^JUgyo (d. K W- V\. By A. AV. NELSON, M.D., NEW LONDON, CONN. V VERATRUM VIRIDE IN TYPHOID FEVER. ITS LOWERING OF THE PULSE AND TEMPERATURE— TWENTY-EIGHT SUCCESSIVE CASES IN PRIVATE PRACTICE, ALL RECOVERING. 1873-1882. " K I THE treatment of every disease at first is tentative and theoretic,—fortunate if at last it becomes in a rational sense specific or uniform. It varies in its methods, even with a common theory, to say nothing of many theo- ries. For a decade, accepting the excess of heat as the measure of chemical and destructive changes, and as the chief cause of death in a disease so prolonged as typhoid fever, how many remedies have been tested !—digitalis, quinine or calomel in heroic doses; veratria, described by Ziemssen, given to induce vomiting and sudden lowering almost to collapse, in the hope that the high fever may not return ; and the cold-bath cure. Before the use of the thermometer, there were the anti-bilious treatment, the turpentine for the enteric symptoms, the empirical acid course ; and, after all others, the expectant method. We note the unsatisfactory character of these treatments by their indifferent interchange, by the liberty of experi- ment within certain limits4, and by the result—a constant percentage of fatality. It has long since come to this: We must take care of our cases, guard against injurious medicines, diets, excesses, and Reprinted from the Archives of Medicine, Vol. ix, No. 2, April, 1883. 2 A. W. NELSON. oversights, and await an unknown termination. The disease, self-limited—if its subjects live long enough !—must exhaust itself any way, unimpeded by human effort. But a cure for this fever should be found, in the same sense specific as quinine in intermittents, salicin in rheuma- tism, mercury in syphilis, arsenic for the skin, the bromides in epilepsy, or digitalis in diseases of the heart. Our art should not be thought entirely out of its infancy when a disorder so fatal, without antidote, ravages the whole world. And the prolonged course of the disease should be a reason and a means of cure, not a cause of de- spair and inaction. There was an axiom accepted, but quite disgraceful,— the cure of rheumatism is six weeks. No longer excusing ourselves in such failure, in the better sense now we say, we cure rheumatism. Veratrum viride, green hellebore, was first brought to the notice of physicians by Professor Wm. Tully, of Yale Col- lege, in his lectures to his classes about 1830, as a substi- tute for colchicum in rheumatism and gout. He claimed it would cure a majority of the cases of these diseases, being "separated medicinally" from veratrum album and much less cathartic, also less so than colchicum. Dr. Chas. Osgood, of Providence, who first published a full account of the drug, Amer. Jour, of Med. Sciences, vol. xvi, p. 296, old series (1835), had his first knowledge from Prof. Tully. He advises its use in pneumonia, rheu- matism, and gout. Norwood, Am. Jour, of Med. Sciences, vol. xxv, page 281, 1853, is the first to allude to typhoid fever. He says: "We have treated several cases of typhoid fever in council (with verat. v.), where all the usual remedies had failed." * * * " Medicine of every kind whatever was withdrawn, and she (the patient) was put on the use of the tinct. of v. v., com- VERATRUM VIRIDE IN TYPHOID FEVER. 3 mencing with three drops, to be increased every three hours." The case improved soon and recovered, though from the text it seems to have been desperate. Norwood continues: " If this were a single or isolated case, we would not have mentioned it, but we have treated a number of cases with a a like effect and success." In this case, he had vomiting, and in the others also. He objects to the giving of quinine and stimulants with the medicine. Ringer says, fourth edition, 1875 : "Typhoid fever, it is said, may be beneficially treated by veratrum," and "in the treatment of the foregoing diseases "—scarlet fever, measles, typhoid fever, etc.—" it is better to give small doses, as one or two minims every hour, rather than larger ones at longer intervals,"—the true way. Barker, of New York, advises veratrum viride in quite large doses in puerperal fever. Agnew, of Philadelphia, in drop or two-drop doses in surgical fever; and Simpson, of Edinburgh, 1872, in the former disease, with some discourse on the helleborism of Hippocrates and the ancients, with which cure he classes this. Their hellebore was a cure for chronic diseases mostly, as insanity, epilepsy, neuralgia, dropsies,—a "separate" drug, yet near kin, botanically, to the v. v. The Woods, of Philadelphia, and Stills, and Bartholow, latest, advise against it, the last two being very sure of in- jurious effects. Stille is contemptuous as to its use in typhoid. Dunglison and J. K. Mitchell, scarcely mention it. Flint, Aitken, Reynolds, Bennett, Graves, Chambers and Niemeyer, do not class it with remedies for fever. Up to 1873, I had only used veratrum viride in three thoracic aneurisms, one with a supposed cure and a relapse. I have never used it in pneumonia. In 1874, in the cases herein reported, this line of thought occurred to me. High temperature, prolonged two or three Aveeks, kills. 4 A. W. NELSON. Personal and recorded experience has only this lesson, spite of quinine, stimulants, effervescents, acids, cold baths. Now, if the pulse could safely, in this fever, be reduced from no, or from 120, which, continued two or three weeks in adults, is usually fatal, to 90, and safely kept at 90 or 85—not at 70 or 60,—the friction of the heart and of the whole circulation one might expect would be lessened, in so considerable degree that the heat would naturally fall somewhat, at least. Just as in the dangerous friction of continuously running a steamship greatly beyond her normal rate of speed, every two or three additional miles per hour increases consumption of fuel geometrically, or by the square—not by simple addition,— and the friction of machinery and breakage are in the same proportion. Nor is the comparison untruthful. Consump- tion of material fuel, in each case, that of the living body and of the ship in motion by steam, are identical—the use of oxygen also. Breakage or exhaustion maybe final in either. Prevention of high heat is, however, very different from the abstraction of heat, by the cold bath. Possibly this veratrum, considered depressing, as usually given, in a prolonged disease, otherwise given, as already intimated, only lowering the pulse to eighty-five or ninety, might benefit; and, by keeping down the heat a degree or two continuously, mitigate some or all symptoms and save life. Besides the poison or ferment of the fever, we contend against its prolonged effects after incubation—rapid circu- lation, high heat, and inflammatory processes. The poison without these might not interfere dangerously with the physiological functions. Even if we could not antidote the ferment or poison, we might antagonize the effects and delay death till vis naturce could restore the normal econo- my or eliminate the faulty product. The excessive friction of the fever at least we might try to obviate. The attempt is to mollify, not to abort or strangle, the disease. VERATRUM VIRIDE IN TYPHOID FEVER. 5 The records thus anticipated are somewhat brief, but the pulse and temperature and worst symptoms besides, are fully given. What was found ? The skin was frequently moist, in some cases constantly, so that a somewhat natural bath followed, with its tendency to coolness; the tongue moist, a possible result of the respiration being more nasal, with- out the sordes often so irksome and significant. Sleep has usually been quite natural, to be expected with the improvement of the skin and tongue. No faintness, no increased weakness as was anticipated ; the patient per- mitted to have his head on the usual pillows, not especially low, as Stills says; no vomiting, except in two or three instances, not necessarily to be attributed to the drug; no dangerous symptoms whatever seem to follow these small and frequent doses. Instead, a mitigation of the fever, of the cerebral symptoms, and of the abdominal, the stomach retaining nourishment well. The pulse is slowed, the tem- perature lowered one or two degrees very often in the second week. Rose-spots have infrequently been observed or have been doubtful. What is of more consequence, the complication of hemorrhage of the bowels, or of perforation, has not occurred. The opinion obtains with me that the ulceration of Pey- er's glands is aggravated greatly by the rapid circulation and high heat as usually prolonged, and that this desirable result of lessened friction and lessened heat, together with the slight tympanitis, the prevented diarrhoea, and the improved tongue during the second week, gives us another type of fever, one non-typical. The usual diarrhoea, under other treatments, must be thought a result of the prolonged high heat, a means of elimination of waste and of the poison generated—conserv- ative in some degree, at least. So is the colliquative diar- 6 A. W. NELSON. rhcea of phthisis. In that we have also sweating. In both cases there is great heat. Reduce the heat in either to nearer normal, and the diarrhoea is no longer troublesome. Again, ulceration in both instances brings on diarrhoea, and high heat increases ulceration. In typhoid with slow pulse the high temperature is also reduced and the general symptoms improved by the vera- trum, in these moderate doses, without reference to the pulse. Convalescence has uniformly been rapid. New London has a general incline eastward toward the Thames, a river having deep currents and ocean tides. The city is most abundantly flushed with pure water from a beautiful lake, a reservoir formed by nature, seven miles distant among hills. Till within three years, there have been no proper sewers, and since, in only a few streets. Vaults and cesspools are stone-walled, not cemented ; and the soil or subsoil, too commonly infiltrated, in many places rests upon granite ledge. Cellars, of course, are sometimes pol- luted. The great quantity of water increases the danger, and often the vaults overflow. The city-limits, the smallest in the State, if not in the nation, with four fifths of the population in the northern fourth, 9,000 in one square mile, croAvd the dwellings too close to these imperfect receptacles. It should be antici- pated that here is a very nest of typhoid, diphtheria, and its congeners. For the past three years only, the ventilation of vaults and the trapping of sinks have been required by law; and sulphate of iron has been freely used. Otherwise there has been little of sanitary precaution. For the ten years during which my observations were made, there has been no epidemic of typhoid, but a severe one of scarlet fever in 1879, and °f diphtheria, eighty-seven VERATRUM VIRIDE IN TYPHOID FEVER. 7 deaths in 1880, and many cases of the latter for several years previous, and high death-rates. Yearly, there have been reported two to five deaths from typhoid, thirty-four in all. Some recoveries by other treatments have been very tedious. The entire population is 11,000. Brief reports convey impressions of a mild type, of con- tinued, of "two weeks " or " bilious " (?), fever. But the common cause, as far as we know, the termination, even in the mild type, too often disastrous, prevalence in the autumn or near to the autumn,bring many varieties under one species. These are all typhoid, with all its occasional dangers and complications. And in my patients, the bodily weakness, absence of appetite, the deafness, coma-vigil, and facies were characteristic, as also the pulse and temperature. Warnings from medical men and expressions of doubt most frequently accompanied statements of cases during their progress to recovery. Surgeon M. C. Drennan, U. S. Navy, in 1880, saw several patients, however, with approval and great interest. All treated from the first, with any degree of thorough- ness according to the method, are given. The preparation used is the officinal tincture, and the doses are from one to two drops per hour, with little other medicine, if any, from the setting in of the disease to convalescence. Age and sex must be considered, but children require a dose propor- tionally large. The elimination of veratrum viride is rather rapid, so that these patients were usually under the influence of from three to twelve drops continuously. It occurred sometimes that the medicine was given only every two hours at night. The entire quantity in twenty-four hours would be from twenty to forty-eight drops; and this would go on day after day for ten, twelve, or fourteen days. By no means is the dose unappreciable. 8 A. W. NELSON. The experience recorded here is sufficient to guard from disaster any physician following these methods. He should, of course, watch carefully the pulse and temperature. In medicines Ave do not chiefly regard names, and the results of careless or excessive doses. This powerful drug, reasbn- ably exhibited for our special purpose, is not then depres- sing or dangerous. It is admitted that arsenic and mercuri- als are sometimes tonic and restorative. Yet mere names alarm our patients, and we yield to their timid scruples to our common disadvantage. The ordinary classifications of drugs are often, in this way, a great damage in our practice —bugbears. Three questions are pertinent. Does the veratrum in these doses reduce the temperature one or two degrees, morning and evening, during the second week? Is .convalescence at the twelfth or fourteenth day a fre- quent result of the treatment? Does the cure render the fever non-typical and less malig- nant in a great degree ? My own conclusion may be thus stated.—A tendency of the typhoid ferment to exhaust itself at about fourteen days the veratrum viride emphasizes, so that very many cases determine at twelve days, some at fourteen or fifteen, a smaller number at three weeks. Very few determine indefi- nitely, as do a large proportion in other treatments. The pulse and temperature and memoranda, all recorded at the time of visit, may be taken as accurate, the thermome- ters being proved. The application of this instrument was almost always in the axilla. REGIMEN. Stimulants.—Essentially none. A little brandy or whis- key in cases 8, 17, and 25 only. Diet.—Milk porridge, oatmeal porridge strained, milk, VERATRUM VIDRIE IN TYPHOID FEVER. 9 beef tea, weak tea or coffee ; orange juice in slight quan- tity ; sometimes a little lemon juice. Rest, etc.—Horizontal posture, upon back or side, both being advised at intervals. No visitors except the family and those needed. An airy room ; a window frequently opened ; temperature 650. Occasional baths of vinegar and water, etc. Mouth, tongue, and teeth to be kept as clean as possible. The excreta disinfected. 1873- Case i.—Miss C, age twenty. Fever. Oct. 29th to Nov. 13th inclusive, visited till thought convalescent. 22d, "relapse or phthisis acuta (?) R.: Tr. cinchon. co. et gentian, co., aa(?) mix ; 3i three times a day." 27th, "pulse 130; v. v., gtt. ss hourly." 30th to Dec. 6th, " pulse 125 to 130. Sibilant and moist rales. No cough." Daily visits. " R. : Tr. v. v., gtt. ii every two hours. Pulse re- duced to 100. Comfortable. Milk diet." Much emaciation. Dec. 8th to 19th, v. v. and diet continued. " Improving. Pulse 100. Rales disappearing." An unexpected recovery was complete, and was ascribed doubt- ingly to the v. v. 1882, still in good health. Case 2.—McC, girl, eight years of age. Coma-vigil, etc. Oct. 4th, pil. hydrarg., gr. iiss. Cold sponging till 6th. 1874. October 4 5 6 7 8 9 10 11 12 13 14 15 16 21 Day 1 2 3 4 S 6 7 8 9 10 11 12 13 18 PuHe.' 100 100 100 80 60 60 55 60 80 100 100 100 100 6S 6p 80 60 80 80 Temp, j J*; 1030 103° 103° 1030 101°.8 ioo°.8 99°-5 99°-5 98" 98 104 1050 1050 1050 io4°.5 I02°.8 ioi°.3 I02°.6 102°.5 102°.2 I02c.2 ioi°.8 102° 98°.S Dejecta 4 1 Tr.v. v., gtt. 12 18 10 8 8 8 8 Tr. aeon. r. gtt . 6 9 5 4 4 4 4 Case. 3.—Oct. 8th, Daniel P., colored, age nineteen years. To Oct. 15th, inclusive, fever. V. v., gtt. iss., hourly. Convalescent in seven days. Case 4.—Robert B., barber, age twenty years. Oct. 23d, not well for four days. No appetite. Headache, p.m. : pulse 100, 70, 60, 70. T. io3°.3, io2°.2, io3°.8, io3°.5, io2°.5 ; till Nov. 1, ioi°.6. V. v., gtt. 15 and 20, daily, 23d to 28th. Mild case. Nov. 2d, convalescent. Case 5.—Nov. 1875. College student, age twenty. Fever. Pulse rapid. Temperature 1020 and 1030. V. v. only. No complication. 10 A. W. NELSON. Case 6.—Vallie L., age seven. Bad privy-vault. Aug. 9, 1876. Fever. R. hydrarg. subchlorid. gr. iss and pulv. rhei. 10th, re- peat calomel, nth, ol. ricini, § ss. August Day Dejecta . V. v.. gtt. Pulse | g. Temp, g; 9 10 11 12 13 14 15 16 17 18 19 20 1 2 3 4 5 6 7 8 9 10 100 90 IOO IJO 120 "5 100 100 90 100 95 90 90 95 no 1IO 90 IOO 90 95 100 99° IOI° 102° 102° I02°.3 I02°.5 102° IOI°.2 ioi".5 IOO° 99° IOI° IOI° 104° IO40 IO40 1030 104° io3°.5 IO30 1030 i°3° IOI°.2| 1 2 2 18 24 24 24 24 24 24 24 24 1 August . 15 16 17 18 19 20 21 22 23 24 25 26 Day 1 2 3 4 5 6 7 8 9 10 11 Pulse |g. 100 100 100 95 100 90 85 85 90 90 100 100 100 100 100 85 90 95 90 Temp.-]™; ioi°.7 1030 1030 102° I02°.6 ioi°.8 I02°.S ioi°.5 I02°.8 ioi°.8 io3°.6 1030 1030 102°.6 I02°.8 102°.4 IC2° I02°.8 I02°.4 Dejecta . 2 2 3 3 1 I 2 2 3 V. v. 15 12 12 12 12 12 12 8 18 Brandy Si §i Si §i Si § i Convalescence undelayed. 1877. Case 7.—John W., age twenty. Ice fouled by sewage used in drinking-water. V, v. only. Convalescent in ten or twelve days. 1878. Case 8.—Mrs. B., widow, age forty-three. For some months in poor health from grief, etc. Aug. 15th. Fever. R. : hydrarg. subchlorid., gr. i, and mag- nesia? calcinatae. Record tabulated till twenty-third day. Mind usually clear. Much weakness, however, during entire sickness, and apprehension. Though temperature did not rise above iooc or ioo°,3 after twenty-third, convalescence was delayed four weeks. The pulse was usually weak. Quinine was given moderately, late in the case. The veratrum was given, perhaps too timidly. Aug. 31st, a day or two, ol. terebinth., gtt. xx., daily. Case 8.—Continued. August . Day Dejecta V. v. Pulse J™; Temp.jjf; :cta . 27 12 90 90 ioi°.4 I02°.4 2 18 28 I 2C '3 J' 85 | 9c 95 ; *°; 100°.5 101 102° j102 18 18 30 15 31 l6 Sept. 1 "7 2 18 3 19 4 20. 5 I 6 21 22 90 100 IOO IOO 95 95 95 95 90 90 ioo°.6 ioo°.6 IO0°.I IOO° 99°-4 I0O° IOO°.2 IOO° 102°.2 2 18 I02°.2 4 18 18 ioi°.4 18 ioi°.6 18 ioi°.4 1* IOI°.2 I02°.2 90 loo0.4 * Dejection normal. I879. Case 9.—Bad vault, bad cesspool, bad sink. Mrs. F., age forty-five ; fat. VERATRUM VIRIDE IN TYPHOID FEVER. II Sept, 12th, R. : hydrarg. subchlorid, gr. iv. Sept. 13th, ext. pilocarpi., fl. 3 i., and tinct. aconiti rad., gtt. i, hourly. Perspired freely and vomited. Coma-vigil, etc., marked. September Day . Pulse] g- Temp.jM". Dejecta V. v. 12 13 14 '5 16 *7 18 I 2 3 4 5 6 7 IOO i°5 no 90 IOO IOO IOO no 95 IOO 90 IOO 103° 1030 1030 IO20.5 1030 IO20.8 103° 1040 i°3°-5 i°3°-5 2 1040 1 103° 24 36 42 48 19 8 90 102° 3 36 Case 9,—Continued. September. Day . 20 21 22 23 24 25 26 9 10 n 12 13 '4 15 Pulse- M. noon E. IOO 95 IOO no IOO IOO 95 Temp.- M. noon 102° ioi°.5 102° I0O°.2 98° Dejecta E. 3 3 I I02°.4 3 ioi°.4 1 I 2 V. v. . . 42 42 42 48 40 36 15 Convalescence immediate. Case 10.—Edwin F., age forty-eight; stout. Bad vault. Sept. 16th, rigors. Himself advised and took six Lee's pills.1 17th, pilocarpus and aconite to sweating. Coma-vigil and delirium during sickness, and very marked weakness. September Day I M. Pulse-; noon \ E. M. Temp.-s noon I E. Dejecta . V. v. . . . 17 18 J9 20 21 22 23 24 25 26 27 29 Oct. 1 I 2 3 4 5 6 7 8 9 10 11 r3 '5 90 85 100 80 80 65 70 90 90 102° ioi°.8 85 102° ioi°.8 102° 75 ioo°,5 99° 70 70 75 70 I02°.5 IO30 103° 102° 99°-8 ioo°. 3 IOO° IO0°.2 36 48 3° 36 36 ,36 ol.nc. 36 18 12 6 ol.ric. Oct. 4th, sitting up. Recovery immediate. 1880. Case n.—John G. D., age four; bright boy, June 5th, not well several days. In bed. Quick pulse, high fever. June 6th, ol. ricini, § ss. Coma-vigil. June 5 6 7 8 9 10 II 12 13 14 Day 1 2 3 4 5 6 7 8 9 10 Puise—E. 120 "5 "5 "5 »5 "5 no IOO 90 Temp.—E. iO3.08 io4°.5 I04°.2 i°3°-5 I02°.2 IO30.2 I03°.2 IOO° 98°.6 Dejecta . 1 la rge V. v. . 6 18 18 18 18 18 18 18 12 Case 12.—Joseph B., age twenty-three years. Basement house— hygiene and surroundings very bad. June 20th, tongue brown and dry. R.: hydrarg. subchlor., gr. iij. Constipation during sick- ness very marked, and ended with it. Recovery. 1 Lee's pills = pil. cathartic, co. 12 A. W. NELSON. June 20 Day 1 (M. no Pulse \ noon (e. (M. 102 Temp. ■< noon |e. Dejecta V. v. . 18 Ol. ricini Quinine Calomel gr. 1 22 3 23 4 24 5 25 6 100 95 90 ioi°.8 90 I03°.2 I03°.2 1030 36 36 S ss. 36 3° S ss. 26 1 27 28 29 7 1 8 9 10 90 80 75 75 1030 ioi°.8 ioi°.4 IOO°.2 1 36 24 24 24 \ ss. S ss- jr. vj gr. vj, gr- vj. gr-vj. 30 July 1: 3 n 12 J 13 75 75 ! 99°.6| 990 SS. I | ss. gr.nj.igr. hj. O.iv* * Solid. Case 13.—Thomas S., age twenty-four years, bartender. Ex- posed to contents of sink-drain during removal, etc. House hygiene bad. Boards with case 9. Afternoon temperatures, 1030, or thereabout. Pulse, 80 only. V. v., gtt. xxiv, daily. June 22d to 29th, a good deal of bronchial trouble. Convalescence sudden and un- interrupted ; eighth or ninth day. Case 14.—Lydia T., mulatto, age nine years. Surroundings very bad ; disinfectants, etc., needed. June 30th, and July 1st, at school but ill; 2d, took pills ; 3d, chilly, headache, diarrhoea— went to bed. During sickness, coma-vigil. At times, restless, legs drawn up, bowels tympanitic. Tongue dry and darkly coated for first week. Several nose-bleedings. July 5th, 6th, 7th, 8th : R.: hydrarg. subchloridi, gr. ii.; bismuthi subnitratis, 3i; pulv. doveri, gr. viij. m. Chart, viij. A powder after each liquid move- ment, additional, to the v. v. This little black girl's case looked very badly. She recovered without an incident. July . . 3 4 5 6 7 8 9 10 11 12 13 14 Day 1 2 3 4 5 6 7 8 9 10 11 12 M. 120 120 120 120 no 105 IOO i°5 i°5 IOO Pulse - noon 130 K. 120 125 120 120 no !°5 TIO i°5 105 105 Temp. |M. I02°.4 I02°.3 I02°.5 1030 IOI° ioo°.7 99° 100°.6 1010 99°-9 |E. 103° 104° 102° I03°.2 1020 ioo° ioi°.4 IOI° 1000.8 99°.6 Dejecta 4 6 4 4 5 4 1 1 V. v. . 15 24 20 22 30 18 18 12 12 12 12 Case 15.—Attended by Surgeon M. C. Drennan, U. S. Navy ; myself in consultation. Harris L., age ten years, son of Dr. L., of Tenn. A brother sick of typhoid in Tenn., at the time, unknown to us. Harris was four weeks from home. Aug. 12th, not well for a week. Mother thinks he has been too much in salt water. Aug. 14th, pil. hydrarg., gr. v; 15th, quiniae sulphatis, gr. vj. Coma-vigil, etc. August. 17 18 19 20 21 22 23 24 25 26 27 28 29 Day . . . 2 3 4 5 6 7 8 9 10 11 12 J3 H Pulse] g; IOO 100 95 95 85 100 95 no i°5 80 95 90 90 110 95 90 105 i°5 IOO 95 no i°5 95 100 i°5 95 Temp.-|M.; io3°.S i°3° ioi°.s IO20 102° IO!°.2 IOI° I02°.6 ioi°.6 IOO° 9«° 99°-4 990 io3°.3 IO20.8 io3°.6 I02°.8 io3°.6 io3°.5 I02°.8 1030 io2°.g I02°.2 IO20 I02°.4 100°. 6 Dejecta 1 I 2 3 2 1 V. v. . 12 20 24 24 24 28 32 3° 40 24 8 Quinine Brandy or sherry 3 3 3 3 4 4 4 4 4 4 4 4 4 Siss S iss VERATRUM VIDRIE IN TYPHOID FEVER. 13 Case 16.—Virginia D., age fourteen years. House over a brook used to carry sewage. Sunlight shut off by high build- ings, south and west. Delirious, etc. Very sick. August Day Pulse (M. Temp.]™; Dejecta V. v. Calomel or morphia 20 21 22 23 24 25 26 27 28 29 30 3 4 5 6 7 8 9 IO 11 12 13 "5 IOO no 90 80 95 80 70 80 85 IOO 120 IOO IOO no 90 95 80 95 90 IOO 90 I02°.5 I02°.S I02°.2 ioi°.8 I020.5I I02°.2 102° ioi°.5 IOI°.2 ioo°.5 I02°.7 io3°.5 1030.5 I02°.S iO30.6 i°3°-5! i°3°'4 I02°.3 I03°.2 IOI° i°3°-4 ioi°.8 1 I I 1 2 2 3° 36 42 34 3° 42 3° 36 M.J 36 24 36 C. 1 M." Case 17.—Second case in house this season. Bad leak from privy-vault under window of sleeping-room. Foul odors. Nellie M., age eighteen. Ordinary health delicate. Aug. 18th, not well for several days. Two Wright's pills. Seidlitz powder. 19th, chills, a.m. 01. ricini, § ss ; tinct. aconiti rad., gtt. i, hourly. 20th, dysuria. Aconite continued, a.m. V. v., p.m. Coma-vigil, or delirium, with great restlessness. Twice escaped from bed. Weakness very marked. Diarrhoea. 7th, 8th, 9th, 10th, nth, 12th, 13th days, R. : hydrargyri subchlorid., gr. i; bismuth, subni- tratis, 3 ss ; pulv. ipecac, gr. i; pulv. opii, gr. ij. m. Chart, xij. A powder after each liquid movement. V. v. being continued. Headache. Nasal bleeding. Tympanitis. August . . . 20 21 22 23 24 25 26 27 28 29 3° 31 Sep. 1 2 3 4 5 6 7 8 9 10 11 12 13 M M. 90 100 95 90 100 8.5 IOO 95 80 85 75 75 Pulse- N. 80 R. IOO 90 90 100 90 80 90 95 9S„, 80 80 «5 M. ioi°.s I02°.5 ioi°.5 I02°.8 I02°.9 I02°.8 I02°.2 I03°.2 101°.6 ioi°.3 IOI° 98°-5 Temp.- N. 98°-5 >K. 102°.5 I02°.5 I02°.8 io3°.6 I02°.S 102° I02°.3 I02°.6 I02°.8 IO20 IOI°.I ioo°.5 Dejecta . . . 3 4 4 4 3 4 5 6 3 5 4 6 2 V.v.,gtt. . . 12 32 42 3° 42 30 24 36 24 24 30 15 Quinine, gr. . 6 Chloral, gr. . 15 Brandy . . . Sss § i 5" S SS S ss After Sept. 12th, convalescence without incident. 1881. Case 18.—Fred. C, age thirteen. Delicate boy. Overflow of cesspool. July 3d, chills. 4th, afternoon, pulse no; tempera- ture 1040. Mother thinks he has worms. Santonin and calomel in small doses. 5th, p.m., 1040. 6th, 7th, 8th, "fever." July Day 1 I02°.S i°3°-5 24 10 7 I02°.S 36 II 8 1000 102° 36 12 9 99° 102 ° 36 13 10 99° 102° 36 14 II IOI° 36 15 12 IOO° 36 16 *3 Temp. IM. IS: 98°.5 12 Case 19.—Thomas E., coal-heaver, age forty-three. Bad sink, 14 A. W. NELSON. pipe without trap goes to unventilated sewer, odor very bad, there- from in the living-room. Aug. 6th, overworked and overheated. Aug. n, in bed, headache, etc. Aconite, gtt. i hourly. Coma- vigil, etc. August . . . Day..... (M. Pulsed N. U. ;m. Temp Dejecta V. v. . . Calomel, gr. (M. >.-{N. E. II 12 '3 14 15 16 J7 18 '9 20 I 2 3 4 5 6 7 8 9 IO IOO 80 95 «5 85 80 75 9° 90 90 85 80 102° 1030 io3°.6 1030 1030 I02°.7 102°.8 I 102° 102° 102° IOO°.2 I 12 24 24 24 32 40 36 36 3° 2 I h 70 99°-3 2 18 Case 20.—Geo. H., age twenty-five, steam-engineer. Aug. nth. feverish two days. Ext. pilocarpi, fl., 3 i; tr. aconiti rad., gtt. i, hourly, and hydrargyri subchloridi, gr. ii, twice. Aug. 12th, p.m., pulse 100, temperature 1040. 13th, 14th, temperature 1020. 15th, p.m., 1030. After that,ioi°. Pulse from 13th being 80; v.v., gtt. xx daily. 23d, 25th, 27th, quinine, gr. vi. Malarial (?). Case 21.—Mary E., age twenty-six, single, nurse-maid. Aug. 13th, been ill a week or so about the house. Sleepless at night. R.: lithii bromidi, gr. v, nocte. 16th, for diarrhoea, R.: hydrargyri subchloridi, gr. ij; bismuth, subnit., 3 i; pulv. ipecacuanha?, gr. i; morphiae sulphatis, gr. i. m. Chart, xv. A powder after each movement. One powder, also, 17th and 18th. 22d and 23d, took tinct. opii, gtt. xx, and ol. terebinth., for diarrhoea. Coma- vigil, delirium, great weakness. Movements a few times without consciousness. Dejecta offensive. August . . . 13 14 15 16 17 18 19 20 21 22 Day .... 3 4 5 6 7 95 g 9 85 IO S^- 100 85 Pulse- £• IOO 95 6s I E. 100 IOO IOO no 105 80 90 65 8S f^ 1030 1030 102° I03°.2 Temp. - £' 103° io3°.7 IO20.5 E. 1030 1030 I04°.5 104°.8 I03°.2 io3°.7 I03° 102° io3°.4 Dejecta . . . 5 1 I 3 2 7 V. v..... 8 20 20 24 30 36 40 42 36 20 Case 21.—Continued. August Day . M. (M Pulsed N |E Temp Dejecta V.v. . (M. 23 II 80 24 12 80 25 13 70 26 14 90 27 15 28 16 29 17 85 30 18 80 ioi°.5 85 IOO°.2 90 IOI° 85 ioo°.7 75 70 990.4 75 102° I02°.8 102° 101°.6 ioi°.4 ioo°.3 99°.2 I I I 1 1 1 1 30 3° 24 30 24 20 18 Sep. 1 20 85 99°-7 VERATRUM VIRIDE IN TYPHOID FEVER. 15 Sept. 5th, went home to Bridgeport against advice. No harm, however. Case 22.—Mrs. B., Swede, age twenty-eight. Acclimated. Eight years ago had ague. Her husband just recovering from a severe attack of typhoid. His pulse, though about the house, 115. Weakened heart. Quite as much trouble as she. He was treated with neutral mixture and quinine. Mrs. B. worn out taking care of him. Vault and cesspool and sink all bad. Coma-vigil, etc. Oct. nth, hydrargyri subchlorid., gr. iij ; ol. ricini, tinct. aconiti rad., gtt. i, hourly, etc. October Day Dejecta V.v. . . Calomel, gr Pulse] g; Temp.jg; II 12 13 14 15 16 17 18 I 2 3 4 5 6 7 8 95 90 90 85 90 85 «5 90 90 I02°.3 I02°.3 I°3°-5 102° 102.°s ioi°.s I03°.3 io3°.3 2 io3°.3 1 12 3° 14 24 24 30 32 I* i* 19 9 95 1030 32 Case 22.—Continued. October . . Day . . . Pulse ■ Temp. ] Dejecta V.v. . . Quinine Calomel, gr. 20 21 22 23 24 26 28 IO II 12 13 14 16 18 80 80 85 IOI°.2 85 90 90 102°.4 I02°,3 102° ioi°.s IOI°.2 I I I 32 32 3° 3° 30 24 6 2 24 6 I Convalescence immediate. Case 23.—John M., age thirty-four, teamster. Sleeping-room, eleven feet square, had an untrapped sink connected with an un- ventilated cesspool; self, wife, and child occupied the room at night, without a Avindow open. Oct. 17th, p.m., pulse 95, tempera- ture 1040. With v. v., gtt. xxiv, daily, it remained, p.m., 1020,1010, ioo°, till it became 98°.6, Nov. 1st. Case 24.—Isadore M., age seventeen, clerk, delicate. Vault close to house, uncemented, foul. Oct. 28th.—Rigors for several days. R.: hydrargyri subchlorid., gr. ijss. a.m. Ext. pilocarpi, fl. 3 i, p.m., with free sweating, vom- iting, and movement. Night of 28th and 29th, sinapisms for pain in lower back. During sickness tympanitis and nose-bleeding, coma-vigil and wandering. October . 28 29 30 31 Nov 1 2 3 4 5 6 7 v>ay . (M. 1 90 2 80 3 90 4 S 6 80 7 80 8 9 10 11 Pulse. N. 8S 80 6s 6.5 75 |e. 90 95 90 85 «5 85 80 85 75 70 70 1 M. 1010.6 iO30.6 103°.4 ioi°.9 Temp. Is. i°3°-7 io3°.8 ioi°.8 IOI° IOO°.2 |e. 104° 1040 1040 I03°.2 1030 1030 I02°.S 102° IOI° ioo°.6 990.6 Dejecta 1 1 1 2 I 1 V. v. . 24 36 24 3° 30 36 30 24 20 18 i6 A. W. NELSON. Convalescence immediate. Case 25.—Matthew V., age fourteen and a half; slender. "Not well for a week. Over-ate, five days ago." Nov. 23d, 8 p.m., chilly. R.: hydrargyri subchlorid. gr. iij. Tr. aconiti rad. gtt.j, half hourly till sweating. 24th, 9 a.m. perspired freely, and dur- ing night. 01. ricini, § ss. and tr. aconiti rad., p.m. R.: Hy- drargyri subchlorid., gr. iss. Coma-vigil, etc. ; unconscious of calls of nature much of the time during sickness. Tympanitis, sorites. A bad case ; recovery hardly expected, emaciation ex- treme, bed-sores barely prevented. November . . Day . . . . Pulse- Dejecta V.v. Temp. ] Calomel, gr. 23 24 25 26 27 28 29 3° Dec. 1 2 3 I no 2 100 no 3 95 90 4 85 80 5 90 90 6 75 80 7 80 80 8 80 90 9 75 70 IO 75 80 11 80 85 I04°.4 1040 103°.6 io3°.8 I02°.8 102° 102°.7 I02°.6 ioi°.9 ioi°.9 io4°.5 1040 io4°.8 103°. 5 103°.6 104° I02°.7 102°.8 I02°.I 1030 102°.5 1 6 2 3 I 1 2 1 2 10 36 1 ol.ric. 30 36 3° 3° 30 30 36 34 3 15 1 Sss. 12 85 70 102° ioi°.7 36 Case 25.—Continued. December . . . Day..... Pulse ]^ Dejecta V v . Temp. ] V. Tr. digitalis, gtt Quinine, gr Whiskey Calomel 5 6 7 8 9 10 11 12 13 1 13 14 15 16 17 18 *9 20 21 85 «5 90 95 90 90 100 95 95 85 85 90 90 90 100 105 100 no ioi°.6 ioo°.7 IOI° ioi°.7 ioo°.3 IOO° IOI° ioo°.7 ioo°.6 101°.4 IOI° ioi°.6 1 ioo°.7 99°-7 1 IO20.I ioi°-4 101°.2 1 toi°.8 1 36 3° 24 12 20 12 6 16 12 6 l6 12 6 24 6 3° 30 Siss ( ol.ric. Siss Siss Sij Siij S»j 2 1 Sss. 95 100 99°- »J 15 23 16 24 85 70 ioo°.7 98°.i 1 5iii S»j Took his whiskey with milk. No delay of convalescence. "J Case 26.—Mrs. G. widow, age forty-six ; fat. Sept. 14, feverish for two days. R.: hydrargyri subchlorid.; gr. iij ; tinct. aconiti rad., gtt. i, hourly, etc., for twenty-four hours. Pulse from 100 re- duced to 90. Skin moist, coma-vigil, wandering during sickness, very weak. V, v.. gtt. 30 to 36, daily, from Sept. 16th to 24th, Pulse 80; temperature morning and evening, 1040,1030,1020, 1000. and 12th, or 13th day, 990 and convalescent. Case 27.—Miss L., age twenty-six, operative. Mill exposed to emanations of sewer-outlet, etc. Sept. 17th, rigors ; not well for five days ; four Brandreth pills, one dejection. VERATRUM VIDRIE IN TYPHOID FEVER. 17 September . 18 19 20 21 22 23 24 25 26 27 28 Day . . . [M. i 2 3 4 5 6 90 7 95 8 9 90 10 90 II 80 Pulse- ■1 ,M. IOO 96 ioo 90 96 90 102°.3 102° 90 85 9° 101°.9 90 ioi°.6 ioo0.5 Temp.- k i°3°-5 I02°.7 102°.5 IO20 102° I02°.3 101°.9 ioi°.s ioi°.g ioi°.4 Dejecta . . 1 3 24 24 24 24 24 24 30 3° 3° 20 V. v. . . . 18 i ol.ric. 1 S«s Case 28.—Wm. McCl., age twenty-five, sailor. Sick five days at sea. Sept. 25th, p.m., pulse 100, temperature 1020. Brought ashore. 26th, etc., pulse 80 ; temperature 1020, io2°,5, etc., V. v. daily, 30 and 36 drops, till Oct. 2. Diarrhoea 26th, 27th, and 28th. R.: hydrargyri subchlorid., gr. ij ; bismuth, subnitratis, 3 ss ; pul. ipecac, gr. iss.; morph. sulph., gr. i. m. Chart, xv. A powder three or four times daily, during diarrhoea. Oct 3d, convalescent.