoid-pneumonia," 
as an excuse for a heavy mortality, of course, an old 
citizen said to me: "Doctor, I remember that fifty years 
ago, when I was a boy in Indiana there was one winter 
a great deal of "typhoid and pneumonia" (as he put it) 
and when they were bled freely they generally pulled 
through, but if they were not bled they died." 
And such exactly was my experience and observation 
during the winter of 1899, in my own practice and in 
that of numerous physicians with whom I came in con- 
tact, as well as in the general current of news from all 
over the country. 
"LaGrip" has been very fatal, we hear, in different 
parts of the country and during certain winters, and this 
means very generally the pulmonary complication of 
"Grip" pneumonia. 
Let the reader reflect that influenza itself, without a 
complication, never terminates fatally. I have never 
seen the "grip" kill any one, but during epidemics of 
that disorder, it is very convenient for the physicianf 
who loses a case of pneumonia, to call it a severe case 
of "grip, ' ' since he is more likely to be excused for losing 
a case of the new scourge than one of pneumonia, a 
regularly occuring disease with which we are all familiar 
and should therefore know better how to treat; and hence the press terms with accounts of fatalities from "grip, ' 
when, if the matter is carefully looked up, it will be 
found that there has been a fatal epidemic of pneumonia, 
in which venesection has not been generally resorted to. 
And the author is not the only physician that has 
been awakened as from a Rip Van Winkle slumber and 
been thoroughly impressed with the idea that venesec- 
tion is the sheet anchor in certain forms of pneumonia. 
We hear the returning wave of phlebotomy from all 
quarters in both the professional and in the public mind. 
While writing this work, which was prepared during 
the month of May, '99, (excepting a few corrections ad- 
ded since) I questioned a medical student from Chicago 
as to the position taken there by his lecturer on practice 
on this subject. 
He replied: "They died like sheep with rots in 
Chicago this winter from pneumonia. 
"All our cadavers w7ere pneumonic subjects, and our 
professor on practice says that we are gradually coming 
back to venesection as the most important consideration 
in the treatment of pneumonia." 
And now a little reasoning right here. 
I assert, as a fact that cannot be controverted, that 
reasonable venesection will injure no case of pneumonia, 
and ask the question: Had we not better keep on safe 
grounds? 
I know from experience that it will save many cases 
that wull not be relieved by any other known remedy. 
In two cases where I considered venesection the 
sheet anchor, one died under the cold-pack treatment, 
the other barely pulled through under it. No impres- 
sion of consequence was produced by the pack treat- 
ment, and because of the heavily surcharged condition 
A Rip Van Winkle in the Practice of Medicine. 
49 50 
of the circulation. In the less severe case a terrible 
sweating crisis probably served the eliminative require- 
ments. 
And how do I know that venesection will save any 
case? Because of repeated successes from it in cases 
just such as have resisted all other means of relief. 
Heroic treatment was abandoned on the ground, 
principally, that it was too depressing ; yet staring us in 
the face is the disproof of this notion, and in the fact 
that the more robust the subject the more severe the 
disease. 
It is notorious that our dangerous and fatal cases of 
pneumonia are among the plethoric, while in more deli- 
cate subjects the disease is scarcely to be feared at all. 
On the theory that antiphlogisticism is wrong treat- 
ment in this disease, it ought to appear that strong and 
robust subjects withstand it better than those of delicate 
constitutions, while the reverse is the rule. 
Our experience and observation on this point is a 
common-sense demonstration which no theory can 
upset. 
But the modern fad of forced feeding generally has 
caused the profession to depart from many well estab- 
lished principles, and in no disease do we see the error 
of the supporting craze more than in pneumonia, if only 
we pause and reflect. 
"Facts are before theories," and the fact that pneu- 
monia is more dangerous and fatal in full-blooded than 
in thin-blooded subjects is a clear demonstration that 
antiphlogisticism is right and the supporting plan wrong 
n this disease. 
The modern and prevailing notion that the patient 
must be supported in the primary stages of acute dis- 
A Rip Van Winkle in the Practice of Medicine. A Rip Van Winkle in the Practice of Mediaine. 
51 
eases and when the vital organs are in a state of conges- 
tion has been completely banished from my mind, both 
by experience and observation and by reason. I never 
could grasp it, and am now thoroughly convinced that it 
is erroneous, and indeed as absurd as would be the argu- 
ment for the turning of a breeze rather than a stream of 
water onto a conflagration with the view of extinguish- 
ing it. 
But the question will arise right here: Is it not true 
that pneumonia is also dangerous in the persons of 
drunkards and those with a broken down constitution, as 
well as in plethoric and robust subjects, and, therefore, 
is not the supporting plan better adapted to such cases 
than the antiphlogistic one? 
I reply that the supporting plan, or more correctly 
the stimulating plan, should in such cases supplement 
antiphlogisticism, and at the proper time. 
I have reasoned in another chapter that the vene- 
section and calomel treatment is supporting, because 
it relieves the heart and the sooner gets the system in 
a condition where the physiological processes may 
proceed more naturally, and that, though the patient 
is for the moment reduced in mere strength, he is 
better conditioned to survive. 
The same question may be put to those who follow 
the prevailing plan of heart sedation and, as I think, 
with greater force of logic. 
The patient is sick and in danger at any rate in 
pneumonia and certain cases need stimulants more 
than others, but the vital question is, what should be 
the treatment aside from considerations of bodily 
nourishment or support? 52 
A Rip Van Winkle in the Practice of Medicine. 
Which would more likely injure a case, if treat- 
ment is to be viewed from this standpoint,venesection 
and calomel or aconite and veratrum? 
And why is it that those who prefer the latter to 
the former seem not to think so much about the dan- 
gers of heart failure under the modern plan of heart 
sedation? 
In those cases that require support the danger is 
especially from heart weakness, and of all treatment 
the most irrational, it is to administer heart depres- 
sants for the relief of heart weakness. 
I reason that in pneumonia the heart is overbur- 
dened and that the conditions existing are the same 
as those produced by medical heart sedation, the pre- 
vailing method which has supplanted venesection 
and calomel, and I reason that, while the modern and 
prevailing plan of primary treatment masks the 
symptoms and paralyzes the heart, venesection and 
calomel relieves the strain on the circulation and thus 
gives endurance to the heart power. 
I therefore argue that, in pneumonia of the drunk- 
ard, venesection is the sheet anchor in the first stage, 
to be supplemented with reasonable stimulation. 
And I would give stimulants as stimulants, and 
not as food. 
Likewise would I argue in those cases where, from 
broken down or debilitated constitutions, the circu- 
lation and the heart are weak. 
In any case of bleeding, in disease or surgical op- 
erations, stimulants counteract the shock of the op- 
eration and, on that principle, I would stimulate, yet 
not desist from an operation necessary alike in the 
weak as in the strong. A Rip Van Winkle in the Practice of Medicine. 
53 
There is a disposition of late to hedge in on the 
modern plan of heart sedation with strychnia, a pow- 
erful heart tonic. 
This is one remedy which I have thoroughly tested 
and found that, when the heart once begins to fail, 
strychnia will not revitalize it. 
Those who use strychnia use it as a secondary 
remedy, and correctly so, but it is not thought of as 
a remedy in the first stage and, if used in first stage, 
would not counteract the depressing effects of a sur- 
charged and poisoned circulation. 
When that condition supervenes known as a "fail- 
ure of the vital forces," which is heart paralysis, or 
which produces heart paralysis, the patient has 
turned the corner. The heart continues to act for 
some days, but, in spite of heart stimulants, it gradu- 
ally and surely fails. 
But what will you do with Bennett's statistics? is 
asked. 
Among other similar hospital reports Bennett 
gives the following from Dr. Dietl of Vienna: 
Cured - - 
Died - - - 
VENE- 
SECTION. 
68 
17 
TARTAR 
EMETIC. 
84 
22 
EXPECTANT. 
175 
14 
No. of Cases 
85 
106 
189 
Deaths 
1 in 5 
1 in 5.22 
1 in 13% 
The explanation of this is very simple. 
It would be a very careless or a foolish physician 
who would treat all cases alike, and surely it was the 
milder cases that were treated on the expectant plan 
and the more severe ones by venesection or tartar 
emetic. 54 
A Rip Van Winkle in the Practice of Medicine. 
The mild cases ought all recover, barring an acci- 
dent, and one death in 13% cases under the diet and 
expectant plan is therefore a high rate of mortality 
and goes to prove what I have claimed all along, 
namely, that many cases are more severe than they 
seem to be. 
A reasonable venesection could no more injure a 
mild case than could a nose bleed or bleeding from an 
accident in a well person, and thus I reason that, had 
the more severe or robust of the patients treated on 
the expectant plan been bled, the rate of mortality 
under it would have been far less than one in 13%. 
On the other hand, it was surely the more severe 
cases that were treated on the more heroic plan, and, 
when we select the worst cases and encounter a mor- 
tality rate of no more than one in five, we have made 
a good record. 
The fact is that the treatment here was on the 
antiphlogistic plan, which is to bleed such cases as 
seemed to require it, and the mortality rate taken al- 
together, just as cases are treated in general practice 
under the antiphlogistic plan, is 53 in 380, or about 1 
in 7. 
Now consider that in bad epidemics of pneumonia, 
since heroic treatment has been abandoned, the mor- 
tality rate is alarming under the prevailing plans of 
heart sedation and expectancy, and consider again 
that we are better able to differentiate between cases 
now than formerly, and that those who favor heroic 
measures resort to them more rationally and in con- 
nection with other improved methods, and we should 
expect a much reduced rate of mortality. 
Besides, as previously stated, Bennett's statistics were confined to too short a period of time to be of 
any real value. 
A Rip Van Winkle in the Practice of Medicine. 
55 
rules governing the practice of phlebotomy. 
Before proceeding- to consider some rules to be ob- 
served in the practice of venesection, let me caution 
the reader against the thought that I am making any 
special effort to point out only special cases that re- 
quire the remedy, for I have quite thoroughly resolved 
to make the practice general and to urge it as very 
generally the safest remedy in pneumonia. 
Besides, if one pauses in an attempt to make up 
his mind as to whether or no he will bleed, he is apt, 
in this day of expectancy, to yield to the negative side 
of the question. And my experience is that there is 
something about the disease that deceives us in the 
negative direction, and, if we make a mistake here, it 
will be in deciding not to bleed. The patient might 
get along without it, but he will also get along as 
well with it in all cases and better in many cases. 
It is best to make a general rule to bleed every 
case. Let this be the state of the mind, and yield the 
other way only when convinced that the case would 
be injured by it. 
Then you are in a safe mental condition on the 
subject. 
It is, however, essential that something be said in 
the way of explaining in what variety of cases vene- 
section is most urgently needed, the time to bleed,the 
amount to be taken, the kind of subjects, age, etc., 
and, as the author views the subject from his own ex- 
perience and from the experience of men who have 
practiced the art extensively, we will now consider 
some of the more important rules. 56 
The best time to bleed is at the early stage,during 
the first twenty-four hours if possible, but we should 
not neglect the proceedure simply because a little late. 
The kind of cases that require bleeding is the next 
consideration. 
All strong and full-blooded patients should be 
bled, and we should never neglect it simply because 
the patient is a little delicate. We are not going to 
kill anyone by reasonable bleeding, and as a rule the 
patient is not bled enough. 
Do not wait to find a red-faced, 200-pounder, but 
bleed all colors and conditions if other symptoms, to be 
named directly, indicate it, regardless of age, sex, weight 
or temperament, and you will be on the safer ground. 
The amount of blood to be taken should be propor- 
tional to weight generally; 20 ounces in subjects weigh- 
ing 150 pounds and 24 ounces for 180 pounds would be 
good average bleeding in an ordinary case where the 
symptoms are not urgent, but not enough in an urgent 
case. Where breathing is oppressed, or where pain is 
great, or where there is cyanosis, or where there appears 
to be considerable congestion about the chest or head, 
one or both, it will be found necessary to take an ounce 
of blood for every five pounds of weight. This will re- 
lax the patient completely and the symptoms will 
subside. 
To one who has practiced venesection to any extent 
it is amusing to note the modesty of even great authors 
on this subject. 
Bartholow (in his text book on the practice of medi- 
cine) recommends bleeding an adult from two to eight 
ounces. Any experienced phlebotomist would only 
laugh at this exhibition of modesty. The professor is a 
A Rip Van Winkle in the Practice of Medicine. A Rip Van Winkle in the Practice of Medicire. 
57 
great author, but on this special subject is not informed. 
This may be seen on reading his article on pneumonia, 
for here he tells us that he has been an opponent to 
phlebotomy, but that a wider experience had changed 
bis mind. He thus evidently had not practiced vene- 
section to any great extent, and thus could not be ex- 
pected to speak authoritatively. With a 1 before his 2 
and a 2 before his eight (12 to 28 ounces) he would 
have come nearer the bull's-eye. 
Some have adopted the rule to bleed until the patient 
breaks out in a swTeat, but I have seen the perspiration 
pour from the excitement of the preparation for the 
operation, and the patient will not be relieved by per- 
spiration alone. 
Others bleed until the patient turns white about the 
face or faints, but this, too, may result from excitement. 
The best general rule as regards the amount of blood 
to be taken is according to the weight of the patient, 
varying it, of course, according to circumstances. 
Next to this general rule is that the urgent symptoms, 
on account of which venesection is resorted to, must be 
reliev,d. Bleed according to weight, and then on 
gradually and carefully or repeatedly until symptoms 
subside is the best rule; until pain subsides, if pain has 
been present; until he breathes easier, if for dyspnoea; 
or until pulse grows w'eaker, where it has been strong. 
The cases where blood-letting is indispensable, al- 
most, or that require it more urgently, are: 
First, when pain is severe in side or head, one or 
both. Bleed until relieved. 
Second, where lung seems to be congested, with op- 
pressive breathing and lividity of face or lips. Bleed 
for results. 58 
A Rip Van Winkle in the Practice of Medicine. 
Third, where there is a dizzy feeling of head, or 
dusky, diffused redness of face. 
While I have stated the three most urgent variety of 
cases that need venesection most urgently, I hope the 
practitioner will not be misled here. If he waits to 
find these kind of cases he will fail to bleed in many 
cases where it should be done. I mention them only as 
most urgent, and ail symptoms may be in abeyance in a 
very bad case. Do not be deceived. 
Some say bleed only when the temperature is high; 
but I have seen cases apparently mild with temperature 
not over 102 F at any time, yet terminate fatally on 
expectant plan of treatment. Temperature is no guide. 
And just so with other symptoms. They all may be 
masked, and so much so that the diagnosis is uncertain, 
and in all masked cases venesection is especially indi- 
cated. Do not wait for diagnosis, but bleed, and then 
you can better diagnose- 
Look out for masked pneumonia. It is not always 
masked so much by the physical manifestations as by 
other prevailing ailments. The physician is often 
masked, rather than the case, or as much so. 
For instance, suppose that typhoid fever prevails in 
the neighborhood or in the family where a case of pneu- 
monia occurs, and suppose that winter cholera prevails 
and that the patient has had it. Then suppose that the 
patient has felt languid and sluggish for some days, 
when you are called and find the patient with a high 
fever, no urgent pneumonic symptoms and everybody 
expecting typhoid- You may consider the fever rather 
high for the first day of illness, but we are not always 
called on the first day of fever. 
I was slipped up on in just such a case. I put it on treatment for typhoid, cold bathing principally, and the 
patient continued to grow worse without a chest symptom 
externally manifested. The case choked down from 
lung engorgement and heart failure. 
I might have diagnosed this special case by the early 
high morning temperature, a bilious tongue, a dizzy 
feeling of the head and clouded mind, which symptoms 
were present, or possibly by a close chest inspection. 
Do not be deterred because the patient is of small 
frame, because tall and slender, nor because of sex or 
complexion. 
Bleed for results and for relief, regardless of all 
things, except age; and only the very young and the 
very old need be exempted. 
I cannot understand, indeed, why even the young 
should be exempted, and I have seen very old persons 
relieved by venesection. 
Reynolds, in his "System of Medicine," cites Andral 
and Frank as authorities for the position that "no age 
nor period of the disease contraindicates venesection." 
This citation is very important, because it is from 
authorities that speak from experience. 
More than likely these authors are about the only 
ones who have tested venesection in children, and they 
are the only ones who have a right to speak, therefore. 
What can these modern authors (who have never 
bled children, and yet who cry out against it,) know 
about it? Absolutely nothing. They are only voicing 
a universal prejudice. 
Suppose that a child with pneumonia should have a 
severe nosebleed (followed by apparent relief, as I have 
seen), or should cut its foot and bleed freely, would you 
imagine that your case is at once hopeless? 
A Rip Van Winkle in the Practice of Medicine. 
59 60 
Yet such is the logical inference from the seeming 
great concern felt by some authors who advise us by no 
means to bleed a child, yet who never bleed anyone 
themselves. 
What is the reason that a child should not be bled, if 
an older person should be? 
The only reason the au hor has for exempting chil- 
dren is that of inconvenience. 
After much observation and experience the author 
has come to the conclusion that, if the physician at- 
tempts to draw fine distinctions between cases to de- 
termine whether or not he should bleed a patient in 
pneumonia, he will too frequently yield to the nega- 
tive side of the question because of the deceptive 
character of the ailment, and that, since any case may 
be bled once in reasonable quantity with absolute im- 
punity, the safest plan is to perform venesection in 
every case, except patients too young for the proceed- 
ure. 
Another consideration is whether a single or re- 
peated venesection should be resorted to. 
Except in special cases of extreme congestion, and 
even here generally, only a single and sufficient vene- 
section should be resorted to, and that in as early a 
stage as possible, repeated once during the next 
twenty-four hours if case is not relieved. 
What is wanted is a decided impression at the 
start. 
Under the old plan venesection was not only the 
sheet anchor, but it was pushed to extremes and re- 
peated often, and, in Bennett's criticism, he points out 
that patients were often bled more than four pints 
during the progress of the case, which together with 
A Rip Van Winkle in the Practice of Medicine. A Rip Van Winkle in the Practice of Medicine. 
61 
other depressing methods was followed by a mortality 
of about one in seven. 
The results may be expected to be quite different 
when we bleed only once and early to get an early 
impression on the disease and at the same time hedge 
in with opium, ergot and other remedies to then 
equalize the circulation and prevent further extrava- 
sation. 
This is a most important point and experience and 
reason has convinced me that early single, yet suffici- 
ent bleeding, followed by remedies calculated to quiet 
and equalize the circulation, will give wonderfully 
good results as compared to the older method. 
If the case is seen later, of course bleed once and 
proceed the same way, otherwise if venesection is at 
all indicated, or if it has been indicated and the 
symptoms have not materially subsided, which is to 
be determined, not by the apparent strength of the 
patient, but by the pulse and temperature, or more 
particularly the temperature. 
The case is not under control until the temperature 
is declining. 
OTHER ANTIPHLOGISTIC REMEDIES IN PNEUMONIA. 
The next remedy in importance in heroism is calo- 
mel in large doses-to adults ten or more grains at 
first dose and repeated in smaller doses every three 
hours until good results are obtained. 
Calomel not only removes pressure from lungs by 
depleting a congested liver but arouses the secretions 
and stimulates the emunctories generally, thus remov- 
ing effete products from the circulation and reducing 
fever. It is thus the most potent febrifuge. It does 62 
A Rip Van Winkle in the Practice of Medicine. 
not mask the symptoms and at the same time leave 
the poisons in the blood, but it removes the poisons, 
when the symptoms subside naturally. While it 
makes the patient feel weak at the time, the physio- 
logical processes are left more free to go on, nnim- 
peded by the pressure of effete matter, and the heart 
is left strong. 
If you do not bleed, push the calomel treatment in 
first stage and give tartar emetic also. If you do 
bleed, administer it rather freely anyway. 
Calomel treatment is especially adapted to the 
treatment of small children and is here generally suf- 
ficient in the line of heroism; but in the adult it is often 
not a sufficient antiphlogistic alone and bad better be 
supplemented with tartar emetic when venesection is 
not resorted to. 
Tartar emetic, unless in very small doses and in 
severe cases, is not suitable for young children. 
Calomel is the greatest of all medicinal derivatives. 
It takes determination away from the head, as well as 
from the lungs, and thus prevents the development of 
brain symptoms that so often arise in the course of 
pneumonia and that not infrequently carry off the 
patient. 
Next in importance is tartar emetic in one-third 
grain doses every three hours during first two or three 
days of illness or until symptoms abate. 
This is a very powerful remedy and belongs to the 
antiphlogistic class, and, while Bennett has so 
strongly opposed antiphlogisticism, this is his rem- 
edy. 
If any remedy is calculated to take the place of 
venesection it is tartar emetic, for it weakens the pa- tient, reduces the fever and softens the pulse as no 
other medicine will, and is free from danger used ra- 
tionally and in adults or any but small children. 
In condemning venesection on account of its de- 
pressing nature, and prescribing tartar emetic in large 
doses, it seems that Bennett preaches a theory con- 
trary to that on which he practices; but he succeeded 
well with the remedy. 
Tartar emetic needs to be given but a few days and 
should be discontinued soon as fever declines. Two, 
three or four days is long enough to keep a patient 
under tartar emetic. 
The blister is of less importance than venesection, 
tartar emetic and calomel. It is really only a second- 
ary remedy. It is a useful counter-irritant to relieve 
pain in first stage and later on is supposed to encour- 
age resolution. It is also valuable in the head com- 
plication applied to back of head, but this complica- 
tion seldom arises after venesection and a course of 
calomel, which should be borne in mind always. 
A most valuable febrifuge and one that is free 
from danger is muriate of ammonia in 30 to 60 grain 
doses every three hours. It may be given in place of 
tartar emetic in debiliated subjects. 
THE NEW AND MOST NATURAL ANTIPHLOGISTIC AND 
NON-MEDICAL ANTIPYRETIC. "CHEST CHILLING." 
And now we must consider the greatest antiphlo- 
gistic method of treatment for pneumonia, cold water 
or "chest chilling." 
Though new to the most of us, the plan has been 
sufficiently tested in the hospitals to demonstrate its 
virtues, and under it the mortality rate has been 
greatly reduced. 
A Rip Van Winkle in the Practice of Medicine. 
63 64 
A Kip Van Winkle in the Practice of Medicine. 
But it must be noted that the comparison made is 
between it and the prevailing- methods, excluding 
venesection. 
It must be remembered that chest chilling is a 
general continuous treatment, while venesection, as 
now advocated, is not as a general treatment but a 
treatment for primary stage. 
1 he method failed in some cases and it is barely 
possible that venesection would have saved the cases 
that were lost. 
It may reasonably be objected that, however suc- 
cessful the cold water plan may prove generally, 
since pneumonia is a disease that manifests itself so 
variously, no general plan can fully meet the indica- 
tions of all cases, and that therefore venesection,calo- 
mel, etc., may yet be the proper remedies for special 
cases. 
The advocates of venesection and calomel may 
consistently hail the water treatment with gladness, 
therefore, not because they see in it an enemy, but 
because it is a friend that also antagonizes prevailing 
general treatment. 
I think that it may be said in truth of the water 
treatment that it is superior to expectancy, because it 
is a vigorous do something plan, that it is far supe- 
rior to drug depression and drug heart sedation, be- 
cause free from poisonous elements that interfere with 
physiological processes, that it is far superior to 
medical antipyretics, because it is a natural febrifuge 
-all of which is proven by the lessened mortali y 
following it-but that there is nothing in it negating 
the utility of venesection, calomel, etc., in the special 
class of cases where these remedies are indicated. A Rip Van Winkle in the Practice of Medicine. 
65 
Let it be urged and adopted as a general treatment to 
supplant the prevailing methods, but let it not "claim 
the earth/' for under it or under any other general 
plan there will be met cases where venesection and 
calomel or a course of tartar emetic cannot be safely 
ignored. 
While the water plan does not need my endorse- 
ment to give it merit, I am glad to say that I have 
tested it sufficiently to believe that it is far superior 
to the old plan of hot fomentations, except in cases of 
frleu ritic co mplicat io n s. 
THE ADVANTAGES OF HEROIC MEASURES IN PNEUMONIA, 
ESPECIALLY VENESECTION AND FULL 
DOSES OF CALOMEL. 
Venesection and large doses of calomel are called 
"heroic" treatment, while treatment with deadly poi- 
sons such as aconite and coal tar derivatives is con- 
sidered mild. 
The reverse is certainly true. 
Indeed the argument for venesection and calomel 
is that they are harmless in the hands of any but a 
fool. 
Again the so called "heroic" treatment is simple 
and exact. We know exactly what to expect from 
venesection and calomel, not so with prevailing drug- 
treatment. 
With venesection and calomel we get just what we 
go after, and when these means are resorted to in time 
and intelligently, with the use of appropriate adju- 
vants, recovery is almost certain, in even the desper- 
ate cases, while when they are not resorted to all bad 
cases are in danger and often prove fatal. 66 
A Rip Van Winkle in the Practice of Medicine 
True a great majority of cases may be treated suc- 
cessfully with other means and many cases require no 
attention at all, but the safe plan, and especially to 
obviate the head symptoms with which so many die, 
is to resort, at an early stage, to the means that are a 
sure bar against serious complications. 
It is only in an occasional season that we meet with 
many of the more severe forms of pneumonia, and many 
physicians, who have practiced only a few years, imag" 
ine that the heroic treatment has had its day. I experi- 
enced an epidemic of severe pneumonia about thirty 
years ago, again about ten years later, again in 1884 and 
not again until the winter of 1898-9. 
Bartholow, in his last text book and in an article on 
pneumonia, says that while he has been inclined to op- 
pose venesection and calomel, "a wider experienqe has 
convinced him of his error," or words to this effect, and 
he gives first consideration to these remedies in the order 
named and as the most important means of relief for this 
disease. 
Osler, in his new work on practice, recommends 
venesection in pneumonia, but I believe in no other in- 
ternal inflammations. He favors it for plethoric subjects 
but does not urge it strongly as a general treatment. 
Freedom from dangerous effects is one of the strong- 
est arguments for the use of a means of cure. When we 
bleed a patient and give calomel we can go home and 
sleep easily. Not so with aconite, chloral, opium and 
poisonous drugs generally, the effects of which must be 
watched with the greatest care. 
Nor will the nurse make any serious mistake when 
venesection, calomel and the blister are the remedies; A Rip Van Winkle in the Practice of MedLcin e. 
67 
but I have known many a poor sufferer to be laid out 
with poisonous drugs- 
What is venesection more than a nosebleed or the 
loss of blood from an accident? And all of us know that 
mercury is a favorite remedy for tubercular and lung 
symptoms. 
The loss of blood simply as a means of relief in a 
single instance cannot tend to produce chronic lung 
trouble, and mercury tends to prevent lung disease; but 
a continued irritation from the pressure of congestion 
and a torpid liver is surely more likely to produce chronic 
lung disease. 
But the greatest argument for venesection and calo- 
mel treatment is that it aborts many cases and renders 
them all mild, and the patient is soon on his feet, while 
prolonged illness and dangerous sequalae are more apt to 
follow the modern prevailing treatment. 
One of the greatest errors, both professional and 
popular, is that the older method of heroism is more de- 
pressing and wearing on the system than the drug treat- 
ment of to day-the prevailing plan. 
Bartholow says that, according to the old practitioners 
and to Sir James Paget, the patient very soon recovers 
from the effects of venesection; that the depression from 
it is only temporary. He calls attention to this in reply 
to the argument that venesection is too depressing a 
remedy; and we all know, on a moment's reflection, that 
a single blood letting is soon recovered from. 
It depresses for the moment: but I have learned that 
this is just what is required. Pneumonia is a disease 
that must be controlled and gotten under subjection on 
the start. If this is not done it will simply run its 
natural course, the milder cases recovering and the more 68 
A Rip Van Winkle in the Practice of Medicine. 
severe ones dying, whatever the palliating means of re- 
lief resorted to. 
Therefore, both as regards the dangers from the im- 
mediate attack and from possible serious sequalse, the 
antiphlogistic plan of treatment is superior to the pre- 
vailing one. 
HEAD SYMPTOMS IN PNEUMONIA. 
Something remains to be said about the treatment of 
head symptoms in pneumonia, and especially because 
they are various and to be relieved by different means. 
And, firstly, they are not likely to arise after vene- 
section and a course of calomel. 
These symptoms manifest themselves in about four 
varieties. 
The first is an active congestion, with severe pain 
occurring in the early stage of congestive cases. 
The second variety begins with a dizzy, full feeling 
about the head in the early stage, but no pain, and soon 
develops into muttering delirium of a quiet form. 
The brain is simply clouded by the presence of sur- 
charged blood, but there is no meningitis nor inflamma- 
tory symptoms. The patient will talk and pick at the 
bed clothes in a half-sleep condition, and occasionally 
he will open the eyes and stare at a given point. It is 
very much like the head symptoms of typhoid fever, 
that often occur at about the same stage-first few days- 
but the similarity is oniy in some of the outward ap- 
pearances. 
In typhoid the eyes are a little injected. Not so in 
pneumonia; the eye will not stare as in pneumonia, and 
the delirium is more consistent. In typhoid, if you 
Venesection is the sheet anchor in such cases. A Rip Van Winkle in the Practice of Medicine. 
69 
wake the patient at all, he is momentarily clear, while 
in pneumonia he will talk both rationally and irrationally 
at the same time. 
In typhoid the condition is meningeal irritation; in 
pneumonia, clouding of thebrainby deoxygenized blood. 
The former is generally relieved by water-pouring (over 
head) ; the latter is injured by this means, but yields to 
venesection and a course of calomel, one or both. 
A blister might relieve it in typhoid, but not in 
pneumonia. 
The third variety is a wild delirium, with a dilated 
pupil. It is meningeal irritation, and I have relieved 
many such with a blister to back of head and neck. 
Venesection and water-pouring will also relieve it. 
The fourth variety, occurring later, is similar to the 
third, but approaches insidiously and is preceded or ac- 
companied by a slight rise of temperature. The first 
objective symptom is often a remark a little out of place, 
yet the patient declares he is better. 
As this condition progresses the pulse grows a little 
faster and weaker, the patient becomes restless and ob- 
stinate, looks out at the window or around as if looking 
for something, spits in the wrong place, takes hold of 
things and holds fast, laughs and curses alternately and 
is difficult to please or to manage, continually claiming 
that he is better, if asked how he feels. 
Of course this condition is seldom, if ever, relieved. 
It does not occur if the case is controlled during first 
stage. 
There may be some meningeal irritation here, but it 
is about the way all cases terminate when not relieved. 
The genearal cause is carbonic acid poisoning and 
heart failure, and, being the regular sequel in cases not 70 
A Kip Van Winkle in the Practice of Medicine. 
relieved, it is not to be relieved short of treatment 
adapted to the primary stage. 
I am not fortunate enough to have relieved a case so 
far advanced, but have known venesection to relieve 
cases that had advanced nearly so far, and since no 
other remedies will relieve, and since it is a matter of 
kill or cure, I shall bleed the next case where I see the 
condition approaching; that is, should T not be called 
until as late a stage. 
I have not so far resorted to venesection in advanced 
stages of the disease, and the profession universally con- 
demn it, here more especially; but, as I have changed 
my mind and my plan on so many other points in con- 
nection with the treatment of pneumonia, I shall carry 
the lance until the patient is either dead or convalescent. 
As elsewhere referred to, Andral and Frank say that 
it is never too late to bleed in pneumonia, and they spoke 
from experience. 
A DISTINCTION. 
The proper distinction must be drawn between pri- 
mary and secondary treatment in pneumonia, and more 
particularly in this than in many other ailments. 
Primary treatment is what I have been considering 
mainly, and by that is meant the chief reliance in the 
first stage. 
Expectorants, sedatives and anodynes, tonics, stimu- 
lants and remedies for special symptoms and complica- 
tions are to be considered alike under all methods of 
primary treatment. 
The expectant plan of treatment, followed by so 
many, consists generally in the use of secondary reme- 
dies only. A Rip Van Winkle in the Practice of Medioine. 
71 
As to primary treatment, the distinction between the 
old and the modern (or prevailing) plans is that the for- 
mer relies on venesection, tartar emetic and colomel; the 
latter on aconite, veratrum and various heart sedatives 
to control the active stage of the disease, and what, in 
the main, is to be decided in this investigation is to de- 
termine the superior plan. 
Both these plans are really heroic, but the modern 
one has been so interwoven with "expectancy" and with 
special fads that one is liable not to draw the proper dis- 
tinction. 
A second distinction is to be drawn, of course, as to 
whether primary or secondary treatment is required in 
each individual case, or whether "heroism" or "ex- 
pectancy" is to prevail. 
The conclusion of the author is that secondary, or 
"expectant," treatment is better adapted to infants and 
small children (excepting that they should have calomel 
freely), butthat heroic treatment is necessary in most 
all other subjects, and that as between the plans of 
heroism, ancient or modern, the former is awarded the 
palm by the crucial test of experience and by every con- 
sideration of scientific enquiry. 
And let it be added that the cold water treatment, 
whether considered primary or secondary, is adapted 
alike to young and old, and, if it continues to prove as 
efficacious as it so far has, there will perhaps be less 
dispute in the future over drugs at any rate. 
If the water treatment is to be relied on, I am satis- 
fied, from experiments made with it, that it must be 
pushed vigorously. By applying a large towel around 
the chest, wrung out of cold water, and repeated every 
five or ten minutes, I have seen the most happy effect. 72 
A Rip Van Winkle in the Practice of Medicine. 
It soon begins to feel comfortable and the fever begins 
to fall magically. 
It will not work half way or reluctantly used. In 
two children, 9 and 11 years old, where the plan was 
followed fearlessly it worked like a charm; in two 
others where the parents were afraid to apply it, I was 
compelled to change off to warm poultice. 
In the case of a lady 56 years old, with double 
masked pneumonia and progressing insidiously, I 
started in with the cold pack instead of venesection. 
The patient was not suffering much pain-pulse, 104; 
temperature, never over 102. Applied cold towel, 
and in 24 hours fever dropped to 101. Family ob- 
jected to treatment and I permitted them to substitute 
warm poultice, because the fever was no higher all 
along. In twenty-four hours fever was back to 102, 
where it remained until eighth day, when it went to 
103; pulse 120, and the patient sank from heart par- 
alysis. 
This patient had taken a good course oi calomel 
during first two days. 
It was in a rather enfeebled constitution, yet not 
apparently so, and seemed to run so smoothly that I 
did not resort to very heroic means in the first stage. 
I took it to be a case for the cold pack or chest 
chilling plan, and, after watching the progress of the 
case, I am satisfied that it would have proven a suc- 
cess but for the interference of a nurse who knew more 
than I did. 
I shall adopt it in lieu of the hot poultice, 
as a regular secondary remedy, but shall not 
forget my lance and other primary remedies in cases 
where heroic measures are indicated. And I repeat A Kip Van Winkle in the Practice of Medicine. 
73 
that pneumonia is a most deceptive disease and your 
case is generally worse than you think it is. 
RECAPITULATION OF SOME IMPORTANT POINTS IN CON- 
NECTION WITH PNEUMONIA AND ITS TREATMENT. 
1. It is the most deceptive of all diseases, the 
main deception being; that, in adults especially, the 
case is often more grave than the physician at first 
imagines. Make no rash promises. 
There is no regular connection between the out- 
ward symptoms and the gravity of the case. 
3. The danger from heart failure or paralysis is 
greater in pneumonia than in any other acute febrile 
disease. 
Threatened heart failure is harder to overcome or 
meet than the same symptom in other diseases; vene- 
section is the most certain safeguard against it, and, 
when it is threatened in later stage, no remedy will 
stay it, save perhaps venesection. 
Heart sedatives and depressants, such as aconite 
and antipyrene, mask the symptoms without relieving 
the pathological conditions, weaken the heart, the 
organ most liable to fail, and are the most irrational 
remedies that can be thought of in the treutment of 
pneumonia. 
5. Though a high temperature is ominous of evil 
in pneumonia, a case with low temperature is not free 
from danger. A case is not under control until the 
temperature begins to decline, a fall of temperature 
from drug treatment is only deceptive, and a rise of 
temperature in latter stage of the disease means cer- 
tain dissolution, except at crisis, when it should 
quickly decline again. The rise of temperature sud- 74 
A Rip Van Winkle in the Practice of Medicine. 
denly at crisis should have been preceded by a consid- 
erable decline, otherwise it portends evil and not 
good. 
6. A high pulse rate is more dangerous in pneu- 
monia than in typhoid fever, and a weak heart will 
not yield to stimulants in the former as it will in the 
latter ailment. 
7. Stimulants are contraindicated in early stage 
of pneumonia unless supplemented by venesection. In 
drunkards both should go together. 
8. Venesection, timely and in reason performed, 
will injure no case, whatever the strength,.size, com- 
plexion, constitutional conditioner complication-no 
more so than a nosebleed. 
9. Venesection is the most certain abortive meas- 
ure known in the treatment of pneumonia, and at- 
tempted abortion should be the first consideration. 
10. As a treatment venesection is exact and free 
from the unknown quantity of variety and from the 
dangers incident to drug depression and heart seda- 
tion. 
11. Venesection is the only remedy that, with any 
degree of certainty, will relieve the condition known 
as carbonic acid poisoning. 
12. Cold water is the most rational external appli- 
cation in pneumonia, but it w'ill not take the place of 
venesection and calomel in cases demanding immedi- 
ate relief on account of congestion or where the blood 
is surcharged with carbonic acid and effete products; 
nor will it relieve the head symptoms caused by the 
same condition of the blood. A Rip Van Winkle in the Practice of Medicine. 
75 
13. The breathing- of cold air, though not argued 
in our general treatise, is of great utility in pneumo- 
nia, and in infants will alone relieve cases seemingly 
hopeless. 
14. Be on guard against "masked" pneumonia, 
and bleed whether diagnosis is certain or not. CHAPTER V. 
cerebro-spinal meningitis. 
Twenty-eight years ago I practiced through an 
epidemic of cerebro-spinal meningitis and lost a great 
majority of my cases, as did also other physicians 
about me with whom I came in contact. 
The treatment adopted was exclusively drug, but 
of course in great variety. I do not remember that a 
single case was treated with cold water or ice or that 
venesection was ever resorted to. I do not think these 
means were as much as mentioned. 
In conversation with an old citizen some time 
afterwards, and in reference to the scourge, he said: 
"Doctor, I remember that old Dr. used to bleed 
everybody when they had a pain in the head. I don't 
know if they had this disease, but people often had 
bad head trouble and they would bleed them." 
"Did it do any good?" 
"Why, yes, of course it did. It most always cured 
them, if it wasn't too late." 
I practiced a great many years before I experienced 
another epidemic of this disease, but in the meantime, 
and during a practice of thirty years, I took observa- 
tions from every available source with the view of 
procuring data on the subject. In treating various 
diseases and cases one will often hear people refer to 
similar cases that they have seen, and we all know 
how prone they are to inform us of the treatment A Rip Van Winkle in the Practice of Medicine. 
77 
given by "old Dr. ," especially in cases where the 
old doctor was the family physician of the narrator. 
From this source the susceptible physician gains 
some very useful information, and it serves a tele- 
scope, as it were, through which he is enabled to peer 
far into the past. 
More frequently do we hear, too, (and more 
eagerly told,) of cases where the patients were given 
up to die and how some neighbor or friend happened 
to think of something never dreamed of by the physi- 
cian, and how the patients then recovered. 
And just such cases do occur, but, if looked into 
closely, it will be found that the old lady or neighbor, 
who violated the doctor's instructions, procured the 
information from some physician who had used the 
same means successfully in time past. 
I will relate a few instances. 
A gentleman once told me, for instance, of two 
cases of cerebro-spinal meningitis that were given up 
to die by two good doctors, whereupon the father of 
the children put ice around them and they got well. 
Another told me of a case of the same disease in the 
person of his brother, where the doctor gave him up, 
but he began applying ice to his back and head and 
he recovered, to the surprise of the doctor, yet he re- 
mained an imbecile. (Well authenticated). 
Another well authenticated case coming through 
a similar source and occurinp- fifty years ago was a 
case of "bad fever in the head," occuring in the win- 
ter time and where the attending physician put the 
patient in a spring wagon and took him half a mile to 
a creek where there was a waterfall, under which he 78 
held the patient's head for some time, and by this 
means cured him. 
But more especially and more frequently, and go- 
ing usually further back, have I heard older persons 
refer to the old habit of bleeding for head troubles 
and express surprise that the doctors had "quit it.'' 
Time and time again have I heard older persons, 
when referring to some one who had died of meningi- 
tis, say, ''I believe he would have gotten well if they 
had bled him. '' 
From experience I came to learn that when head 
symptoms develop in typhoid fever, water poured over 
the head early would relieve the symptom invariably and 
absolutely. I had also learned that venesection would 
do the same thing in typhoid, pneumonia or any other 
ailment. 
I next reflected that cerebro-spinal meningitis (the 
active form) is really only a rapid and powerful determi- 
nation of blood to the head, the same thing that we 
have, in a milder form, in other ailments, as in typhoid 
fever, and concluded that what would relieve one would 
relieve another form of the same disorder. 
Therefore when cerebro-spinal meningitis appeared 
in 1898 9 I resolved that if a case fell under my care I 
would resort to heroic measure. 
The opportunity came, and I will present the clinic 
exactly as it ran. 
One clinic does not establish much, generally, but in 
the case here presented and the means resorted to, to- 
gether with the fact that I have relieved more than a 
hundred cases of meningitis and brain fever occuring in 
the course of other diseases by the same means, I believe 
A Rip Van Winkle in the Practice of Medicine. A Rip Van Winkle in the Practice of Medicine. 
79 
I have much more than I would have in an isolated case 
under drug treatment. 
It is more particularly in drug treatment of disease 
that we hold to the rule that "one swallow does not 
make a summer/' and this because we do not know 
whether nature or the remedy is responsible for results. 
I hold it to be vastly different in the use of appliances 
where one can see and trace so clearly the effects of the 
treatment. It is here more like it is in surgery, where 
we can see at once that ligation of a vessel arrests hem- 
orrhage. We see the symptoms come and go as we 
apply or withhold the remedy-water-and we see the 
blood leave the injected eye and the symptoms vanish 
when we perform venesection. 
So that, all things considered, I present the clinic 
with implicit confidence in the means of relief resorted 
to, with such happy results. 
A TYPICAL CASE OF CEREBRO - SPINAL MENINGITIS, 
WITH COMMENTS. 
W. T. Robust, farmer, 20 years old, weight 150 
pounds. Had been afflicted with aching, or soreness, in 
back of neck and shoulders for some weeks, and had 
headache two days previous to attack, but said nothing 
about latter symptom and was eating his meals heartily. 
Ate a very little supper, however, on Wednesday even- 
ing, and said he did not feel well-ached all over-and 
lay down on lounge in room next to dining room. 
His father finished supper in a few minutes, and on 
going in next room to ask son how he felt, found him 
unconscious and pulling his hair. 
I saw patient two hours later and found him seem- 
ingly semi-conscious and screaming out occasionally, 80 
A Rip Van Winkle in the Practice of Medicine. 
with pain in head. Pulse 40 to 80, beating slow a few 
beats and then faster a few beats. 
The veins of the whites of the eyes were injected; 
tongue foul. 
I got the patient's bead over a tub of ice water at 
edge of bed and began to pour it over his head with pint 
cup, letting it fall from an elevation of from two to 
twelve inches directly on base of brain. 
Patient dropped to sleep in a few minutes, but I con- 
tinued the water pouring forty-five minutes, when he lay 
back on bed much relieved, and pulse was beating 
seventy per minute. 
"Where is your pain?'' "In head.'' 
He occasionally screamed "Audi!" 
"What hurts you?" "My head." "Where and 
how?" 
Placing hand at base of brain he said, ''Right here 
is the center and it feels like needles shooting out 
once in a while from here up into my head and right 
down my backbone." 
Administered good dose of calomel and Dovers 
powders at once and began giving mixture of bro- 
mide and chloral. Gave two more doses of calomel 
during next twelve hours and considerable chloral 
mixture, but owing to sickness of stomach had to dis- 
continue all medicine per stomach, but administered 
morphine hypodermically in moderate doses. 
Continued to pour water over his head at intervals 
and as pain returned, and patient seemed considerably 
relieved and slept twice two hours at time on Thurs- 
day night. 
On Friday at noon the treatment did not seem to 
be controlling the case sufficiently, eyes yet injected A Rip Van Winkle in the Practice of Medicine. 
81 
and patient suffering- intensely at times. Intervals of 
relief were shorter. 
I now opened vein of arm and took full thirty 
ounces of blood-pint cup twice full, nearly brimming- 
-when patient fainted away. 
1 he eyes cleared up at once, patient complained of 
being- very weak and said everything- looked dark. 
He seemed exhausted, but never complained of pain 
in head afterward. 
After this, ice water tried once to head seemed to 
hurt, and I used a little tepid water at times. 
The calomel, assisted by injections, had acted be- 
fore blood letting-. 
Stomach remained very irritable, paining and 
burning with vomiting, but yielded to creosote and 
charcoal, soda and water. 
On Saturday morning at 8 o'clock patient became 
entirely rational and asked what had been the matter. 
He had been conscious at times, but in only a 
dreamy way, and now said he remembered nothing. 
I kept him under a little opium for a few days to 
keep nerves quiet and, with a light diet, (not forced 
on but withheld,) gradually increased, recovery was 
uninterrupted, mind remaining clear. 
It may be noted particularly the effect of water and 
of pain in head upon the nervous system. 
At one time, after water had been poured over the 
head for nearly an hour at a stretch, the patient 
took a severe chill, rubbing his hands together and 
his teeth chattering violently. 
I took this to be a shock from the water, as it per- 
haps was. But at another time, after water was ap- 
plied only a few minutes, the same thing* occurred 82 
A Rip Van Winkle in the Practice of Medicine 
and we stopped water. This time, however, the eyes 
remained injected and he screamed out twice in rapid 
succession with "Oh, my head!" whereupon I applied 
the water again, and thoroughly, with good results. 
Another time, when using water not so cold, he 
said, "Colder," when ice was added to his comfort. 
In fact his actions or suggestions were my guide in 
the application of water, both as to temperature and 
as to duration. If not cold enough he indicated it; if 
not applied long enough he would remain restless, 
while when the effect was sufficient he either went to 
sleep or would ask to be allowed to lay back on his 
pillow and rest. 
OBSERVATIONS 
The first thing that will arise here in the mind of the 
critic is that I have presented but one case and, contrary 
to all precedent, offer it as basis for a disquisition. 
But I reply that I have offered a hundred cases. 
Remember that it is a symptom we are considering, 
and not a disease; and if the physician would treat 
symptoms more, and differentiate between diseases and 
vary treatment less, he would meet with better success 
often. 
When we have determination of blood to the head, it 
matters not what the disease is, the indications for 
treatment are the same, unmistakably so, and on the 
same principle that we give anodynes for pain, whatever 
the ailment. 
Besides, and more forcibly true, active rushing 
cerebro-spinal meningitis is the same thing in all cases, 
sporadic or epidemic, and whether in the disease specially 
named as such or in the course of other diseases where A Rip Van Winkle in the Practice of Medicine. 
83 
the symptom manifests itself; and, if a given means of 
relief acts so instantaneously, and under close observa- 
tion such as satisfies us that the relief is from the remedy, 
then we have a demonstration that the remedy relieves 
the symptom. 
Why is opium lauded so highly as a remedy for 
cerebro-spinal meningitis? Simply because it relieves 
pain and acts just the same in all cases. 
Of course, we have' all known for a long time that 
opium relieves pain, and hence we do not hesitate in 
giving it. Well, so have I known for a long time that 
cold water and venesection relieve head congestions 
absolutely and more universally, permanently and quickly 
than any remedy yet discovered, not excepting opium 
nor the anesthetics. The authorities know this, es- 
pecially of venesection, and refer to the "wonderful 
effect'' (as remarked by Hare) of this ancient means of 
relief. 
Why the authorities so generally recognize this means 
of relief (venesection especially) and yet condemn the 
practice can be explained only on the assumption of a 
habit of thought growing out of the "blood-letting con- 
troversy'' and the modern craze for support and forced 
feeding; but the position is based on neither experience 
nor rationalism, as it appears to me. 
"Facts are before theories,'' and the facts are that 
venesection relieves head congestions and, though it 
weakens for the moment, does not lessen real vitality 
nor the powers of euduranc*. 
For passive congestion, or after the active stage, the 
blister is wonderfully efficacious, especially in the head 
symptoms of typhoid fever, pneumonia and cholera in- 84 
A Rip Van Winkle in the Practice of Medicine. 
fantum, with strong stimulation in desperate cases of the 
latter ailment. 
To the question, "How much water and how much 
blood-letting?" I reply: "Just enough to absolutely con- 
trol the symptom and, as the relief of the symptom is 
the cure of the disease, the fact constitutes the rational- 
ism of the treatment. 
In that variety of cerebro-spinal meningitis, occuring 
in epidemics of the disease, where the head symptoms 
are more or less masked and approach more slowly, in 
which cases there appear low typhoid symptoms, occur- 
ing generally in older subjects and characterized by a 
sallow skin and frequently by a little yellowness of 
whites of eyes, vigorous stimulation should supplement 
phlebotomy and cold water. We have here more of that 
typhoid, or typhus, condition which calls for strong 
alcoholic stimulants. 
CONTRA. 
The first medical journal I picked up after treating 
the case I have presented contained an editorial by 
the editor, in which he condemned venesection in ce- 
rebro-spinal meningitis and advocated as principal 
treatment, and as that on which to rely, "expect- 
ancy" and a supporting diet from the start. 
Of course old "expectancy" conies to the front 
when there is really no remedy to be had, and of 
course it is next to impossible for a member of the 
profession to say much about the treatment of any 
disease without advocating support. I verily believe 
that most, or some, of our medical colleges would un- 
hesitatingly grant diplomas to their students if, on A Rip Van Winkle in the Practice of Medicine. 
85 
examination, they but readily answer "expectancy" 
and "support" in reply to all questions. 
If you adopt the expectant plan in this disease, 
you may "expect" the patient to die, and I note that 
the wfliter just referred to gives the mortality rate at 
from 30 to 75 per cent. 
And pray, what could we expect from feeding? 
The patient would die before a meal could be digested, 
and besides the stomach is exceedingly irritable in 
this disease and generally rejects everything. 
Talk about feeding a patient stricken with violent 
meningitis and that will be beyond hope in twenty- 
four to thirty-six hours, unless relieved! The laity 
should know more than this. It's the height of ab- 
surdity. 
No disease that comes on with a rush should be 
fed, and in fact food should be withheld until you get 
control of the symptoms. 
Verily the profession has gone mad on feeding. 
Generally the system is surcharged with bilious or 
effete matter, often as a result of overdieting, and 
elimination, rather than feeding, is indicated. 
In his remarks against venesection the same writer 
urges that "even wet cupping has been followed by 
bad results." 
True enough, any remedy that falls short of meet- 
ing the requirements of the case would be followed by 
bad results, and what should we expect from a little 
cupping in a case that demanded the abstraction of 
two pints of blood or more? 
That we cannot bleed young children is no argu- 
ment against venesection in those cases where it can 
be performed. 86 
A Rip Van Winkle in the Practice of Medicine. 
In children I would wet cup at once and thor- 
oughly, but it is a very delicate proceedure (child's 
play) in an adult, or even a youth, and will fall short. 
In small children the disease generally acts very 
rapidly, and I have been called two miles, and on first 
manifestation of the disease, to only find the subject 
dead on my arrival. 
In children I would administer a potion of opium 
and of whisky, administer a little chloroform carefully 
and abstract blood from the nape of the neck freely 
with wet cups, then pour water over the head gently 
and continuously, keeping up opium and whisky 
carefully and withdrawing chloroiorm as quickly as 
possible. Of course fine and careful work is demanded 
here and only the physician personally can do it. 
The argument that venesection is too depressing a 
remedy to be resorted to in cerebro-spinal meningitis, 
as claimed by some eminent authorities, is not based 
in scientific truth, as I view it. On the other hand I 
claim that blood letting in this disease and in pneu- 
monia is supporting, by relieving the blood pressure 
from a local congestion in the former and by doing 
the same thing and by also removing a part of the 
surcharged blood in the latter. 
Only reflect a moment here! 
A person is strong, healthy and eating heartily 
to day, and to-morrow is attacked with violent head 
symptoms. What is there about him or within him 
that tends to depress but the local congestion? What 
is there to contraindicate venesection but the local 
congestion, which can be and is instantaneously re- 
lieved by it? Bleed to relaxation and what have we 
left? A patient that feels weak but whose system goes A Rip Van Winkle in the Practice of Medieine. 
87 
on performing' itg functions quietly and undisturbed 
by the local congestion. 
At the same time, while we are thus relieving the 
local congestion, put the patient under the supporting 
and quieting influence of opium, the great and only 
medical specific for this disease, and no fears need be 
entertained in the direction of depression. 
What has frightened men into the belief that 
venesection is depressing is that, while they have half 
way performed it, the disease has killed the patient. 
The rule should be to bleed until you get results- 
relaxation-and please reflect that you can bleed 
spasm and pain clear out of a man in any case, and 
this is what is needed. 
A little bleeding and a little water would be fol- 
lowed by bad results also, but enough brings returns 
better than 75 per cent mortality. 
I have found that timidity in the use of the lancet 
and cold water has led many men to abandon remedies 
that, properly used, would cause a change of opinion. 
When I encounter the disease again, if ever, I 
shall bleed on the spot, (except in small children,) re- 
peat if necessary, and expect to be compelled to use 
the water less heroically. 
The author's resumme on cerebro-spinal meningitis 
is that it is a disease characterized by one special condi- 
tion-determination of blood to the meninges-and that 
the condition is counteracted and relieved by a definite 
and exact treatment-venesection and cold water, sup- 
plemented with opium, if necessary, and with stimulants 
in cases assuming a typhoid form. 
No modern author that I know of recommends vene- 
section in cerebro-spinal meningitis. Osler, the latest 88 
A Rip Van Winkle in the Practice of Medicine. 
work out, says that venesection is not indicated, but I 
think he has simply caught up the cry against it without 
much thought on the subject. He, however, recom- 
mends the application of ice and cold water. He also 
falls into the common error (as it appears to me) of sup- 
port in the way of "nutritious diet." CHAPTER VI. 
TYPHOID FEVER. 
About thirty-five years ago, and just before I com- 
menced the study of medicine, I was in attendance at a 
high school which was broken up by an epidemic of 
typhoid fever, and I and other members of the family 
were stricken. 
The physician that attended our family treated many 
cases in the community without losing one, while an- 
other physician in the same community, who treated 
many of the cases from the same school, lost many of 
his patients. 
I remember the treatment of the successful physician 
to have been, in part, immediate checking of the bowels, 
ice to head and bowels, and starvation-prohibiting sweet 
milk emphatically. 
I remember that some of the patients of the unsuc- 
cessful physician died of hemorrhage from the bowels. 
I did not realize at the time that the result in each 
case depended on treatment, but supposed it to have 
been merely accidental or because some cases were more 
severe than others. On this point I have changed my 
opinion, as will appear as we proceed. 
The memory of this epidemic almost passed out of 
my mind as I went on in the study and practice of medi- 
cine, until experience and observation brought it clearly 
back. 
In the college lectures and text books I learned more 
of the medical remedies for typhoid fever than of diet 90 
A Rip Van Winkle in the Practice of Medicine. 
and other non-medical means that are of so much value 
in the treatment of the disease, and when I began prac- 
tice I relied a little too much on the former and not quite 
enough on the latter. 
And, as it so transpired, the members of the fraternity 
with whom I came in contact during my first years of 
practice, had no special plan of treatment for this dis- 
ease-treated it variously and, as I now believe, relied 
also too much on medicines and not enough on sys- 
tematic dieting and external appliances. 
Practicing in a malarial district, too, as I was, the 
people expected the doctor to break up a fever very 
quickly, and the physicians were much in the habit of 
administering anti-malarial remedies, even when and 
after a diagnosis of typhoid; in fact, typhoid and malaria 
were frequently associated. 
I, however, very early adopted the expectant plan in 
this disease and met with fair success. I was careful 
about diet, checked the bowels moderately, gave turpen- 
tine emulsion and no strong medicines, and in this course 
have been reasonably successful through many years. 
However, I have been to some extent and at times 
pulled away from old methods by the modern craze for 
feeding, by the claims of some writers that the bowels 
should move daily in the course of typhoid fever, and by 
the many reputed specifics offered from time to time for 
the cure of a disease that is not cured with medicines. 
The silly and chaotic state of the medical, or profes- 
sional, mind in recent times on the management of 
typhoid fever is seen in the quinine craze of only about 
twenty years ago, originating in Getmany,and consisting 
in an attempt to abort typhoid fever with a single dose 
of quinine containing from 75 to 100 grains. A Rip Van Winkle in the Practice of Medicine. 
91 
The mortality following this plan caused it to be soon 
abandoned; yet I presume it was only the knock-down 
argument that abated the craze, for, as it seems to me, 
only a half witted man would grab at such a straw. 
More recently have been offered such specifics as 
iodine and carbolic acid, arsenite of copper, sulpho- 
carbolate of zinc, etc., as bowel disinfectants, various 
antipyretics and remedies to meet all variety of cases and 
conditions, while none of the inventors seem ever to re- 
flect that no antiseptic can counteract the evil effects of 
a careless diet, and that no artificial antipyretic can take 
the place of water. 
Few there are who reflect that antisepsis, either in- 
ternal or external, is not a remedy, perse, in typhoid 
fever; that at most it is but of trifling importance. As 
pure air is better than foul, and clean garments better 
than dirty, so antiseptic precautions and remedies are 
preferable to filth and carelessness; but, unless your 
case is managed properly otherwise, they are of no value. 
This is proven by the fact that typhoid patients will re- 
cover in illy ventilated apartments, with bad sanitary 
regulations and with never a change of linen, if treated 
otherwise properly, while with wrong treatment other- 
wise the mortality will be great, notwithstanding the 
patients may have pure air, the most scientific sanitary 
surroundings, a daily change of linen and any form of 
internal antiseptic medication. 
I will treat typhoid fever in the hovels of the poor, 
in crowded tenements and with two patients to the 
bed and let them drink the same water from which 
they contracted the disease; I will bathe them in 
water, not to cleanse them but to cool the fever and 
refresh the nerve centers, check the bowels on the 92 
Spot and cut off the diet, except waler orange or cur- 
rant juice and whisky'in particular cases, (see further 
on) and cure my cases; while you may treat the aris- 
tocracy, have the advantage of all modern antisepsis 
and, if you will let the bowels run, use cold water 
sparingly and feed your patients on milk, you will 
make a bad reputation as a physician and be of great 
pecuniary benefit to the undertaker. 
Antiseptics and specifics such as are in vogue are 
not remedies for typhoid fever. The disease consists 
of an inflammation and its consequences. The cure is 
the suppression of the inflammation primarily and in 
counteracting its consequences incidentally-which 
see as we proceed. 
It seems to me that the profession have of late 
years gone mad on "specifics" and disinfectants in 
typhoid fever and, in consequence, are neglecting es- 
tablished and, as it appears to me, more rational 
treatment. 
Sulpho-carbolate of zinc, carbolized iodine, arse- 
nite of copper, etc., are offered as specifics and on the 
theory of antiseptics, of course. 
Experience has shown them to be worthless, and 
the slightest reflection teaches us why. 
They cannot quiet the inflamed parts as does opium 
and are not to be compared with turpentine as reme- 
dies for tympanites. 
Their only possible efficacy is as disinfectants and, 
when we reflect that the lining of the bowel can not 
be washed off and done up like an external sore or 
wound, we see at once the uselessness of disinfect- 
ants. 
A Rip Van Winkle in the Practice of Medicine. A Rip Van Winkle in the Practice of Medicine. 
93 
But there is one specific which acts on a different 
principle, and experience teaches us that it is superior 
to all others as a disinfectant. This is nitrate of sil- 
ver. 
What we have is a condition of inflammation of 
the lining of the bowel, and what is required istodry 
up this condition. 
Nitrate of silver, on mixing with the fluid contents 
of the bowel, and whatever the character of these 
contents, foul or otherwise, forms an astringent and 
stimulating wash on the same principle that it is used 
in conjunctivitis. 
Prof. William Repper, of Philadelphia, speaks in 
the highest terms of nitrate of silver-having treated 
100 cases successfully with the remedy. 
The proper dose for an adult is one-sixth to one- 
fourth grain, made into pill with gum accasia, every 
six hours, made fresh every day, and continued 
throughout the course of the fever. 
The profession have, from some cause, also gone 
mad on support and feeding in acute febrile diseases. 
While reflection and science teach us that overeating 
is the prolific source of many acute diseases, yet when 
it has produced its result, when the cup begins to run 
over as it were, when the system is revolting against 
the oppression of overfeeding, the profession cry ''Add 
fuel to the fire." 
Nowhere is this species of modern medical insanity 
more clearly seen than in the management of typhoid 
fever. Physicians are feeding typhoid fever patients, 
when food only ferments and acts as an irritant to the 
diseased parts, and then attempting to counteract the 
Let us reason out its mode of action. 94 
A Rip Van Winkle in the Practice of Medicine. 
injury by means of antiseptic specifics, just as they 
apply warm poultices over burning- surface55 and or- 
gans and expect to correct the result of such folly by 
the administration of poisonous antipyretics. 
But the climax of medical insanity is reached in 
the modern craze of forced milk feeding-, which bounds 
beyond ignorance, and can, in reason, be regarded as 
nothing short of criminal carelessness. 
I have known nurses to administer, under direc- 
tions from the attending physician, half a gallon, a 
gallon and over a gallon of sweet milk to a typhoid 
patient in twenty-four hours, and I have heard both 
allopath and homeopath actually boast of the quantity 
of milk they had succeeded in forcing down the un- 
willing palate of a patient, only to form irritating 
curds and gases along the tract of a diseased bowel. 
It has transpired during the past fifteen years that 
I have been called in consultation with many physi- 
cians in typhoid fever cases (perhaps fifty cases), and 
I believe that every case that died, except one or two, 
had drank sweet milk freely, had tympanites and died 
from bowel hemorrhage. (One or two died from 
meningitis, and where no attempt was made to keep 
the head cool.) 
I have seen the same thing in some penal institu- 
tions and hospitals that I have visited; have heard of 
it here and there all over the country and have every 
reason to believe that the habit of dieting on milk in 
typhoid fever is quite general. 
We see it mentioned approvingly in the public 
press and recommended in that trashy class of litera- 
ture known as ' household physicians." A Rip Van Winkle in the Practice of Medicine. 
95 
I think that the carelessness with which milk is 
exhibited in typhoid grows out of its general endorse- 
ment as a proper article of diet in this disease. The 
doctor is asked if the patient can drink milk, and he 
replies, "Oh, yes, milk is regarded as the proper diet 
in typhoid fever," and it is given "ad libitum." The 
average doctor is, however, responsible, for he usually 
prescribes it outright and in excessive quantities. 
It is astonishing how little the physician reflects 
on this matter of milk diet. I am quite sure that I 
have known them to prescribe milk for a patient very 
sick and feverish, in quantities exceeding what a well 
and hungry man could consume and remain in health. 
Only think of it-more than a gallon in twenty- 
four hours! 
A quart or less, however, might kill as certainly. 
Milk taken into the stomach must first be curded 
before digested, and it undergoes only the first process 
in typhoid fever stomachs, excepting the more watery 
portions that may be absorbed. 
In the healthy subject even milk is known to be a 
feverish diet, and this because it is, in the ordinary 
form, difficult to digest. It has an old and true repu- 
tation of being a "feverish diet.'' 
Some friend of the milk diet has demonstrated 
that, under its administration in typhoid fever, the 
bacilli at once decreased in number, and of course 
anything that destroys the germ morbi must be con- 
sidered great. 
But this proposition is easily disposed of. Milk 
is constipating and anything which checks the 
diarrhoea checks the multiplication of bacilli. It is, 
however, a dangerous astringent, and we have better 96 
A Rip Van Winkle in the Practice of Medicine. 
remedies for the diarrhoea than a mass ot irritating 
curds. While milk binds the bowels it injures in 
other ways, and I have known hemorrhage to result 
from its exhibition after convalescence had about set 
in, just as I have seen relapses follow the eating of 
some hard substance or the administration of a dose 
of castor oil. 
Another result of the milk diet and of careless 
dieting generally is a condition of chronic inflamma- 
tion, or induration, of the bowel glands, following 
which may occur perforation or peculiar nervous 
manifestations, with extreme asthenia - generally 
fatal. 
I have seen such cases where the nervous mani- 
festation has been treated for remittent fever, but 
where post-mortem examination revealed only a con- 
dition of chronic inflammation of Preyer's glands. 
The lining of the bowel had gotten in a condition 
similar to that of the conjunctiva, commonly called 
"granulated lids.'' 
I take the following from the Therapeutic Gazette: 
Dietetics in Typhoid Fever-Dr. Bishop believes 
(North Carolina Medical Journal) that excessive tem- 
perature and many other disagreeable symptoms that 
arise in the course of a case of this fever are as much 
due to overfeeding as to any other one thing that can 
be mentioned. He says that Fothergill graphically 
describes the condition of the alimentary canal of 
typhoid patients in these words: 
"There is also a brown, chapped tongue, well re- 
tracted, the brown fur consisting of an accumulation 
of dead epithelial scales, significant of the condition 
of the whole intestinal canal, with brown sordes on A Rip Van Winkle in the Practice of Medicine. 
97 
the teeth of similar origin, accompanied by the for- 
mation of crusts on the lips.'' 
"Now, here we have an alimentary canal in a dry, 
parched condition, all the secretions held in abeyance, 
the dead epithelial scales making it hard and glossy 
(or at least the parts that are open to inspection). 
The sensibility of the nerve endings are obtunded, 
especially those of the special senses of taste and 
smell, the power of absorption is greatlj' lessened. 
Brunner's glands and Peyer's patches are swollen and 
tender. Now we give milk for nourishment, but docs 
it nourish? He can't help thinking that it does not. 
What does it do? It passes through a buccal cavity 
devoid of salivary secretions, enters a stomach whose 
How of gastric juice lias been materially lessened, if 
not altogether stopped. After it has remained here 
for a longer or shorter period, almost wholly unacted 
upon by the gastric secretions, herefore virtually as 
an offending body, it is probably passed or washed 
into the intestines by the next drink of water or milk. 
Well, as this is kept up steadily every two hours by 
day, and, as described in one hospital, every three 
hours by night, we can easily imagine why the bowels 
become full of gas, and the abdomen tense, with a 
tympanitic resonance. The curds become hard and 
abundant, irritate the tender glands of the intestines 
and cause pain in the stomach in its feeble efforts to 
digest them. 
"Now, assuming that these conditions are all true, 
what must be the result when milk is given, as much 
as the patient can or will drink, as done in one case 
mentioned, and six ounces, mentioned in another case, 
every two hours? 98 
"Tympanites, constipation or diarrhoea, high fever, 
delirium and coma, all of which are to be treated 
according to the most improved methods.'' 
And the patient dies, I add, generally of bowel 
hemorrhage. 
Bartholow (Text Book on Practice) falls in with the 
procession and recommends milk diet, but he admits 
that it has been greatly abused. 
Reynolds (Reynolds' System of Medicine) says that 
if milk is exhibited it should be given in small quantities 
at a time and with seltzer or soda. He seems to have 
realized that danger might result from a careless use of 
the article. 
Excepting an indispensible article, all medicines and 
articles of diet fraught with danger should be prohibited. 
Osler, the great diagnostician, recommends three 
pints of milk in twenty-four hours, but he loses six per 
cent of his cases and mentions the fact that he meets 
with cases where bowel hemorrhage occurs. 
In Hare's medical therapeutics we read: "In the 
dietetic management of typhoid fever the tendency at the 
present day is toward over-feeding, and especially with 
milk.'' 
The author then goes on to quote from Sir William 
Jenner, who condemns the careless administration of 
milk, and to urge the free exhibition of pure water, a 
deficiency of which is found to exist in the blood of 
typhoid fever patients. 
It has been proven to a demonstration that milk, in 
any considerable quantity, taken into the stomach of 
typhoid fever patients, forms ihto offending curds and 
produces disastrous consequences, 
A Rip Van Winkle in the Practice of Medicine A Rip Van Winkle in the Practice of Medicine. 
99 
It so transpires that the last two cases of typhoid 
fever that I have seen, and in consultation with two 
neighboring physicians, were fed on milk freely. I saw 
both in third week of sickness and found the bowels 
tympanitic. One died of hemorrhage from the bowels, 
the other from severe chill and nervous shock, the re- 
sult, as I thought, of an irritated condition of the bowels. 
I have §een these results so often that when I am called 
to see a case of typhoid now and find tympanites, I say, 
"been drinking milk?" and receive an invariable repiy, 
"yes." 
On guarding a lady against the exhibition of milk in a 
case I was treating recently, she turned to her daughter 
and remarked, "You know how much milk they said 
they gave John?" "A gallon a day," she added, referring 
to a relative in a distant state. Said I, "he died, did 
he?" "O yes," she replied. 
The practice of forced feeding and the resort to milk 
diet doubtless grew out of the old theory that typhoid 
fever is a self-limited disease in duration, that patients 
affected with it become necessarily much reduced, and 
that therefore a probably fatal termination from asthenia 
is best guarded against by timely support. But, even 
admitting the theory of self-limitation, (which has been 
exploded,) the error of the conclusion drawn from it, 
that the patient should be supported in the early stage of 
the disease, is seen in the persistence with which he holds 
up, even after repeated relapses, and the rapid con- 
valescence from an extremely asthenic condition. 
Experience teaches, indeed, that typhoid patients 
carefully dieted seldom, if ever, die from mere asthenia 
and that forced feeding-often prolongs the case and re- 
duces the patient. 100 
A Rip Van Winkle in the Practice of Medicine. 
I call to mind one particular case, where two relapses 
occurred (caused by the careless exhibition of cathar- 
tics), and in which, practically, no nourishment was 
taken for seventy-three days excepting whisky and water 
and the patient recovered as readily and as nicely as 
though convalescence had continued when it first set in 
on the twenty-eighth day and previous to the first re- 
lapse. 
I have known numerous cases to relapse from 
careless dieting, and forced feeding in the first stage 
is, in my opinion, not to be distinguished from care- 
less dieting. 
On the other hand, I see case after case abort un- 
der a starvation regime and case after case run a mild 
course on a water diet alone. 
Experience, observation and reason have forced 
upon my mind the conclusion that starvation in the 
first stage, or during the febrile excitement, conduces 
to strength later on, hastens recovery and more surely 
accomplishes what irrational forced feeding seeks to 
do. 
In the meantime the average physician seldom 
thinks of keeping the head cool nor of relieving it of 
congestion by the old established means of water 
pouring or ice, or the lance in desperate cases, but 
relies solely on medical depressants that generally 
only mask the symptoms. 
The prevailing plan of treatment for typhoid 
fever, therefore, is to feed and encourage, rather than 
to abate it, and to then turn and mask it into silence 
and death. 
The result of this treatment is a mortality rate of 
from 25 to 40 per cent in hospitals and under eminent A Rip Van Winkle in the Practice of Medicine. 
101 
care, and as I believe as high as 50 or 60 per cent 
among- the less informed and less experienced mem- 
bers of the profession. 
In an address before a body of physicians in New 
York City, Dr. Simon Baruch reminded his hearers 
that the records of the Board of Health, New York, 
(1876-1885,) shows 7,712 cases of typhoid fever, with 
3,184 deaths, or a mortality of 41 per cent, and he ex- 
pressed the opinion that the mortality was equally as 
high in private practice in that city. 
Not only in the great hospitals and in private 
practice do we witness the lamentable results of the 
prevailing plan of treatment, but in otherwise well 
regulated penal institutions and in the army and navy 
we see an alarming mortality from typhoid fever, re- 
sulting from doubtless the same cause, exclusively 
drug treatment and forced feeding. 
The hospital ship "Relief" left Porto Rico with 
167 typhoid fever cases on board. Fourteen died on 
the voyage of only a few days, to which add a reason- 
ably probable number of fatalities that must have oc- 
curred after the ship's arrival, would raise the mortal- 
ity to a high per cent. 
In Gen. Miles' annual report he gives 6,616 deaths 
from all causes, 2,774 of which were from typhoid 
fever. 
The annual death rate in this country from ty- 
phoid fever, according to Prof. V. C. Vaughn of the 
University of Michigan, is 50,000. 
Fifty thousand lives annually from a treatment 
that is more like "kicking a man when he is down," 
as Dr. Page says, than like rationalism. 102 
A Rip Van Winkle in the Practice of Medicine. 
Now let us consider the antiphlogistic method of 
treatment, consisting in the cold bath or pack, free 
use of cold water externally and internally and a re- 
stricted diet or starvation as a general treatment, and 
even venesection in special cases where early and vio- 
lent head symptoms supervene or in very plethoric 
subjects, and incidentally a stimulating treatment in 
a great variety of cases and checking of the bowels in 
all cases. 
I shall begin with a consideration of the general 
plan of hydrotherapy, since, when it is practiced vig- 
orously at the onset of the disease, special treatments 
are seldom required. 
The plan generallv is as old as time itself, but it 
has of course undergone various modifications and', as 
now advocated and practiced, is said to have been in 
use by a limited number of physicians at a very remote 
period. 
The revival (if such it be) of radical hydrotherapy 
may be attributed to Brand of Germany, and is termed 
the "Brand method." It consists of the cold bath 
treatment exclusively, and in referring to it little is 
said by the authorities as to the system of dieting 
adopted or of the medical remedies used in connection 
with it. Those who advocate it, however, and who 
have adopted it, so far as I have learned, recommend 
the free exhibition of water and p-ive statistics show- 
ing that under it the disease either aborts or runs a 
shorter or milder course. Hence not much is said 
about dieting or medicines. Hare gives the following 
results from the method: 
Jurgensen, (Tubingen) 217 cases, 1 death. 
Vogl, (Munich) 221 cases, 6 deaths. A Rip Van Winkle in the Practice of Medieine. 
103 
Military Hospital, (Strasland) 257 cases, 1 death. 
Military Hospital, (Stettin) 186 cases, 3 deaths. 
Brand, (Private Practice) 342 cases, 1 death. 
In all 1223 cases 12 deaths-1 per cent. Says 
Hare: "Not one of these twelve deaths occurred in a 
case that came under treatment before the fifth day." 
Dr. J. C. Wilson treated sixty-four cases by this 
method at the German Hospital, Philadelphia, with- 
out a single death; Dr. Peabody eleven cases at Belle- 
vue Hospital with same resnlt, and wherever it has 
been resorted to comes the same report. The results 
from it are so gratifying- and absolutely convincing 
that Hare concludes: "We are guilty of criminal neg- 
lect if we permit prejudice, difficulty of execution or 
any obstacle to deter us from adopting it.'' 
Dr. Baruch, in his address previously referred to, 
lays great stress on the importance of the bath treat- 
ment, and Osler says that it is about the only thing 
necessary in the treatment of typhoid fever. 
The method consists in immersing the patient in 
water at 65 degrees F. for fifteen minutes, and repeating 
it every three hours so long as the temperature remains 
at 103 degrees F.; or the patient may be placed in a tub 
and the water poured over head and shoulders. 
But much more remains to be said about the cold 
water treatment. 
Often seri jus head symptoms develop early in the 
progress of the disease, and when the temperature is 
not over 102. It is characterized by muttering de- 
lirium, substilius tendinum and injection of the whites 
of the eyes. The pulse and general strength may be 
good. 104 
A Rip Van Winkle in the Practice of Medicine. 
This is relieved by pouring cold water over the 
head, held over the side of the bed, and repeated at 
short intervals, or as necessary. It is superior to ice. 
The patient should be encouraged to drink freely of 
pure, cold water, preferably of soft water. The con- 
tinued febrile condition deprives the blood of water (as 
demonstrated by scientific research), and thus its free 
exhibition restores normal conditions and invigorates, 
refreshes and strengthens the patient. 
It is often necessary to apply cold cloths or ice to 
the bowels to prevent or arrest hemorrhage in cases that 
have been badly managed in the start, and even though 
the temperature be not high. 
In private practice the wet sheet pack may be used 
instead of the bath, and with equally good results. 
I have of late years resorted to the more liberal use 
of cold water in typhoid fever, and with the most grati- 
fying results- And I have come in contact with no 
practitioner who has tried it and failed to find it the 
most successful of all methods. There is no longer any 
question about it. 
I am not prepared to say what method of dieting was 
resorted to by Brand and others in the cases treated on 
the bath plan, but I presume that, as the treatment was 
expected to abort the disease or to cut it short, as it did, 
it was not considered necessary to pay much attention 
to nourishment, and that, therefore, the patients were 
not forceckfed. And I note that Dr. C- F. Page, of 
Boston, an enthusiastic advocate of the cold bath treat- 
ment, is a most radical opponent to forced feeding. In 
a pamphlet on the subject he advocates absolute starva- 
tion, except the free exhibition of cold soft water. A Rip Van Winkle in the Practice of Medicine. 
105 
But in private practice we come in contact with a 
great variety of conditions not met with in hospital ex- 
perience, and hence other things are to be considered. 
And an equal importance to anything else is the 
whisky treatment, which, though seldom required in 
cases well managed from the start, is nevertheless of in- 
calculable importance in some cases and conditions- 
Indeed we occasionally meet with a case in which we 
have at the outset a weak heart, a very high fever and a 
dry tongue, with perhaps subsultus tendinum (twitching 
of the muscles) noticed when we take hold of the hand 
and which denotes great prostration. 
Here stimulation is urgently called for, according to 
Reynolds, and I have seen its charming results in a suf- 
ficient number of cases to satisfy my mind on the subject. 
As suggested by the same author, too, stimulants are 
a valuable adjunct to the cold bath method in this variety 
of cases. 
Remember that it is when we have both the rapid 
pulse and the high temperature that stimulants are indi- 
cated; for we have delirium and . subsultus from head 
symptoms when the temperature is not high which does 
not denote general weakness, and we may have a rapid 
and weak pulse in case of hemorrhage when the temper- 
ature may be at or below normal and when stimulants 
are contraindicated, or we may have an infantile pulse 
without high temperatuie toward convalescence, or head 
symptoms with low temperature at the same stage, when 
stimulants are not specially indicated. 
Again, a sudden rise of temperature often precedes 
a hemorrhage, when also stimulants are contraindicated. 
The cases requiring stimulants are where the weak 106 
A Rip Van Winkle in the Practice of Medicine. 
heart with rapid pulse accompanies a persistent and con- 
tinued high temperature. 
An early dry tongue generally indicates stimulation. 
The following extract from an article on the subject, 
by C. Binz, in "Quain's Dictionary of Medicine," may 
be read with interest: 
Physiological Action.-Alcohol is a powerful an- 
tiseptic, probably from the fact that it is capable, even 
when diluted, of preventing the development of septic 
germs, such as vibrios and bacteria, as well as of para- 
lyzing the activity of those already formed. In small 
quantity, and slightly diluted with water, alcohol pro' 
motes the functional activity of the stomach, the heart 
and the brain; whilst a like quantity largely diluted ex- 
erts but a limited influence upon these organs; if, how- 
ever, the dose of alcohol be often repeated, it is readily 
assimilated, and becoming diffused throughout the sys- 
tem, undergoes combustion within the tissues of the body, 
imparts warmth to them, and yields vital force for the 
performance of their various functions. 
Simultaneously with this consumption of alcohol, the 
body of the consumer is often observed to gain in fat- 
a circumstance due to simple accumulation of fat fur- 
nished by the food remaining unburned in the tissues, 
because the more combustible alcohol furnishes the 
warmth required, leaving no necessity for the adipose 
hydro-carbon to be used for that purpose. Three and 
one-half fluid ounces of alcohol per day is sufficient to 
supply about one-third of the whole amount of warmth 
requisite for the human body during twenty-four hours. 
* * * Doses somewhat larger, but still suffi- 
ciently moderate not to cause intoxication, act, for the 
most part, in the same way; but, as an additional effect, A Rip Van Winkle in the Practice of Medicine. 
107 
they produce a distinct decrease of temperature in the 
blood, lasting half an hour or more. As far as the mat- 
ter has hitherto been explained, this latter effect depends 
upon a directly depressing influence exerted by alcohol 
on the working cells of the body, and upon a temporary 
paralysis of the vaso-motor nerves. The latter is fol- 
lowed, of course, by dilatation of the superficial vessels, 
particularly those of the head, in consequence of which 
a larger surface of blood is exposed, and the loss of heat 
by irradiation into the air js increased, the temperature 
of the circulating fluid being thus lowered; whilst, the 
combustion being carried on by the cells being retarded, 
the generation of heat from this source is diminished.'' 
And, under the heading of "Therapeutic Applica- 
tion,'' the same writer says: 
"There can be no doubt but that a healthy organism, 
supplied with sufficient food, is capable of performing 
all its regular functions without requiring any specially 
combustible material for the generation of heat and the 
development of vital force. But the case assumes a 
different aspect when, in sickness, it transpires that, 
while the metamorphosis of tissue goes on with its usual 
activity, or with increased energy, as happens in many 
diseases, the stomach refusing to accept or digest ordi- 
nary food, fails to supply material to compensate for this 
waste. Here it is, then, that a material which can be 
most readily assimilated by the system, and which, by 
its superior combustibility, spares the sacrifice of animal 
tissue, is especially called for; and such a material we 
have in alcohol. Small, but oft repeated, doses of alco- 
hol, largely diluted with water, are generally well tol- 
erated by the weakest stomach; and, thus given, the 
absorption and oxidation of the spirit goes on without 108 
A Rip Van Winkle in the Practice of Medicine. 
difficulty or effort on the part of the patient's system. 
In this sense alcohol is a food; for we 
must regard as food not only the building material, but 
all substances which, by their combustion in its tissues, 
afford warmth to the animal organism, and, by so doing, 
contribute toward the production of vital force and keep 
up the powers or endurance. As fever patients can tol- 
erate large quantities of alcohol without showing any 
sign of intoxication, it is allowable, and sometimes even 
necessary, to rise in the scale of doses beyond the limits 
ordinarily prescribed." 
In an article on alcoholism, in same work, John 
Curnow, M. I)., says, in relation to the contraction of 
habit from the use of alcohol in sickness: "In the ex- 
perience of the writer the exhibition of large doses in 
fevers and acute affections has never done this-in- 
deed, in several instances, a great dislike to stimu- 
lants has been produced." 
In same work W. H. Broadbent, M. D., in an arti- 
cle on typhoid fever, says, "In a large proportion of 
cases no alcohol is necessary from first to last; it is 
scarcely required in the early stages of the disease, 
except perhaps in drunkards; and at no period should 
it be given as a matter of routine, or merely because 
the case is one of fever, but only to meet certain 
definite indications. These are mainly evidences of 
weakness of the heart-frequent, weak and fluttering 
pulse, and weakness or absence of the first sound of 
the heart. When, as is usually the case, the tongue 
is also dry and the teeth and lips are covered and the 
mouth lined with sordes, the indications for the use of 
stimulants are unmistakable. The effect should be 
watched; when alcohol does good the pulse becomes A Rip Van Winkle in the Practice of Medicine. 
109 
less frequent and of better strength and volume, and 
the temperature is usually lowered, an important in- 
dication also is that the odor of spirits is not detected 
in the breath. When very high temperature and other 
unfavorable prognostic symptoms set in very early, 
stimulants may be given without waiting for the con- 
ditions above mentioned. Alcohol is again often re- 
quired as an adjunct to the treatment of fever by the 
cold bath. The safest form of stimulant is brandy or 
whisky; the quantity needed will vary greatly in dif- 
ferent cases; in some two or three ounces in twenty- 
four hours will be sufficient, in others ten or twelve 
ounces will be required." 
In Reynolds' System of Medicine we find the fol- 
lowing rules laid down for the administration of alco- 
hol or whisky in typhoid fever: 
"Stimulants, in any considerable quantity, are not 
("generally") needed in the early period of the dis- 
ease. When required they should be w°ll diluted. A 
few ounces of wine, in the form of wine whey, or dry 
port mixed with an equal quantity of water, may be 
given. Effervescent wines must of course be avoided. 
"If the heart's action be weak, or the patient tends 
to lapse into the typhus state, brandy may be freely 
given, carefully avoiding excess. 
"The following general rules may be observed in 
the administration of alcoholic stimulants in this dis- 
ease: 
As long as the pulse remains under 120, and re- 
tains moderate force, six or eight ounces of wine, or 
fonr ounces of brandy, given within twenty-four 
hours, will be sufficient. When the pulse ranges be- 
tween 120 and 130 and is small we may double these 110 
A Rip Van Winkle in the Practice of Medicine. 
quantities; and if the heart does not respond to the 
stimulant after twelve hours thrice the original 
amount may be given. 
"The bulk and force of the pulse must be our chief 
guides; and, if these notably fail from day to day, we 
must daily increase the quantity of the stimulant un- 
til the patient is supplied with as much as half an 
ounce every half hour, always diluted. 
"When there is much hectic, and the pulse is 
small and sharp, strong stimulants often appear to 
increase the irritability of the system, and in such a 
case we should give them sparingly and in the early 
part of the day, trusting to a small dose of quinine, 
with or without opium, according to circumstances, in 
the evening." 
It has been my fortune to meet with cases and 
conditions in my private practice where I have seen 
demonstrated the efficacy of stimulants according to 
the principles and rules laid down by the authors here 
quoted. 
In one case of a young lady, aged 20, I gave a 
thorough test. 
I diagnosed typhoid fever, yet she had not the 
usual symptoms well marked. I had eight cases of 
typhoid fever in the same block, and four members of 
the family of which this young lady was a member 
were stricken with what I called typhoid fever, yet it 
acted something like sporadic relapsing fever, or a 
union of typhoid and intermittent fevers-"typho- 
malarial," if thetc be such a special ailment. 
It was in a family poorly fed, and all four of the 
cases relapsed on about the fifteenth day, two of them 
relapsed twice each and none of them from any known cause. It was not in a malarial district and there 
were no malarial troubles in the neighborhood, nor. 
did any of the cases present any clearly marked symp- 
toms of intermittent fever, nor were they treated with 
quinine, excepting the one whose case I am specially 
considering, to whom I administered twenty or more 
grains of quinine on about the second day of illness 
on account of peculiar cramping spells and chilly sen- 
sations with a temperature of 106 F. There were two 
succeeding spells of this kind on I think the second or 
third days of illness, yet no clearly marked intermis- 
sion nor bilious symptoms peculiar to intermittent, 
remittent nor relapsing fevers, and no bowel symp- 
toms peculiar to typhoid. The head remained clear 
throughout in all four of the cases, until in the third 
week in the case of the one in which the whisky test 
was made. 
Be the disease whatever it may have been, the patient 
on about the eighteenth day of illness, and after a re- 
lapse, presented the symptoms that called for heroic 
stimulation, according to the foregoing authorities, and 
it is at any rate certain definite symptoms and not the 
disease per se that call for stimulants. 
The pulse was weak and ran 145 per minute; the 
temperature was 105; the tongue parched and seemingly 
paralyzed; she was mumbling, and reaching out with 
her hands; her eyes were half closed and she was gradu- 
ally growing worse and weaker and was supposed to be 
dying. 
I began to pour down whisky and water at the rate 
of sixteen ounces of good rye whisky in twenty-four 
hours. 
A Rip Van Winkle in the Practice of Medicine. 
111 112 
A Rip Van Winkle in the Practice of Medicine. 
At the end of twenty-four hours she seemed to be 
holding a little better than her own; at the end of forty- 
eight hours there was improvement. I reduced the 
amount to eight ounces during the next twenty-four 
hours, when she grew worse again. I increased the 
amount to sixteen ounces again during the next twenty - 
four hours, when decided improvement appeared. Here 
the disease seemed to be broken, as it were, and I gradu- 
ally reduced the amount of stimulants, and stopped them 
in a few days. 
It was twelve months before she regained her usual 
strength. 
Of course, this was not a typical case; but remember 
that stimulants are called for to meet certain definite 
conditions and symptoms, whatever the disease. In a 
typical case of typhoid, treated on the plan of hydro- 
therapy and starvation during first stage, we might also 
have an early condition which would call for stimulants, 
but not so late as the third week. By this time the 
patient should be convalescent, barring mismanagement 
and accident. 
In the extreme asthenia of protracted cases, and 
where ordinary articles of diet are not tolerated, three or 
four ounces of whisky per day serve a good purpose, but 
heroic stimulation comes in to control urgent symptoms, 
and is required for only a few days. 
A Prof. Richardson, of a Rondon hospital, has ex- 
cluded alcoholic stimulants from the institution and fur- 
nished more favorable statistics of cures generally, as 
compared with other institutions, where alcohol was 
used; but this proves nothing in the consideration of a 
special subject such as we are handling. We are con- 
sidering special conditions in a special disease, while the A Rip Van Winkle in the Practice of Medicine. 
113 
report of Prof. Richardson was based on the treatment 
of general diseases, and he may not have had a special 
case such as I have here presented. 
In attempting to prove anything in the treatment of 
disease, individual cases must be considered; and if 
stimulants are to be bodily banished from the physicians' 
armamentarium, I ask: "What should I do in a case 
similar to the one I have presented?'' 
I want to add here that for a similar condition in 
pneumonia-high temperature and pulse, with delirium 
and subsultus-I would not expect relief from stimu- 
lants. 
It is because that in typhoid fever the condition is 
caused by bacteria, or basillus, blood infection, for which 
alcohol is a specific, as it is for snake-bite or septicrmeic 
poison, while a similar condition in pneumonia is occa- 
sioned by a deficiency of oxygen in the blood, or car- 
bonic acid poison, for which alcohol is not a specific, and 
which may be relieved, if taken in time, by venesection, 
calomel or other eliminants. In the one case the poison 
may be killed, or neutralized; in the other it must be 
eliminated. 
The specific indications for alcoholic stimulation in 
typhoid fever are, as I believe, basillus infection, mani- 
fested or reflected by the symptoms that have been de- 
scribed, and extreme asthenia in protracted cases. 
While it is probably true, as affirmed by Binz, that 
alcohol holds up the patient in protracted cases by sup- 
plying artificial heat, I believe that it is called for more 
frequently to counteract the effects of bacteria absorp- 
tion, or as an antiseptic, than to supply heat and strength 
or as a food; for, while it serves the food purpose in 
cases much reduced, it is often at an early stage that it 114 
A Rip Van Winkle in the Practice of Medicine. 
is more urgently called for, and when these urgent 
symptoms are overcome the patient may then go on 
with but little, if any, stimulation, though many days of 
gradually falling fever. 
To recapitulate, or to explain more clearly a little 
here, it will be observed that I hold to two theories as 
to the use of stimulants in typhoid fever-first, as an 
antiseptic, or to counteract the effects of germ absorp- 
tion', and, second, as an artificial support, or to supply 
artificial heat when the vital forces are waning. 
It may be a question as to whether alcohol is a food: 
and all well-informed persons know that its continual 
consumption tends to weaken and undermine the con- 
stitution. But many drugs that are useful in disease are 
injurious in health, and many that are proper for a time 
would be poisonous if continued indefinitely. 
For practical purposes in disease, I care not whether 
alcohol be considered a food or otherwise. "Facts are 
before theories," and when, in repeated trials and ex- 
periments, it is demonstrated to my mind that in certain 
special cases alcohol will do what no other known 
remedy will do, and bring results for good that cannot 
be had without it, I shall continue to give to it a place 
in therapeutics. 
On this question of alcohol the professional mind is 
tending to take a drift exactly similar to that taken after 
the blood-letting controversy of 1857-8 and to do away 
with it entirely. 
When the physician used to bleed for everything 
and in all stages of disease, many cases were injured, 
rather than benefited, by venesection ; but in the revo- 
lution of thought against heroic treatment it has been 
almost forgotten that, as the best authorities assert, it is A Rip Van Winkle in the Practice of Medicine. 
115 
yet the sheet anchor in a limited number of cases and in 
certain conditions. Notwithstanding an extremist occa- 
sionally states that its days are entirely past, on reflection 
he admits its occasional utility. 
So now we occasionally note a radical statement, 
such as uttered by S. N. Davis, that "alcohol is of no 
value in any case, and absolutely injurious in all cases;" 
but at the same time we find such men totally unprepared 
to meet the arguments of such authors as Reynolds and 
Binz, or to tell us how to dispense with it or what we 
may safely substitute for it in cases such as I have cited, 
in cases where habitual topers are prostrated with certain 
maladies, in certain cases of diphtheria, and especially 
in certain septisaemic conditions, where it has been 
proven to be the sheet anchor. 
I believe that alcohol, like venesection, has been 
abused, and that it should be used with greater care and 
less generally than it hitherto has been, but that it has 
no place in rational therapeutics is a dogmatism unsup- 
ported by science and contrary to the accumulated 
experience of the profession. 
Not many months ago Prof. Davis was asked a few 
pointed questions on his anti-alcohol position, and in a 
leading medical journal (Medical Brief, of St. Ronis), 
but the profession have not been enlightened with a 
reply. 
Prof Davis' statement was a bare assertion-a dog- 
matism-supported by no argument. 
Toward convalescence we often have, in typhoid 
cases, a dull condition of the brain, which may be called 
passive congestion, and similar to what appears in many 
cases of cholera infantum. 
The patient is crazy, but not wild. 116 
A Rip Van Winkle in the Practice of Medicine. 
This condition, in both of the diseases named, has 
always been relieved, in my hands, by a fly blister to 
the back of the head. 
For diarrhoea and bowel tenderness I have used 
tannin, opium and turpentine, with cold applications, 
with universal success. 
As nourishment in typhoid fever I rely on pure 
water, which supplies the deficiency of that article which 
exists in typhoid, coffee as a mild tonic, orange or cur- 
rant juice to supply carbo-hydrates sufficiently in ordi- 
nary cases, and whisky to also supply carbo hydrates 
and to counteract bacteria poison or extreme asthenia in 
desperate cases. 
Ordinary food, and especially milk, cannot be di- 
gested, and, while a little might be absorbed, the more 
solid elements remain as only irritants, and destroy lives 
innumerable. 
We get more carbo-hydrates, or real support, from 
orange or currant juice than from any quantity of milk, 
and fruit juices need not be given in any great quantity. 
Apple, peach or pear juice contains malic acid, and 
is often too much inclined to start the bowels to moving. 
Otherwise with the berry tribe. 
I begin the treatment of typhoid fever with the cold 
bath or cold applications sufficiently to control fever, 
especially in head and bowels; and, to refresh the pa- 
tient, I cut off the diet at once, except as herein previ- 
ously indicated, which, as ordinarily viewed, amounts 
to starvation; check the bowels on the spot, and expect 
a mild run of the disease and an early convalescence. 
With this treatment typhoid fever ceases to be a self- 
limited disease and is shorn of all its horrors. A Rip Van Winkle in the Practice of Medicine. 
117 
The treatment is not new; it is as old as written 
medical history, and is only being revived, modified and 
improved. 
It is simple as simplicity itself, and under it the 
patient needs little professional attention. I have 
treated cases without ever seeing- them. 
The patient cannot digest food, stop eating; he is 
hot, cool him off with the most natural means; if he 
has diarrhoea, control it with laudanum and tannin, 
as you would any diarrhoea, and, if weak and ex- 
hausted, give a little whisky. This course, pursued 
the earlier the better, will obviate serious complica- 
tions and guarantee a speedy recovery. 
But the physician will be called to see cases of ty- 
phoid in various stages of the disease, cases out of the 
ordinary in manilestations of symptoms, and cases 
that have been badly handled or neglected. These 
may be called emergency cases and require careful 
handling. 
First here may be mentioned cases with early and 
severe head symptoms. Often these cases are so ur- 
gent that, but for the history and other symptoms, 
they may be mistaken for meningitis, but happily, as 
the same means of relief are suitable for both, differ- 
ential diagnosis need not worry us. 
They are relieved at once by venesection and water 
pouring, one or both, as indicated and as the judg- 
ment of the physician may determine. The safest 
course is heroic and thorough treatment. Water 
pouring may be tried for a few minutes, and if relief 
comes, its continuance at intervals may, together with 
general bathing, be sufficient. In robust subjects, 118 
A Rip Van Winkle in the Practice of Medicine. 
however, venesection may be necessary, and there is 
positively nothing- to be feared from it. 
As a rule drug treatment will not relieve them, 
nor will the application of ice take the part of water 
pouring. 
The cases in which we have a weak heart, high 
fever and a parched tongue early in the course of the 
disease and that require stimulation, have been re- 
ferred to previously. I need only add here that,when 
the head symptom is also present in these cases, the 
treatment for head symptoms may supplement stimu- 
lation, and that both act admirably together where 
indicated. 
Occasionally, hovever, even at a late stage, the 
head symptom may be violent and require heroic 
treatment. It should be relieved regardless of the 
apparent strength of the patient, and I desire to em- 
phasize this point, for here is where timidity causes 
the physician to shrink from his duty. Heroic meas- 
ures will not kill the patient, but continued head irri- 
tation surely will. 
Violent head symptoms will often supervent in 
conjunction with increased or severe diarrhoea. That 
is, diarrhoea and head symptoms will occur simultane- 
ously. 
Both must be controlled at the same time, for, 
while in many diseases the head is relieved by the re- 
vulsive effects of cathartics, it is not true in typhoid 
fever that diarrhoea relieves brain irritation. The 
reverse is the rule. 
Serious head symptoms, as also serious nervous 
depression will often follow in cases that are, by mis- 
take or otherwise, treated on the quinine plan during the first stage. Boost the patient up on quinine 
during early stage and it will collapse later on. 
But the class of cases that excite our pity and that 
at the same time require the most delicate handling 
are those that have been medicated and dieted to their 
injury. 
It may seem presumptions in one physician to 
condemn as wrong the acts of another in the treat- 
ment of disease, and it is generally so, and I speak 
here only after having- been convinced.beyond all 
controversy. 
I know, if I know anything about medicine, that 
continued purgation and free feeding in typhoid fever 
produces always alarming bowel lesions. 
Every physician ought to know this, and it has 
been known before the writer hereof was born, yet it 
is the great number of such cases that I have seen in 
consultation that have demonstrated the truth to my 
mind. 
In such cases we find, usually about the third week 
of illness, a slight or considerable tympanitic condi- 
tion of the bowels. The patient is bright, tempera- 
ture not high often and convalescence seems to be ap- 
proaching, when suddenly the temperature rises a 
little and a hemorrhage follows about twenty-four 
hours later, and the patient collapses in a day or two, 
if not sooner. 
If the case is seen before the hemorrhage occurs, 
ice applied to the bowels and laudanum internally may 
prevent it and the patient may yet recover, after a 
hemorrhage, under very careful management. But 
cold to the bowels must be kept up, with laudanum 
and turpentine rather freely internally. 
A Rip Van Winkle in the Practice of Medicine. 
119 120 
A Rip Van Winkle in the Practice of Medicine. 
The application of warm poultices to the bowels in 
such cases, as practiced by some, invites more blood 
to the inflamed glands, extends the inflammation and 
hurries off the patient. Dr. Page, in ridicule of this 
practice, asks: "Would you expect to cool a red-hot 
poker by placing it in a bed of coals?" 
The condition here is a chronic inflammation and 
induration of the glands of the diseased bowel, result- 
ing from the presence and irritation of indigested 
food, gases or milk curds, and it results generally in 
hemorrhage, perforation or exhaustion. 
While typhoid subjects do not usually die from 
mere asthenia, they may do so in this variety of 
cases, and because the condition is a continued bar 
against feeding, when the patient should have been 
by this time in a condition to take nourishment, and 
it is also a bar against the use of stimulants, which 
might keep up the fires of life in a very protracted 
case and in the absence of bowel congestion. 
But it sometimes occurs in these cases that this 
condition of the bowel causes a peculiar nervous man- 
ifestation simulating intermittent or remittent fever, 
when the physician, misjudging his case, resorts to 
quinine, only to see the symptoms continue and the 
patient's time shortened. 
The attempt to thus control symptoms, here, that 
are not understood, only serves to prevent the patient 
from dying of asthenia, to say the least, and because 
it hastens a fatal issue. 
If it clearly appears that the tympanites is caused by 
the presence of milk curds, a dose of oil or calomel may 
be of benefit. I have seen three or four cases in young A Rip Van Winkle in the Practice of Medicine. 
121 
children where calomel brought relief in such cases, and 
the treatment is endorsed by the best authorities. 
If the condition is simply chronic inflammation of 
the bowel lining, nitrate of silver is the remedy-one- 
fifth grain in pill four times a day, prepared fresh every 
day. 
I would, however, caution the reader here against 
the notion, entertained by some, that tympanites is gen- 
erally to be relieved by cathartics. 
On the other hand, cathartics, or even laxatives, only 
aggravate the trouble, barring the presence of curds. 
There is no case, except where sweet milk has been 
drank carelessly, where the bowels should be moved for 
the relief of tympanites, and a continuation of the usual 
diarrhoea is almost sure to be followed by tympanites. 
In the early stage of the disease, and generally, tym- 
panites is caused by inflammation, aggravated by cathar- 
tics, but prevented by the timely use of astringents, cold 
applications and opium. 
The belief that tympanites can be relieved by remov- 
ing the accumulated secretions, and on the theory that 
they act as matter offending to the inflamed glands, is 
one of the greatest errors made in the treatment of 
typhoid fever. 
So long as the pathological condition remains the 
secretions will re-form as often as removed, and to per- 
mit or to force the bowels to move continually only opens 
a dam which continues to fill with increasing rapidity 
and to the exhaustion of the patient. 
The pathological condition must be dried up by 
means of astringents and remedies that induce repose, 
when secretions previously poured out will take care of 
themselves. SUPPLEMENTAL. 
ABSURDITY OF FORCED FEEDING IN ACUTE DISEASES. 
"Instances of longevity are chiefly among the abstemious. 
-Arbuthnot. 
A prevailing hobby endorsed and adopted by the 
medical profession generally, allopath, homeoepath 
and all schools, is that, in all ailments the patient 
must be supported and, whether nature protests 
against it or morbidly demands it, every ailment is 
crammed and stuffed from start to finish. From the 
old maxim of "starve fevers" and from the old habits 
of "fasting and prayer,'' as means of cure, the pendu- 
lum seems to have swung to the extreme in the other 
direction, and devils are expelled by forced feeding. 
There is scarcely an article written for the medical 
journals on the general treatment of any disease, or 
a disquisition for the text books, that does not teem 
with the demand for support, whatever the ailment or 
conditions of the organsof digestion and assimilation. 
To "support'' seems to fill in at every point where 
rational medication cannot be conceived of and phy- 
sicians seem really to vie with each other as to how 
much they can say in favor of it, and to boast of how 
much nourishment they can crowd upon a system often 
unprepared for its reception. I see leading editorials 
in medical journals urging support in cerebro-spinal 
meningitis, when, in this disease, usually the stomach 
revolts at everything in the shape of food, and when A Rip Van Winkle in the Practice of Medicine. 
123 
the system is surcharged with effete products that 
have accumulated from overfeeding and lack of exer- 
cise, often, and in pneumonia when clearing of the 
alimentary tract is generally most urgently demanded 
and when the organs of digestion are out of order, 
and I have met in practice and heard of hundreds of 
physicians who force from half a gallon to a gallon of 
sweet milk into the stomach of typhoid patients dur- 
ing twenty-four hours, when secondary digestion is 
absolutely suspended, resulting in the accumulation 
within the bowels of curds, undigested products and 
gases, and producing hemorrhage and destructive in- 
flammation. Now everywhere it is recognized and 
remarked about that overeating is the prolific 
cause of most acute ailments, yet no sooner has over- 
eating produced the disease than that the physician 
urges support-"santiUa samilibus curantur," or "the 
hair of the dog cures the bite." 
What do you want to feed typhoid fever f®r, when 
the patient has no appetite and when digestion is abso- 
lutely impossible? The abstemious are never bilious; 
and when, in pneumonia, the liver needs unlocking and 
the stomach is foul, what do you want to feed for? 
In meningitis, when the patient must be relieved in- 
stantly, if at all, why talk about support? How much 
time have you here to build up the system? An irritable 
stomach is characteristic of meningitis, and the patient 
vomits food, medicine and everything else. Going to 
nourish this patient, are you? It will die while you are 
trying it. 
Of all the absurdities ever conceived by men pre- 
tending to scientific attainments it is that of feeding in 
acute febrile diseases, when the organs of digestion are 124 
A Rip Van Winkle in the Practice of Medicine. 
not at work, when assimilation is impossible, and when 
the entire system is in a strain, attempting really to 
throw off a surplus of dead products resulting from over- 
feeding. 
Jesus Christ was a better physician than many mod- 
ern savants. 
Speaking of one possessed of a "devil'' (which was 
probably a case of epilepsy, or at any rate some form of 
bodily ailment,) he said, "This kind are driven out by 
fasting and prayer," or a similar statement. 
He had at least learned the value of abstemiousness 
as a factor conducive to health, and to this extent I 
have become thoroughly converted to Christianity. 
Stop forced feeding in acute febrile diseases, and the 
days of your patients "shall be longer upon the earth." APPENDIX. 
While it may seem that the author has been a little 
dogmatic in much that is contained in this work, 1 
believe that it will be admitted that his dogmatism 
has been generally on the side of experience and 
against that form of theory that is unsupported by 
experience. 
1 heory, however plausible, may be wrong; how- 
ever ridiculous, it may be right. 
Medicine is an inexact science, and, year by year, 
theories come and go. Often a theory which we rely 
on today is thrown to the dogs tomorrow, and, unless 
a theory has been long established and well supported 
by experience, it is, for practical purposes, of no more 
worth, often, than the grossest superstition. I have 
seen the most fine spun theory of the educated savant 
fail where the common sense of an uneducated house- 
wife has succeeded. 
Don't turn the deaf ear to a seeming ignoramus 
who, with contradictory or absurd theory, presents a 
fact, for beneath his reasoning there is often a fact 
which, though he knows, he cannot explain. He has 
seefi something or felt something or instinctively per- 
ceived that which perhaps no theorist can explain 
and, therefore, has often no solid reason to gainsay. 
For instance, an uneducated man said to me that 
"doctors ought to bleed more for head troubles." He 
SOME PECULIAR THEORIZING. 126 
A Rip Van Winkle in the Practice of Medicine. 
said he had spells of aching- of the eyes, and believed 
bleeding would help them. 
I asked why he thought so and he gave me a fact 
and his theory for it. He said that when his wife 
was confined she had spasms and at the same time 
was flooding, and the doctor bled her in the arm, 
whereupon both the spasms and the hemorrhage 
ceased. His theory was that in the hemorrhage the 
blood did not come from her head, but when she was 
bled from the outside veins above the waist the blood 
came from her head and cured her, and, being cured, 
of course the uterine hemorrhage ceased. 
Now there may, after all, be something in this 
theory, though none of us can explain it. But the 
fact was that the operation, based on the. theory which 
he said he got from the doctor, was followed by suc- 
cess, and the same procedure is urged by the authori- 
ties in such cases. 
The author relieved a woman once under similar 
circumstances. 
I held the uterus down, however, with my hand 
while I bled her. 
Another man said, "Back in Kentucky they used 
to bleed everybody once a year in the spring and you 
never heard of much bad sickness there." 
I asked him how he accounted for it. 
"Why," said lie, "it takes out the bad blood and 
purifies the system." 
Now, while this man could give no rational expla- 
nation as to why and how the blood became bad, nor 
how that vensection "purified" it, 1 believe there is 
a correct theory for the procedure he related. I be- 
lieve that overeating in some way surcharges the A Rip Van Winkle in the Practice of Medicine. 
127 
blood with poisonous elements that tend to accumu- 
late beyond the powers of the emunctories to elimi- 
nate ,them and that, often, venesection is highly 
beneficial as a depurent. 
It goes without saying that reasonable abstemi- 
ousness is the greatest preventive means against 
many ailments, and I believe that overeating makes 
the blood too rich or too thick, or surcharges it, and 
venesection cures these conditions that abstemious- 
ness tends to prevent. 
The excuse or reason generally offered by the many 
people who believe in venesection and who wish to be 
bled, is, "I believe I have too much blood," or, "I 
believe my blood is too thick." 
There is not much theorizing here, but I believe 
they are telling a great truth. 
Overeating makes too much blood, as well as too 
much flesh often, and, while a course of diet com- 
menced in time would do about as much or more than 
venesection, people are not apt to regulate their diet, 
and besides are often in need of relief before they have 
thought of it. 
The physician often laughs in derision at the man 
who wants to be bled because his blood "is too 
thick," but it is the full blooded who seek the remedy 
and who experience relief from it, and it is a scientific 
fact that venesection makes the blood more watery. 
So that, often, the patient knows more than the 
physician, however little he may know about medicine 
generally. 
I have known of persons who had been bled to 
their relief beg and plead for a venesection at the 
hands of the physician, only to be refused and to die 128 
A Rip Van Winkle in the Practice of Medicine. 
from what ought to be held as "criminal careless- 
ness." Physicians, as a rule, know a great deal less 
than they are given credit for. 
Thousands of people outside the profession yet 
hold to venesection traditionally, and to that tradition 
the subject often links a form of instinct which makes 
him really wiser than the most logical theorist. 
It is a wise physician who can give to tradition and 
instinct the proper weight in the practice of the heal- 
ing art, but it does not require a very profound mind 
to know from obssrvation that the physician who runs 
wild on theory often knows less of practical worth in 
some things than the ordinary housewife. 
The extremes of absurdity to which mere theory 
may carry the medical mind is seen in the conclusion 
of the recent "tuberculosis congress" held at Berlin, 
that phthisis pulmonalis is "not hereditary." 
Any one but a very learned physician would be re- 
garded aS a fool in making this assertion, and perhaps 
the great lights who promulgated this wonderful evo- 
lution of theoretical insanity did not reflect that no 
layman (and few physicians) on top of dirt will more 
than ridicule the conclusion. 
THE EFFECT ON THE AVERAGE MEDICAL MIND OF 
MODERN BACTERIOLOGICAL RESEARCH. 
I have somehow been peculiarly impressed with the 
effects on the practice of medicine of recent bacterio- 
logical research and discoveries, whether as practi- 
tioners, we should be more of a bacteriologist than a 
physiologist and pathologist or vice 
Should we attempt to run down the basillii and the 
bacteria, or is it better to simply treat an inflamma- 129 
A Rip Van Winkle in the Practice of Medicine 
tion on common sense and well established principles? 
This subject has a more particular bearing- on the 
treatment of typhoid fever. 
This line of investigation has done, and is doing-, 
much in the way of explaining- the cause and nature 
of disease, but perhaps less of a helpful nature in sug- 
gesting improved methods of treatment. 
The nature of disease is not changed by these in- 
vestigations and, whatever the discoveries, methods 
of treatment that have proven successful before, will 
not be abandoned after them. In treating internal 
inflammations, it does me no good to know that each 
has its special microbe as cause or effect. I have 
simply an inflammation, and if certain remedies dis- 
covered previously to the discovery of the bacillus,, 
have proven successful as means of relief, we should 
adhere to them, notwithstanding- none of them are 
microbe killers nor disinfectants. 
Numerous specifics have been offered for the treat- 
ment of typhoid fever on the antiseptic theory, but 
they have proven to be of little value compared to cold 
water and starvation or to opium as an antiseptic. 
Their effect is absolutely nil in the absence of the 
means of relief herein suggested. Theoretically they 
should be alone sufficient, practically experience has 
proven them next to worthless. 
Time and time again I have met physicians who 
seemed to have swallowed the bacteriological diction- 
ary, who were filling the stomach and intestines with 
antiseptics and germicides as the only means of cure, 
but who were, at the same time, neglecting the use of 
water and the older remedies for relief, paying no at- 
tention to diet and letting the bowels run, and losing 
most all their patients. 130 
A Rip Van Winkle in the Practice of Medicine. 
Of course, they were "very bad cases to start with'' 
and "the doctor was very faithful." 
During the past year I saw two cases of typhoid 
fever with two neighboring physicians, both of which 
patients died. 
The physicians were both bright and good general 
practitioners. 
On consultation with the first one I was confronted 
with a germicide and "specific" vocabularly almost 
beyond mv comprehension and a shelf of pellets, tab- 
lets, triturates and powders unknown to me as reme- 
dies in this disease; but the diet had not been suffici- 
ently guarded nor any attention paid to a violent 
meningeal complication, and the patient died early in 
the battle with specifics. 
In the other case, the physician permitted the bowels 
to run "any number'' of times a day, actually gave 
castor oil every day to keep them moving, allowed the 
patient to eat and drink most anything he wanted, and, 
when tympanites developed from the free consumption 
of sweet milk and potatoes, and when fever raised and 
the case turned for the worse in the third week, my 
worthy collegue explained that there had occured "a 
new and extensive bacteria invasion,'' which he had 
however failed to prevent by the administration of the 
germicides, antiseptics and "triple phosphates'' such 
as I never heard of. 
The patient died from bowel hemorrhage. 
Now both of these physicians were trying to learn 
something and deserve credit for it, but they had been 
absolutely hypnotized by bacteriological theorizing and 
germicidal fads. 
Neither had even thought of the use of cold water or 
ice nor of the old reliable remedies for typhoid fever, A Rip Van Winkle in the Practice of Medicine. 
131 
and of course venesection and water-pouring which (one 
or both) would have relieved the case with early violent 
head symptoms (it being a robust subject too) were never 
dreamed of. 
In the attempt to run down bacteria does not the 
physician often forget that the diseased germs may orig- 
inate and multiply within the bowel or diseased part, as 
well as to come from without in the first instance? And, 
if so, will not reflection teach him that continued irrita- 
tion of the inflamed part, by means of ingesta, may mul- 
tiply germs faster than he can kill them with germicides 
and antiseptics? 
We may destroy the germs successfully, yet, after 
convalescence is established, the eating of a piece of 
apple or a dose of oil, by irritating the tender recently- 
healed glands, may induce a new inflammation and an- 
other regular course of fever, thus demonstrating that, 
by irritation, the causative germs have originated en- 
tirely from within. 
I do not believe that the bacteria, once absorbed, can 
be eliminated by artificial means, but that, once entering 
into the blood, they must be consumed by internal 
thermogenesis, of which process fever is the out- 
ward manifestation. And, if this is true, how absurd 
the attempt to control the fever by means of antipyretics, 
rather than to first subdue the local inflammation, when 
the germs cease to multiply and the fever abates naturally. 
I think that Prof. Cantini, of Naples, has correctly 
stated the case in the thought that "fever (in typhoid) 
is the expression of organic reaction against microbic in- 
fection" and that the "microbes are destroyed by fever 
combustion." 
And from this we must infer that, so long as germs 
multiply, the fever must continue, and that, therefore, 132 
A Kip Van Winkle in the Practice of Medicine. 
instead of trying to kill germs we should rather attempt 
to prevent their multiplication by suppressing the local 
inflammation. 
I repeat, therefore, should the physician not be more 
of a physiologist and pathologist than a bacteriologist? 
Physiology teaches me that, when digestion and as- 
similation are suspended, food acts as only an irritant. 
Pathology teaches me that in typhoid fever the blood 
is deficient in water, from which I infer that, in the pro- 
cess of microbe combustion, the watery elements are 
consumed and that the re-supply of these elements con- 
stitutes rational scientific treatment. 
Pathology teaches me again, and as we all under- 
stand, that the more extensive the internal inflammation 
the more the danger of systemic infection. 
This we knew before we knew anything about mi- 
crobes and when we designated the danger as a form of 
septicaemic, rather than a "microbic infection." 
Simply that things are called by different names, not 
that we have gotton any real practical information. 
It gives us an insight as to the character of the ma- 
ter ies morbi" a more scientific conception, and, while 
it thus brings more science to our support, it does not 
add so much to what physiology and pathology has 
taught us. 
Certainly bacteriology is but a handle to pathology 
and its researches should be encouraged, but the thing 
I am trying to impress is that the practitioner too often 
relies on only the handle and gets his cup sometimes 
upside down. 
And we may reflect that, while the successful treat- 
ment of typhoid fever herein set forth has been sustained 
by bacteriological research, it was evolved independently 
of the microscope. 
What has bacteriology taught us? 
(THE END). A "RIP VAN WINKLE" 
IN THE 
Practice oH Medicrpe 
J " 
The Resurrecbiop of a Hero, and 
Revival of a Arb 
BY 
H. J. PARKER, M. D. 
IWAYTON ULiSW 
1899. 
" Fact| are Before