>?ilaB*1*B#c3?V*;v«r«*^, •* ^ (rsm^sastessss^ .y-SJV^i NLn 001522M0 2 NLM001222402 PARESIS (MEOtCUSj OF THE SYMPATHETIC CENTERS FROM OVEREXCITATION BY HIGH SOLAR HEAT, LONG CONTIN- UED AND SUDDENLY WITHDRAWN, ETC. SO-CALLED MALARIA; ITS ETIOLOGY, PATHOGENESIS, PATHOL- OGY AND TREATMENT. BY ./ CHARLES T. REISER, M. I>'giJJ>>v U7 - ST. LOU IS : GEO. O. HI'MP.OLl) &('(). 1«79. I87£) PREFACE, The aim of this work, is to establish the truth in regard to the nature of the derangment of the human organism, usually described under the name "malarial or malarious diseases," "malaria/' "palludal poisoning," and "marsh miasma." In or- der to accomplish this object, meteorological influences have, to some extent, been considered. The domains of Natural Philosphy, Chemistry and Physiology have also contributed a few of their precious facts, to assist in the elucidation of this extremely complex question. Want of time has prevented a fuller elab- aration. Should this [obstacle be removed, at some future period, and should the subject then seem to require it, a more complete presentation may be undertaken. This work has been done amidst the perplexing cares of heavy professional duties. The sense of the necessity of an investigation of the subject, is the result of thirty years personal experience and observation, in regions of country specially favoring the prevalence of the disease. vi PREFACE. The liberal quotations, from several works of great merit, were deemed absolutely necessary in order to present the subject in the best and most impartial light. Thirty years of practical experience has fully dem- onstrated an imperative need of a more advanced and scientific presentation of the etiology and pathogen- esis of this disease. Chas. T. Reber. Shelbyville, HI. CONTENTS. CHAPTEE I. Suggestive Thoughts CHAPTER II. Investigation on Conduction op Heat. . 11 CHAPTER III. Insolation and Refrigeration ... 24 CHAPTER IV. Introductory Remarks.....27 CHAPTER V. Human Temperature.....30 CHAPTER VI. Relation of the Temperature Centers to the Vaso-motor Centers .... 32 CHAPTER VII. Rejection of Obsolete Terms ... 35 CHAPTER VIII. Animal Temperature ; Its Relation to Health, etc........38 CHAPTER IX. Reasons for Progress.....41 CHAPTER X. The Sympathetic Centers .... 44 CHAPT BR XL The History of the Theory of Heat . . 46 CHAPTER XII. Animal Quinoidine.....47 viii contents. CHAPTER XIII. Predisposing and Exciting, and Special Excit- ing Causes ...... 53 CHAPTER XIV. Irritability of the Nfrvous System . . 55 CHAPTERXV. Abnormal Irritability.....58 CHAPTER XVI. Excitation Paresis.....60 CHAPTER XVII. •Condition of Air—Effect .... 62 CHAPTER XVIII. Fjffect of Topography on Solar Heat and Thermal Diseases.....65 CHAPTER XIX. The Theories of Decomposition, Fermentation, etc........ 70 CHAPTER XX. Pathology and Symptoms .... 73 CHAPTER XXI. Type—Rhythm—Mode—Form ... 82 CHAPTER XXII. Diagnosis.......87 CHAPTER XXIII. Treatment.......95 CHAPTER XXIV. Location of Sick Room, the Bed, the Linen, and Posture of the Pataent . . Ill CHAPTER XXV. One of the Causes Why New Views are so Slowly Accepted.....112 THERMAL PARESIS; OR THE SO-CALLED MALARIA. CHAPTER I. suggestive thoughts. ***** * * # # * "In the elevation of temperature that takes place during a paroxysm of fever, however, it is not merely a matter of increased production of heat and dimin- ished loss of heat, but we have to do with a modifica- tion or disturbance of the power that regulates the heat of the body, by which disturbance, according to Liebermeister, the average grade of temperature is raised to a higher point than is normal. This has given occasion to a belief in the existence of a special center presiding over the regulation of animal heat. Whether this is an excito-caloric or a moderating cen- ter, or whether it possesses a double character, this much seems to be certain, that in fevers, and espe- cially in intermittent fevers, this nerve-center is so af- fected by the specific malarial poison that it is dis- turbed in its functions, either momentarily or for 10 THERMAL PARESIS. some time, whereby intermissions and remissions are produced. A certain number of the manifestations that accompany the fever, headache, dizziness, ma- laise, violent trembling and convulsions, etc., are either likewise dependent on the direct influence of the malarial poison on the central nervous system, or must be regarded as results of the increased supply of heat in the body, and as the effect of the heated blood on those nerve regions."1 I will only add what, indeed, every physician knows in regard to what is stated in the last clause above quoted, that the manifestations alluded to may be, and commonly are present, before any increased heat supply has taken place—prior to the fever. 1. Hertz, in Ziemssen, Vol. II, pp. 632-633. CHAPTER II. INVESTIGATIONS ON CONDUCTION OF HEAT. " Why does not cold wood produce an action equal to that of the cold metal ? Simply because the heat communicated to it is accumulated at its under sur- face; it cannot escape through the bad conducting wood as it escapes through the metal, and thus the quantity of heat withdrawn by the wood is less than that withdrawn by the copper. A similar effect is produced upon the human nerves. When you come into a cold room and lay your hand upon the fire- irons, the chimney-piece, the chairs and the carpet, in succession, they appear to be of different tempera- tures ; the iron chills you more than the marble, the marble more than the wood, and so on. It is needless to say that the reverse takes place when we enter a hot room, that is to say, a room hotter than your own body. You would certainly suffer if you lay down upon a plate of metal in a Turkish bath j but you do not suffer when you lie down on a bench of wood. By preserving the body from contact with good conductors, very high temperature may be en* dured; eggs may be boiled and beefsteaks may be cooked by the heat of an apartment in which the bod- ies of living men sustain no injury. Blagden and Chantrey exposed themselves in ovens to tempera- 12 TEERMAL PARESIS. tures considerably higher than that of boiling water. Let us compare the condition of the two living human beings with that of two marble statues placed in the same oven. The statues gradually become hotter, until finally they assume the temperature of the air of the oven ; the two men under the same circum- stances do not similarly rise in temperature. If they did, the tissues of the body would be infallibly de- stroyed,, the temperature which they endured being more than sufficient to stew the muscles in their own liquids. But, the fact is, that the heat of the blood is scarcely affected by any augmentation of the ex- ternal heat. The heat, instead of being applied to increase the temperature of the body, is applied to change the aggregation of the body ; it prepares the perspiration, forces it through the pores, and, in part, vaporizes it. Heat is here converted into potential energy; it is consumed in work. This is the waste- pipe, if I may use the term, through which the ex- cess of heat overflows; and hence it is that, under the most varying conditions of climate, the temperature of the human blood is practically constant. The blood of the Laplander is sensibly as warm as that of the Hindoo; while an Englishman in sailing from the north pole to the south, finds his blood hardly height- ened by his approach to the equator, and hardly diminished by his approach to the Antarctic pole. When the communication of heat is gradual—as it always is when the body is surrounded by an imperfect conductor—the heat is consumed in the manner indi- CONDUCTION OF HEAT. 13 cated, as fast as it is supplied, but if the supply of heat be so quick, (as it would be in the case of contact with a good conductor) that the conversion into this harm- less potential energy cannot be executed with suffi- cient rapidity, injury to the tissues is the result. Some people have professed to see, in this power of the liv- ing body to resist a high temperature, a conservative action peculiar to the vital force. No doubt, the ac- tions of the animal organism are connected with what we call its vitality; but the action here referred to is the same kind as the melting of ice, or the vaporiza- tion of waters. It consists, simply, in the diversion of heat from the purpose of temperature to the per- formance of work."1 The foregoing remarks on con- duction of heat, etc., from a lecture by Sir John Tyn- dall, furnishes a beautiful and important statement of facts bearing on the subject of the effect of heat upon the living human body. But they are incomplete, and unreliable, because the action of the vital and nerve forces is ignored. The fact that perspiration and vaporization are actively engaged in cooling the body, and, so to say, insulating it from the heat of the surrounding air, while it is yet 20° F. below that of the body, has been ignored or overlooked; while the temperature of the air is below 98° F., there is, of course, no conduction of heat from it to the body; yet, as is well-known, there is profuse perspiration and vaporization, when even the temperature of the 1. Tyndall. On Heat as a Mode of Motion. 14 THERMAL PARESIS. air is still many degrees lower than that of the body. Perspiration and vaporization are, therefore, not the " waste-pipes" by which the body relieves itself of heat communicated to it from the air, since no heat has yet been thus communicated. The fact no doubt is, that perspiration and vaporization are, in the proper sense, vital processes, set in action in a reflex man- ner by the sense of heat imparted to the sentient nerves of the surface, and from thence transmitted to the sympathetic nerve-centers, stimulating or ex- citing them in such a manner as to cause perspiration and vaporization by means of the reflex activity of the vaso-motor nerves. Truly, as Mr. Tyndall says, tl the flesh of the body would be stewed in its own liquids," if the heat to which men subject themselves were permitted to come in actual contact with their bodies. The force of this fact has not been fully ap- preciated. It is not that the air is not a good enough conductor to blister the skin if brought into actual contact at a temperature of 212° F. I have been in a Turkish bath heated to this degree, but perspira- tion and vaporization did not allow any air hot enough to blister to come in actual contact with the surface of my body. The truth no doubt is, that the excessive heat of the air is cooled, mainly, on the out- side of the surfaces of the body, and is not " changed into potential energy in passing through it—is not applied to change the aggregation of the body." It is, therefore, not the application of heat to the nerve-centers that causes their excitation and subse- DEFENSE AGAINST HEAT. 15 quent exhaustion and paresis; the nerve-centers are excited chiefly by an impulse given upon the surface by excessive heat, and transmitted to them through the nerves. Consequently, the concluding statements quoted above do not embrace the whole truth, and are even in part erroneous, in assuming " that the ac- tion referred to is the same in kind as the melting of ice, etc.," and "that it consists simply in the di- version of heat from the purposes of temperature to the performance of work." There is a very active effort by the nervous system to protect the body against the entrance of heat (by means of surface moisture and vaporization), rather than for the pur- pose of changing or consuming heat in the body. It is incorrect to assume that the "perspiration is prepared, forced through the pores, and in part va- porized " by the heat communicated to the body from the surrounding air. All the heat requisite for these purposes is unquestionably furnished by the same process as that which evolves animal heat under ordinary circumstances. Nor can this process be sus- pended without deranging the function of nutrition, as it would result in impairing the healthful degree of oxidation required for normal tissue change, so that it becomes evident that the human body neither re- quires, nor can it safely permit, any considerable or even appreciable amount of heat to be communicated to it from the air. In a room heated to only 80° or 85° F., we feel quite uncomfortable, although this is a temperature considerably below the normal tempera- 16 THERMAL PARESIS. ture of our bodies; the discomfort, no doubt, being due to the difficulty the body encounters in relieving itself of the amount of heat usually lost in the in- sensible perspiration and ordinary surface radiation. In these considerations on the subject of conduc- tion of heat, the quality of the living human body as a conductor does not seem to have been taken into account. It seems, however, to have been taken for granted that the heat was received by the body, else it would not have been necessary to account for its disappearance from the body, " converted into poten- tial energy, it is consumed in work," is the language used. There is, however, no statement as to its con- ducting capacity. Liquids are non-conductors even under ordinary circumstances, and if their particles are of extreme mobility, as in the circulating blood, its conducting power is surely not enhanced. In the surface capil- laries it may also be likened to a spray, and in this condition its conducting power or power to receive heat must be entirely negative. Then, again, the in- numerable thin partition walls of heterogeneous, me- chanical or physical texture, moistened on all sides by the rapid blood-spray currents, must have an ex- tremely low conducting capacity. By placing a piece of asbestos on the hand, a red- hot ball of iron can be supported without inconven- ience, in consequence of the bad conducting capacity of the asbestos, which is due to the especial texture of that substance. This being true of this fixed min- EFFECT UPON NERVOUS SYSTEM. 17 eral silicate, what, indeed, shall be said of the integu- ment of the human body (a heterogenous, elastic, mo- bile, vascular compound) as a conductor of heat, ad- mirably fitted for vaporization and radiation of heat, but not at all so for its reception ? But this is not all. The healthy, living human body makes an ac- tive vital defense against the introduction of heat. "In fact, we are sure that elevation of temperature and relaxation of arteries cannot exist with any other than a paretic condition of the sympathetic. Taking first for consideration the ordinary low or asthenic fevers with which we are familiar, let us see how far we can account for their phenomena, on the assump- tion that the poisonous miasma has weakened the vaso-motor system, as well as the others. The in- creased temperature, the quick, but soft and weak pulse, the hyperemias of various viscera, may all, ac- cording to the foregoing views, be regarded as nat- ural results. The increased secretion of urea may be accounted for partly by the augmented chemical changes which take place in the mass of the blood (considered for the time as a solid tissue) uncontrolled by the sympathetic nerves, and partly by the in- creased amount of renal action depending on the same cause. (Oppler has shown that the kidneys actually form a considerable portion of the urea secre- ted.) The hypertrophy which affects the glandular solitariae and agminatse in typhoid may also be traced to the same nervous paresis, and may be regarded as 18 THERMAL PARESIS. analogous to the enlarged spleen of ague or the goitre of Swiss malaria. " To regard this hypertrophy as an attempt at elimi- nation seems to me quite a mistake. It is no more to be considered such than the enlargement of the cor- related mesentric glands is, which takes place at the same time. Both are similar structures, and both hy- pertrophy under the same conditions, viz.: hyperemia and loss of nerve influence. The condition of the other systems in low fever quite corroborates our as- sumption as to the condition of the sympathetic. The quiet, muttering delirium, the unconsciousness or half unconsciousness, testify how the brain is enfeebled, while the down-sunken posture in bed, and the sub- sultus reveal the extreme muscular debility. The feebleness of the heart's action, and the softening of its texture, prove how the vital energy is depressed. The readiness of the skin to slough shows how its nutritive power is impaired. In certain cases it seems as if the sympathetic system was but little impaired, and the main stress of disease fell upon the cerebro- spinal. * * * It was very curious to see a patient with a skin of a natural temperature, a per- fectly natural pulse, tranquil respiration, clear eyes, no headache, a soft and fallen abdomen, incoherent, or with a low muttering delirium, excessive subsultus, extreme debility. " 1st. The almost universal prevalence of these dis- eases in all parts of the world is a striking fact. Most intense and widespread in the tropics, where the ma- ACTION OF SO-CALLED MALARIA. 19 larious influence sets its stamp on almost all morbid action, it prevails as far north as 62°. 2nd. The apparent absence of anything special or peculiar in the conditions which give rise to it. Moisture and warmth seem to be the efficient cause of this strange malignant influence. A soil, or even a rock, needs but to have been wet and to undergo drying to be- come a source of disease. Even drying wood is ade- quate to produce the miasm. I am aware that evi- dence has been collected to show that ferruginous soils are eminently prone to generate malaria, but it cannot, I think, be contended that this fatal quality is peculiar to this kind or to any. Rather, it seems like the fulfillment of the original curse pronounced on the ground for man's sake. Excess of water and complete dryness arrest the development of malaria, indicating plainly that the formation of the poison is somehow connected with the act of drying. 3rd. The obscure (but obvious) relation between malarious dis- eases, influenza and cholera, and the much greater prevalence of these disorders in some years than others. 4th. The very various diseases which ma- laria commonly produces, as fever, neuralgia and dys- entery. These may stand as representatives of the chief kind of morbid action, showing how multiform may be the phenomena which spring from this origin. 5th. The especial predilection of malaria for the ner- vous system, and the vast, almost endless variety of disorders it is capable of generating through the in- termedium of this system. This circumstance, and 20 THERMAL PARESIS. the consequent tendency of ague to be associated with peculiar, anomalous and alarming symptoms, as in the so-called pernicious fevers, give a deep interest to the study of malarious affections. * * * It is quite clear, therefore, that a practitioner should be well acquainted with the manifold manifestations of malarious intoxication if he desire to meet the require- ments of his day. It is by no means sufficient to know how to manage a tractable, well-behaved ague; we should be prepared for a variety of strange, anom- alous and puzzling forms of disorder which will be sure to perplex us if we have no clue to guide us to comprehend them. This clue will be found (1st) in a, knowlege of the laws of neuropathology as devel- oped by Bernard and others; (2nd) in an acquaintance with the action of malarious influence on nervous tis- sues. * * * With regard to the second topic, it may be remarked that the phenomena from which we have to judge do not all present the same char- acter. The contracted vessels and skin, and the rig- ors of the cold stage of ague, appear to evidence a stimulation of vaso and muscular motor nerves, while the increased temperature, the full pulse, the flushed surface, and the dilated vessels of the hot stage, all show the existence of a state of paralysis of nervous and muscular tissues. "The diarrhoea, dj^sentery, splenic, hepatic or thy- roidal enlargements which are so frequently produced by malaria, can only be interpreted as results of dila- ted and paralyzed arteries, and consequent excessive ACTION OF SO-CALLED MALARIA. 21 flow of blood to an enfeebled tissue. In some cases,. paralysis of some of the voluntary muscles has re- sulted from exposure to malaria. * * * The general conclusion from these facts clearly is that the action of malaria is mainly paralyzing, though its operation may sometimes appear to be stimulating. I say appear, for I am very much disposed to think that the stimulation is only apparent, and this for two rea- sons. First, the voluntary power is certainly weak- ened, and the quasi-spasmodic contraction may pro- ceed much like those of chorea from a state of undue mobility and excitability of the nervous centers. Secondly, there is certainly, as I can testify from personal experience, a remarkable hyperesthesia of the cutaneous nerves, which are far more sensitive to cold than in the healthy state. This hyperesthesia as well as the motor disorder may result from pare- sis of the centers according to the general law, that power and excitability vary inversely. It is by no means improbable that the whole train of disorders may result from a primary vaso-motor nerve paresis, giving rise to increased heat of the blood, which then might produce at first an unhealthy irritation of the nervous centers, issuing sooner or later accord- ing to the quality of the nervous power in exhaus- tion and paralysis. It is well-known that increased heat of the blood is one of the earliest occurrences in fevers. However this may be, whether the spasmodic phenomena result from fevered blood, or from the direct action of the poison, there is no question that 22 THERMAL PARESIS. the stimulation is of an unhealthy and injurious kind, and that we have in the co-existence of the appar- ently differing phenomena above mentioned another proof of the connection existing between spasm and paralysis. The result of the action of malaria may probably vary a good deal according to the idiosyn- crasy of the individual, and according to the virulence of the poison itself. Just as to some persons a moderate dose of opium proves a powerful stimu- lant, while in others it causes more or less power- lessness, so it may be with malaria. Beyond any doubt the prolonged operation of malaria has a re- markably enfeebling and lowering effect on nerve power, both the cerebro-spinal and sympathetic sys- tems."1 I deem it to be impossible to add anything to im- prove the demonstration of the importance of the sub- ject. The fact that the cause of the disease produces its evil results by way of paresis of the nerve-centers is also demonstrated beyond question. However, the statement "that excess of moisture, and complete dryness, arrest the development of malaria." is not universally true. (See Oldham, "What is Malaria "; Humboldt, "Narratives," chaps. xvi, xx and xxv, pp. 66, 67, 242 and 575; Tristram, " Travels in Sahara," 287; Davy, " Ionian Islands and Malta," 247; McKinnon, "Climatic Fevers," Reports, Royal Commission in India; Hertz, in 1. Clinical Observations on Functional Nervous Disorders. By C. Hanfield Jones. 1867. pp. 34-35. NEUROPATHOLOGY. 23 Ziemssen's cyclop., Yol. II, pp, 564-584; Hammond's " Hygie;.e "). The paths pointed out for complete elu- cidation of this subject—"a knowledge of neuro- physiology and neuropathology, and an acquaintance with the action of malarious influence on nerve tis- sue" cannot but lead to correct and beneficial results. CHAPTER III. INSOLATION AND REFRIGERATION. Dr. Kirchner has recently carried out a series of experiments on animals with a view to gain an in- sight into the pathogenesis of the two allied processes, insolation and refrigeration. He deduces from them that the latter may be characterized as prostration of the vital forces, and, first of all, of respiration and circulation. The morphotic and chemical alteration of the blood resulting therefrom, particularly its im- poverishment in oxygen, is the immediate cause of the derangements that directly threaten life. Warmth, on the other hand, acts an as irritant on the animal organism, and when in excess leads to exhaustion. This constitutes the essence of insolation. As in the case of refrigeration, the foundation of the symptoms is the exhaustion of the oxygen of the blood, which here too is the consequence of failing respiration and circulation. The appearance of rigidity during ex- posure, either to cold or heat, indicates excessive lack of oxygen in the blood. This rigidity is like the rigor mortis, an anemic muscular tetanus. * * * The deleterious action of extreme temperatures on the organism is heightened by other weakening in- fluences which tend to impair the supply of oxygen and to exhaust the resisting power of the system. INSOLATION AND REFRIGERATION. 25 Here must be mentioned particularly the misuse of alcohol. In addition to these acute effects of cold and heat, there are analogous chronic conditions, which must be ascribed to the gradual action of ex- treme temperatures in the organism. They are char- acterized by manifestations of anemia and exhaustion, and their higher grades partly constitute the basis of the tropical and polar cachexia. It is still an open question whether any other specific diseases owe their origin to the influence of heat and cold. The fact that abdominal typhus occurs more frequently during the latter part of summer and towards the end of winter, has not yet been satisfactorily accounted for ; and, as in many eases, no external source of infec- tion can be discovered, it is, in fact, possible that the morphotic and chemical alterations of the blood and tissues, which have been proved to be the patholog- ical effects of insolation and refrigeration, play at least a subsidiary role in the production of the infec- tion.1 Dr. Kirchner mentions as the effect of refrigera- tion, "prostration of the vital forces, and first of all, respiration and circulation." If this does not mean depression or exhaustion of nerve power it is impos- sible to discover what it does mean. Warmth, he says, acts as an irritant on the animal organism, and when in excess leads to exhaustion, and that " this consti- tutes the essence of insolation." Then comes this con- tradictory sentence (which is probably a mistransla- 1. Allg. Med. Cent. Zeit,^o. 47, 1878. 26 THERMAL PARESIS. tion): " The foundation of the symptoms is the exhaus- tion of the oxygen of the blood, which is the conse- quence of failing respiration and circulation." He obviously intends to state that exhaustion of the vital (nerve) force results: (1) in impaired respiration and circulation, (2) deficient supply of oxygen to the blood. " The foundation of the symptoms," there- fore, is the exhaustion of the vital (nerve) force, and not the exhaustion of oxygen of the blood, which evidently is but an effect. There is a strange overlapping of what may be called the intermediate effects of the exhaustion pro- duced by heat, passing at once from " insolation " to the " chronic cachexia." It is not at all likely that the stage of chronic cachexia can often be reached with- out previous disturbances occurring, sufficiently well marked to require attention ; cases that reach this stage without active manifestation of disease are very rare exceptions to the general rule. Such can hardly be possible, since deficiency of oxygen in the blood means also excess of carbonic acid, which, when in very moderate excess, is a cardiac and re- spiratory stimulant, producing fever, and when in great excess, results inevitably in phenomena that could not be overlooked. The so-called malarial diseases fill the omissions alluded to, between insolation and chronic tropical cachexia. INTRODUDTORY REMARKS. 27 CHAPTER IY. INTRODUCTORY REMARKS. What do we know of things that we do not perceive by our senses ? Let us imagine ourselves blind and deaf, and without the senses of smell and taste, possessed of a general sense of feeling only—what would we be able to learn ? How much could we know of any subject ? This is our condition in regard to heat—to it we are blind and deaf; neither do we smell or taste it. The opinion commonly held, that we can taste heat, is a mistaken one. We only feel it in the mouth, as on other parts or surfaces of the body. We call this sensation warmth or heat. It is only through a certain range of temperature that we know heat by our own sensations or feeling, as is well shown by the fact that a very hot object applied to the body, un- recognized by our special senses, may cause a sensa- tion of extreme cold, or pain, and an extremely cold object may cause a sensation of burning or pain only. We may as well admit, at once, that we know but little of heat by means of our senses—our perceptions —and that very nearly all that we know of its proper- ties and power we have learned by observing its ef- fects. The observation has been made, and proved by experiment, that heat causes or is changeable into 28 THERMAL PARESIS. light, mechanical motion, chemical action, electricity and magnetism, and that it maj^ be active, sensible, or at rest—latent. These suggestions show the difficulties which are in the way of a full and correct knowledge of heat, and these difficulties are here, only hinted at. To appreciate them fully it is necessary to study the subject of heat more in detail. It is necessary to in- vestigate the subject of solar heat and its various phenomena, its source, quantity, effect, radiation, reflection, refraction, convection, conduction, etc. This leads us to the questions or facts of the dew point, rain, evaporation, frost, congelation, thermo- electricity, thermodynamics, specific heat or capacity for heat of different substances, or the same substance in different circumstances, and its effect upon vege- table and animal life and growth. These remarks are made with the design of calling attention to the interesting phenomena and astonishing effects of heat, which cannot be appreciated without a diligent study of the more recent works on physics and chem- istry. Our task is to ascertain the effect of solar heat upon the human body In order to do this it is necessary to take into ac- count the properties and influences of the atmospheric air, and the source, production and regulation of ani- mal heat, and the absorbing, conducting and radiating power of the living human body, whose normal tem- perature is 98° F. Where does this heat come from, EFFECT OF SOLAR HEAT. 29 how is it formed, how does it happen to be maintained under so many and so great differences in tempera- ture of the surrounding atmosphere and other dis- turbing influences ? We know that friction develops heat, consequently we account for a portion of the heat produced by muscular exercise and the friction of the currents of the swiftty circulating blood. We also know that combustion—chemical action—evolves heat, consequently we account for another and the chief portion of animal heat by the oxidation of the blood and tissues, and the innumerable chemical changes which take place in digestion and nutrition, as also in the removal of the worn out molecules of the tissues and the processes of the secretions. Chemical action is no doubt the main source of animal heat. But what regulates this chemical action so as to produce just heat enough to maintain the temperature at 98° ?—the standard of health—whether the temperature be 32° F. or even lower, or 100° F., or even higher. When the atmospheric temperature is below 98° F., the body, of course, loses heat by radiation and convection, which must be supplied by an increase in production. But what regulates the rate of the production ? We are well aware that the sympathetic nerve centers regulate and preside over digestion, circulation, nutrition, secretion and respira- tion, but the fact of its regulating heat production has been very strangely overlooked or disregarded. 30 HUMAN TEMPERATURE. CHAPTER Y. HUMAN TEMPERATURE. The question, How does the body maintain its nor- mal temperature of 98° F., when the temperature of the surrounding atmospheric air is above it ? is one of the most interesting and important in the whole range of physiology.1 If it receives any of it (exter- nal heat), its temperature must rise unless the heat be changed into some other form of force. It is evi- dently a very bad conductor, else we should surely be destroyed upon going into a Turkish bath at 212° F., as is frequently done. But its safety depends mainly upon its defense by means of free perspiration and vaporization of water from its surface, thereby chang- ing the excess of sensible heat into latent heat upon the surface before it has entered the bod}'. This effort to protect itself is not always successful, as is seen in sunstroke. When the surrounding temperature is far below 98° F., the normal point, there is increased activity in respiration, circulation and heat production; when- ever the surrounding temperature is above the normal degree, there is an active effort, wonderful in its char- acter, to protect itself from its injurious effects 1. Dalton's Physiology, p. 317. HUMAN TEMPERATURE. 31 mainly by free, copious perspiration covering the sur- face of the body with water in order that evaporation may convert some of the excessive sensible heat into latent heat, or some other form of force. Where resides the power presiding over these activities man- ifested in protecting the body against deficient or ex- cessive outside temperature ? H. C. Woods, Jr., says, in a center located higher than the pons varoli.1 That it resides somewhere in the centers of the sympathetic system there should no longer be any doubt. They (the temperature centers) are intimately associated with the vasomotor centers. In the undue excitation of these temperature centers, unduly stim- ulated by the frequent calls upon them through the afferent nerves to maintain the normal temperature; the frequency and urgency of these calls suddenly changing from one to another condition, from hot to cold, and especially in the over-excitation by a high outside temperature, loaded with moisture, (thereby preventing free surface vaporization) their tone, po- tentiality, health, normal condition is altered, lowered; they become unduly irritable, and therein lies the fundamental cause of all diseases now known by the term malarial, as well as the fundamental cause of many other diseases not so well marked by a distinct rigor, etc. 1. H. C. Woods, Therapeutics; Ott, on [Action of Medi- cine, p. 42. 32 RELATION OF TEMPERATURE CENTERS. CHAPTER VI. RELATION OF THE TEMPERATURE CENTERS TO THE VASO- MOTOR CENTERS. That the temperature centers are closely associated with the vaso-motor centers is evident, from the fact that in diseases remarkable for disturbances in tem- perature, there is also a well marked derangement of the circulation, and this, in some instances, even before the distinctive disturbances in temperature take place. But then, in farther illustration and proof it is only necessary to keep in mind the fact that "malarial" diseases are not always marked by chills and fever, or either of these phenomena. We have organic affec- tions of the spleen, derangements of various forms of the liver and stomach, intestines, mesenteric glands, diarrhoea, dysentery,catarrh, neuralgia, dropsy, asthma, paralysis, apoplexy, insanity, skin diseases, etc., unquestionably owing to the same " malarial" cause, yet without the distinctive chili and fever, and these diseases are all due to disturbances of the cen- ters governing temperature, respiration, circulation and nutrition. Why the periodicity in the inter and remittent forms? It is now a well established fact that there are regular electrical and barometrical tidal waves, as well as irregular or accidental ones. There are also rythmic processes, or states in the RELATION OF TEMPERATURE CENTERS. 33 human system beside the obvious ones of the lungs, heart and arteries. There are also ry thms in temper- ature and blood pressure, and tissue metamorphosis. Hence it is easy to comprehend that marked periodic or rythmic disturbances may occur in temperature and circulation. Further proof lies in the fact that the cinchona alkaloids, giving tone and strength to the sympathetic centers, cure the " malarial" diseases. So to a greater or less degree of other substances that give tone to the sympathetic centers. They have more or less effect, as strychnia, opium, arsenic, iodine, etc., al- though none are equal to the cinchona alkaloids, just in proportion as they are not equal to these in tonic effect upon the sympathetic centers, as they are une- qual to these in preventing shock, which is in reality a disturbance, an undue excitation of the sympathetic centers of temperature, respiration and circulation. Many and various direct exciting causes produce chill, followed by reaction (fever), but if the tone (poten- tial energy) of the sympathetic centers is unimpaired, health is speedily restored. When, however, the po- tential energy of the sympathetic centers of temper- ature and circulation have been lowered by the undue and prolonged excitation of heat, especially solar heat, health is not established until those centers have been restored to their normal energy; which is never speedily accomplished, requiring both time and well- suited remedial and hygienic measures. In this fact lies the reason and necessity for a correct pathology. 34 THERMAL PARESIS. If we deem, or suppose, the disease due to some nox- ious element floating in the blood, or fixed in the tissues, we are very apt to imagine, or believe, that we can neutralize it by administering a suitable an- tidote, and since 20 or 30 grains of a cinchona alka- loid frequently arrest chill and fever we conclude that to be the necessary and sufficient amount, and that quantity having been administered, we cease treatment. If, however, instead of being guided by this erro- neous view we act upon a knowledge of the fact that the disease is due to abnormal irritability and en- feeblement of the sympathetic centers, we cannot reasonably believe that it is possible to cure the dis- ease in 24 hours, and that what we accomplish by 20 or 30 grains of quinine is simply a removal or a sup- pression (frequently only temporary) of its most prominent symptom; consequently we continue the treatment of the case by the administration of tonics and well-suited hygienic measures. From many years observation I am fully convinced that the old material notion of these diseases is fraught with mischief to both patient and physician, the patient suffering from frequent relapses and long-continued ill health, while the physician becomes distrustful of his science, and disgusted with his art. It is on this account that these thoughts have been put upon paper, with a full appreciation of the satisfaction that practice, based upon the view advanced, gives to both patient and practitioner. REJECTION OF OBSOLETE TERMS. 35 CHAPTER VII. REJECTION OF OBSOLETE TERMS. In order, then, to remove and avoid the erroneous ideas resulting from the use of the word malaria, it will be advantageous to discard this term, and to adopt in its place the term hyper-therma, or excessive heat. For it is quite evident that the air, per se, has nothing to do with the production of the diseases now known as the malarial diseases. If even the cause were some gaseous emanation from vegetable decomposition or other sources, a microscopic fungi, or any other material thing, the air would be only the vehicle, at most, and there- fore should not be charged as the cause of so much evil. But more than this, it is altogether unscientific, since we know that it is not the cause. And since high solar heat is the only unusual thing, or element, which is always present where these diseases prevail, and since we know that they do not prevail without it, do we not, even therefrom, know that it is, at least, the chief cause of them ? There are, no doubt, aux- iliary causes (as also conditions counteracting its injurious effects), which modify or increase its dis- turbing powers, such as foul air in ill-ventilated rooms, unsuitable or badly-cooked food, over-work, and all other agencies which depress health. It is 36 THERMAL PARESIS. supposed unnecessary to enter into a fuller consider- ation of the propriety of using terms that convey truthful as well as useful ideas. Accordingly, the term, hyper-therma, is adopted, not to convey the idea that a normal degree of heat is bad or injurious, but that a long-continued high solar heat, and the changes it undergoes, and the effects it produces, di- rectly and indirectly, causes an abnormal irritability of the nerve-centers of the human body, which re- sults in disease. The decrease and the increase of the body temper- ature, the chill and the fever, the depressed and the accelerated heart's action, pulse and respiration; the coated tongue and anorexia; the constipation and diarrhoea or dysentery; the deranged urinary and biliary secretions; the headache, delirium, convul- sions and coma; the derangement of the intellect, sensation and voluntary motion; the neuralgic pains ; the functional and organic diseases of the liver, spleen, lungs, stomach, intestines and skin; anaemia, chlorosis, hydrsemia are not the immediate result of excessive heat, but they are the immediate result of unduly irritable nerve-centers, whose office it is to govern temperature, circulation, respiration, nutri- tion, sensation, voluntary motion, etc.; and this ab- normal irritability, or lack of potentiality of the nerve- centers, is undoubtedly the effect of excessive heat. The derangements above indicated have been said to be due to a specific poison present in the blood, or, per- haps, deposited among the tissues. If such were the REJECTION OF OBSOLETE TERMS. 37 case, we can be certain that there would be a fixed period of incubation, and a regular course and termi- nation in these diseases, as in small-pox, measles, scarlet fever, etc., and that they would be contagious and present definite pathological lesions, and that, once arrested, there would be no recurrence without exposure to the specific cause. 38 THERMAL PARESIS. CHAPTER VIII. ANIMAL TEMPERATURE; ITS RELATION TO HEALTH, ETC. The vital processes of the human system are soon arrested by a body temperature of 92° and under, and 107° and over. Some birds have a normal tempera- ture of 112° F. Horses and cattle have a lower tem- perature than man ; frogs and reptiles have a temper- ature of about 56° F., lower still. The constituent elements, ultimate and proximate, and the arrange- ment of general structure of all the vertebrata, in- cluding man, are similar, or so slightly different that it is impossible thereby to explain their differences in body temperature. And we can conceive of no rea- sonable explanation, except by a difference in tone or potentiality of their nerve-centers. It has been said, in answer, that the body temperature is in pro- portion to the respiration and consumption of oxy- gen ; and while this proximately true, it is not an explanation of the cause of the difference in temper- ature, but is simply presenting the same question in a different form, and the question then is, why do they breathe faster or slower, and consume a greater or smaller amount of oxygen than man ? Normal, healthful digestion, absorption, circulation, nutrition and secretion can proceed only at the normal temper- ature of about 98° F. Consequently, this necessary ANIMAL TEMPERATURE. 39 degree of heat generation demands as much combus- tion in cold as in warm weather. And in order to accomplish a certain amount of physical or intellect- ual labor, as much force production—combustion—is requisite in cold as in warm weather. But in cold weather, radiation of heat from the body is greater than in warm weather. Consequently, increased com- bustion takes place. It appears that a certain amount of radiation is favorable to health, since health is best maintained at a temperature of about 65° to 75° F., which is from 33° to 23° F. below that of the body. No doubt a considerable amount of heat is lost by radiation when the very best health exists. When, however, the temperature of the atmosphere ap- proaches that of the body, the conditions of temper- ature and radiation favorable to health gradually disappear, and when it is equal to that of the body, or even higher, health is seriously jeopardized, because the necessary amount of radiation can hardly take place. The body, through the power of its sympa- thetic temperature governing centers, attempts to relieve itself of its surplus heat by perspiration and vaporization, by which processes a large amount of heat is made to disappear, and when the condition of the atmosphere is favorable to free vaporization and radiation, success usually attends these efforts; but when the atmosphere is already saturated with moist- ure, vaporization and radiation are so greatly inter- fered with that the nerve-centers, in their efforts to regulate the temperature, suffer over-excitation and 40 THERMAL PARESIS. lose their tone in a manner similar and parallel to that which results from over-excitation of the centers of sight, hearing, intellection, etc., and finally fail to maintain the bodily temperature constant, disease in various forms, heretofore called malarial, becoming manifest. It appears unnecessary to multiply words on these points. 1st. That the temperature of the body is governed by the sympathetic nerve-centers as a temperature center. 2d. That in order to the healthy performance of this function, those nerve-centers must possess a cer- tain degree of tone potential energy). 3d. That long-continued high atmospheric temper- ature, especially when saturated with aqueous vapor, produces over-excitation of those heat governing nerve-centers, resulting in a depression of their nor- mal potential energy. 4th. That the abnormal state of those centers is the cause of all the diseases for a long time past known by the term malarial, or malarious diseases. REASONS FOR PROGRES8. 41 CHAPTER IX. REASONS FOR PROGRESS. It has been imagined and proclaimed unnecessary to discover the true cause of these diseases, on the ground that the medical profession knows perfectly well how to treat and cure them. It must, however, be readily conceded that successful treatment, in pre- vention, especially, but also with a view to cure, de- pends, to a very great extent, upon a correct knowl- edge of the cause and pathology. And this knowl- edge enables us to understand the action of our rem- edies, to prescribe intelligently, judiciously, and with confidence and success. But above all, the satisfac- tion of knowing the truth is beyond price. How is it possible to endure, to go on and on, for centuries and ages, in ignorance on so important a subject, im- portant in the highest degree, socially and financially, to millions of human beings ? But, it will be asked, what benefit will the knowl- edge that these diseases are caused by luminous solar heat, bring ? Can these diseases thereby be avoided ? A fitting answer would be this: How do you avoid injuring your retina—sense of sight? The answer should, and probably would be, by not over-straining it, especially in a bad light. Just so of the sympa- thetic temperature centers—avoid overstraining them, 42 THERMAL PARESIS. especially in a bad solar heat. When the body is surrounded by an excessively heated atmosphere, the urgent mandate (figuratively speaking) goes out from the temperature-centers to the skin to protect and relieve the body from excessive heat by perspiration and vaporization. When, on the following night, with a clear sky and a dry atmosphere, radiation is going on very rapidly, so that the temperature has fallen from 30° to 50° or more, down to perhaps 40° F., the temperature-centers are sharply excited by the call from the surface of the body for more com- bustion—heat. These alternating and different exci- tations of the temperature-centers must be avoided if we would avoid the diseases heretofore known as the malarial diseases. The proper name for these dis- eases, based on pathological lesion, would be " Paresis of the temperature or sympathetic centers." Therefore, as a means of protection, it is neces- sary— 1st. To avoid excessive solar heat, and especially very active bodily exercise in such solar heat, lest thereby further overtaxing the temperature-centers. 2d. To avoid too rapid and too low cooling after having been subjected to high solar heat. 3d. To avoid excess and deficiency of food; espe- cially the saccharine and fatty kinds, in improper quantity, and badly-cooked, or stale, or unripe foods, and impure drinking water. 4th. To wear suitable clothing—cooler in the day- time, warmer at night. REASONS FOR PROGRESS. 43 5th. Surface and underground drainage, to prevent too much aqueous vapor in the atmosphere, which hinders free radiation from the body; shade trees, etc. These points it is particularly important to observe, but there are many minor ones that it is by no means safe to neglect—temperance in all things, cleanliness, bathing, well-ventilated, dry rooms, and, in short, all the conditions necessary to good general health. 44 THERMAL PARESIS. CHAPTER X. THE SYMPATHETIC CENTERS. It may be advantageous to recall to mind a few points in regard to the sympathetic centers, and, per- haps, better, to the entire arrangement of the gray nerve-cells, their structure, of cell nuclei and pro- longation or poles, dividing them into a-polar, uni- polar, bi-polar and multi-polar cells, situated in the ganglia of the great ganglionic chain from the brain to the coccyx, in the heart, the retina and other or- gans, and in great abundance in the spinal cord, medulla and brain, all connected and associated by means of the nerve-fibres into a harmonious sym- pathetic apparatus—the center and governor of circu- lation, respiration, calorification (temperature), diges- tion, assimilation, dissimilation, secretion, sensation, voluntary and involuntary motion, memory and intel- lect. With these facts in mind it is not difficult to comprehend how a derangement of its tone—poten- tial energy—causes giddiness, syncope, delirium, neu- ralgia, stupor or coma, convulsions, paralysis, chills and fevers, diseases of the lungs, heart, liver, stom- ach and intestines, and skin, as well as the very dangerous so-called congestions. To persons who have not resided in districts where this disease prevails, nor otherwise acquainted with THE SYMPATHETIC CENTERS. 45 them, it might be interesting to see reliable reports of cases under these several heads. Since it would be of no particular advantage to them, not being concerned in their prevention or cure, it is deemed unnecessary to here present such reports. Enough such cases have appeared in the medical journals and been reported to medical societies. If collected and published, they would fill a large library, and satisfy the curiosity and scruples of the most obdurate skeptic. Those who have lived, and especially those who have practiced medicine in such districts, do not require verbal evi- dence of the occurrence of such cases. With them there remains no doubt. 46 THERMAL PARESIS. CHAPTER XL THE HISTORY OF THE THEORY OF HEAT. Hippocrates believed heat to be the cause of the diseases which afterwards came to be known by the designation " malarial." Many other careful, thought- ful, scientific men have held the same opinion, espe- pecially in the past fifty years. By whom the term malarial was first adopted is probably unknown. Not unlikely, however, by Galen, since he was de- cidedly materialistic in his views, and no one holding the opinion that heat is a material substance, would be at all inclined to accept the theory that the so-called malarial diseases are due to its effects. The fact, however, that heat is not a material substance 1 but a force, or mode of motion, changeable into other forms of force, is now so widely recognized and firmly established, that all theories based on the supposition of heat being a material substance must be abandoned. It may be humiliating to acknowledge that more correct ideas of heat and its effects were prevalent 2,200 years ago than are commonly held now, but such superior knowledge has shown that much idle boasting has been indulged in by men in modern times. 1. Tyndall, Herschell, Fownes. ANIMAL QUINOIDINE. 47 CHAPTER XII. ANIMAL QUINOIDINE. The substance or property discovered in man and animals by H. Bence Jones, and subsequently by Dr. Chalvet in wines and various foods, and therefore not properly named, may be an agent or condition neces- sary to a healthful condition of the sympathetic nerve-centers. This is rendered probable by the fact that it is present in the blood in much smaller pro- portion or even entirely absent in the so called mala- rial diseases. It is not improbable that this substance or property is destroyed or so modified by heat—its fluorescence changed—that the nervous system be- comes affected. In this may lie the secret of the ben- eficial effects of the cinchona alkaloids. But since fluorescence is evidently due to a peculiar molecular condition, and not to the nature of the atomic ele" ments of certain organic compounds, it is quite prob- able that there is no such substance as " animal quinoi- dine,"—the peculiar molecular action of many sub- stances, in certain conditions, having the effect of mak- ing non-luminous rays visible—fluorescent. Whether the molecular condition of the blood, or of some of its constituents, which gives rise to fluorescence, has any relation to the health and tone of the,nervous system is a very interesting question, the solution of which 48 THERMAL PARESIS. will probably throw much light on pathology and therapeutics. Since the foregoing pages were written, Dr. Abel, of Lakewood, Illinois, has kindly furnished me with a copy of Dr. Oldham's book, entitled " What is Ma- laria ?" The facts and incidents concerning the eti- ology of the so-called " malarial" diseases, presented in this unpretentious volume, utterly demolish the notions commonly entertained and very elaborate- ly set forth in some of the text-books on the prac- tice of medicine, both the vague "malarial" and the more definite " marsh miasm " theories. Indeed, so far as facts bearing on the etiology of these dis- eases can be of any service, this little volume covers the entire ground, and the deductions made from those facts are also invaluable, but perhaps they are hardly sufficiently definite to be readily apprehended and accepted by the reader. Dr. Oldham says, " No doubt, in those who have suffered from malarial fever and especially from repeated attacks, there is an im- paired state of the heat generating powers, or in other words a diminished power to resist the effects of cold; and this condition^it is which causes the great ten- dency to a recurrence of the complaint, on exposure to a very moderate degree of chill. This state, in most cases, passes off gradually as the health improves, after a longer or'shorter residence in a healthy cli- mate ; but it occasionally remains for a very long time. It is then admitted, that a great sensibility to cold predisposes to, and that exposure to chill causes, ANIMAL QUINOIDINE. 49 the so-called relapses of malarious fever. But, as I have already shown, these are the very influences which produce the primary attack. Thus, an impaired state of the heat generating power is produced by continued exposure to great heat and this renders the system highly sensitive to the effects of chill. " Then, the seasons at which malaria is most preva- lent, are those in which comparative cold succeeds rapidly to the greatest degree of heat, and in which the vital powers, depressed by the previous high tem- perature, are least able to resist the effects of the ra- pid alternations of heat and cold. Night is the most deadly time, and especially the latter part of it, when the animal powers are at the lowest, and when, from the general loss of heat by radiation, they are tried to their utmost to maintain the temperature of the body. In the situation in which malaria is most common- ly met with, the already overtaxed heat produc- ing powers have also to contend with the intensely chilling influence of damp. It is moreover found, that the measures which afford the greatest protection against the influence of malaria, are those which tend to preserve the body from violent alterations of tem- perature. In short, it is clear that the cause of ma- larious fever is chill." " Thus, each attack of intermittent or remittent fe- ver, whether primary or secondary, arises from the operation of the same cause, and while the increased liability to recurrence after frequent or severe at- tacks is owing, not to the presence in the system of 50 THERMAL PARESIS. any dormant poison, but merely to a depressed state of the heat producing powers, similar to that which is produced by continuous exposure to great heat." Unfortunately Dr. Oldham weakens his position, and obscures his deductions, by asserting that " it is clear that the cause of malarious fevers is chill." By " chill" he means abstraction of heat from the body, producing a sensation of chilliness or cold. But since elimination of heat is a normal and constant act of the healthy body, a process necessary to the pres- ervation of health, it is evident that there must be a prior disease—paretic condition of the sympa- thetic heat regulating temperature-centers—else the abstraction cf heat could have no direct evil result. The loss of heat and sensation of chill, are no doubt excitants of the nerve-centers, and it can be readily perceived that this excitation increases the paresis already present, from over-excitation by solar heat, still further; but to say that " chill is the cause of malarious fevers," is confusing, and, to a consider- able degree, incorrect. However, Dr. Oldham's work, taken as a whole, is probably as complete a demon- stration of the true etiology of the so-called malarial fevers, as it is possible to produce or reasonable to desire. The January, 1879, number of the St. Louis Med- ical and Surgical Journal has just come to hand this morning, in which I find a synopsis of a paper on " Sunstroke," by Dr. C. H. Hughes, in which he pre- sents "a truly scientific view of the pathology and ANIMAL QUINOIDINE. ol etiology of that disease, and which confirms, admir- ablj', the views herein advanced in regard to the so-called malarious diseases. In the same number I find, also, a charming paper by Dr. Trader, of Sedalia, Mo., on " Our Surroundings," in which he handles and exhibits ores, dug from a veritable " Comstock," abounding in the richest and most precious scientific facts, bearing on the etiology of these diseases. I had intended to notice, in a more especial manner, the views of some of the authors of standard text- books on the practice of medicine, as Aitken, Tan- ner, Roberts, Watson, Niemeyer, Hertz, in Ziemssen, Dunglison, Wood and Flint, but cannot do so now for want of time and space; neither can I compre- hend any real necessity for it, nor benefit to be derived therefrom, since it would be impossible to give thtir views in extenso, and an incomplete or partial presentation of their views of the subject is not deemed advisable. I may add, however, that I think it would be advantageous to those who have not recently or specially examined this subject, to study carefully the views of all the authors named; for their views .are not all alike; and to compare them impartially in the light of recently discovered facts in the physiology of the nervous system with those herein presented. From the theories presented, it be- comes apparent that the views on the subject have been in a transition state—undergoing development for some time past. In an article by Dr. Littell, published in the trans- 52 THERMAL PARESIS. actions of the American Medical Society for 1866, are given some very valuable and irresistible facts and arguments against the old and crude theories of " malaria," and against the narrow facts and imma- ture views of Lancisi in favor of his theories on marsh miasm. I would be glad to embody some of Dr. Littell's facts and conclusions, but cannot for want of time. I will, however, add that in my opinion his paper is well worth a careful reading. Its conclusions have not been accepted for very obvious reasons; yet they are really very nearly correct, so far as they re- late to endemic malarial diseases. Had he not so se- riously confounded electricity with solar heat and nerve force, and had he not been so extravagant as to claim that even the contagious diseases (some of which are known to have a specific cause) are due to electricity, his interesting paper would have had greater influence. The similarity between solar heat, electricity, and nerve force, is certainly very striking, and that heat is convertible into electricity, and vice versa, is an established truth ; but the same cannot be said as to electricity and nerve force, nor as to heat and nerve force, for, although there is a remarkable idendity in their effects in certain conditions, it were futile to claim that they are identical in nature and Bource. Whether any part, or at most any appreciable part, of the excessive solar heat which destroys the potential energy of the nerve-centers, is converted into electricity when it disappears as sensible heat, upon the surface of the body, is a question of very difficult solution, and probably of no practical impor- tance, in relation to the so-called malarial diseases. CAUSATION. 53 CHAPTER XIII. PREDISPOSING AND EXCITING, AND SPECIAL EXCITING CAUSES. In order to give additional clearness to the subject of the etiology of these diseases, it may be well to make a division of their causation into predisposing and exciting, and special exciting causes. Such distinc- tions are probably mainly applicable only to inter- mittent, remittent and malarial typhoid fevers, and diarrhoea and dysentery. At any rate, these forms of the thermal diseases are more frequently precipita- ted, or excited into their characteristic phenomena by special causes (such as a damp chilling air or wind, mental and bodily fatigue, sudden over-exer- tion, indigestible food, menstruation, and so on), than the thermal cachexia. Many attacks of these diseases occur, in which no special exciting cause can be discovered, fairly considered, having any influence in the causation of the disease, the whole cause being solar and radiant heat. In such cases, heat is at once the predisposing and exciting cause. But there are many attacks the outbreak of which are clearly traceable to a special exciting cause, such as those before named; and it is these that are included under the phrase, "special ex- citing causes." I will illustrate the subject in this 54 THERMAL PARESIS. way: A man undertakes to walk a certain dis- tance without food or rest; he becomes gradually exhausted, and if the distance be too great he falls down from sheer exhaustion, it being the whole cause of his fall, predisposing and exciting. But if on his journey he meet with unexpected obstacles, hills, mud, fences, for instance, he will fall the sooner, and these obstructions may properly be held as special exciting causes to his fall. In the thermal diseases we have frequent and numerous causes of this character. They are very well calculated to mis- lead us in our search for the true cause of these dis- eases, and are the main source of the confusion and misconception that has existed for so many years in the minds of the profession upon this subject; the whole field of professional vision having been occu- pied by the multitude of special exciting causes, the great chief cause, solar heat, underlying the whole subject, was seen but dimly, or not perceived at all. IRRITABILITY OF THE NERVOUS SYSTEM. 55 CHAPTER XIV. IRRITABILITY OF THE NERVOUS SYSTEM. In the normal condition of man there is necessarily a certain standard degree of sensibility or irritability, or in other words, molecular activity of the nerve fibers and nerve cells. It is by this means (nerve ex- citability) that the human organism adapts itself to so many and varying circumstances, and defends and maintains itself against a multitude of pernicious influences from within and without. Unfortunately we have no means of much practical value of meas- uring the degree of this normal irritability. By means of the thermometer we have ascertained the fact that the normal degree of human temperature is 98° F. By means of the same instrument we also discover all variations from this standard normal degree; but we possess no means of detecting such characteristic con- ditions of the nervous system with any great measure of accuracy. It is true we can measure surface sensi- bility, and by means of electricity we obtain some idea of motor irritability, but for fullness of import and practical value, there is no comparison in this with what we learn of temperature by the thermom- eter. We estimate the condition of the brain by its in- tellectual manifestations; that of the spinal cord by 56 THERMAL PARESIS. its motor and reflex activity or irritability; but by what means shall we determine the degree of irrita- bility, the tone—the potential energy of the sympa- thetic system—the great governor of the organic or vegetative functions? We can form only a vague and doubtful estimate of its conditions from the manner in which the organic functions are performed. For our purpose it is unnecessary to refer to the excitability or special manifestations of excitation peculiar to the cerebrum, cerebellum and spinal cord, since we are concerned with phenomena which de- pend mainly upon the irritability and tone of the sympathetic. It is owing to this property of the sympathetic mainly, that the sensation of hunger arises when the body needs nourishment, and the senation of thirst when it is in want of water; that the pupil contracts when exposed to strong light; that the sense of dyspnoea arises when the blood is in want of oxygen and surcharged with carbonic acid ; that the heart and arteries are caused to act so as to convey nutriment elements to the tissues ; that the mouth " waters " at the sight or smell of savory articles of food; that the parotid pours forth an abun- dant secretion, of suitable quality, upon the placing of food in the mouth; that the secretion of gastric juice takes place when the food reaches the stomach; that the bile, pancreatic and intestinal secretions are poured out by presence of the food about the orifices of the ducts; that the peristaltic action of the intestines takes place; that the presence of unwholesome, irri- IRRITABILITY OF THE NERVOUS SYSTEM. 57 tating or poisonous substances causes nausea, vomit- ing, diarrhoea, pain and general disturbance of the organism; that conception causes development of the uterus, mammas, etc.; that irritation of the nipples causes increased flow of blood to the mamma?, in- creased secretion of milk and contraction of the uterus; that the introduction of a catheter may cause syncope; that the injection of fluids, even water into the peritoneal cavity, may cause death from syncope and shock; that the application of warmth or heat to the surface produces perspiration and thus protec- tion against excess of heat. To say that the functions of the cerebral, spinal and sympathetic are distinct and independent of each other would be entirely erroneous. There is a most complete and undistinguishable inter-communication and inter-dependence between these three anatomical divisions of the nervous system. Nor can any mate- rial difference in function be reasonably expected from structures so nearly identical in cellular, nu- clear, granular and fibrous elements, differing mainly only in general arrangement and distribution. The purpose of the whole being the same—the growth and preservation of the human organism; the cere- brum to gain cognizance of surrounding objects, and to estimate its condition relative to those circumstan- ces ; the spinal system for purposes of action, locomo- tion, aggression, prehension, defense; the sympathetic for the internal economy—digestion, assimilation, nu- trition, reproduction, temperature, etc. 58 THERMAL PARESIS. CHAPTER XV. ABNORMAL IRRITABILITY. The normal irritability—tone—of the nervous sys- tem demands for its maintenance a certain amount and degree of excitation. If secluded from objects and conditions which act as healthful stimuli, it soon loses the properties which characterize it when in a normal condition. It cannot be deemed necessary to give illustrations of this fact. It is a fact patent to every intelligent mind. When, however, the stim- ulus is of a (1) pernicious character, or (2) too fre- quently repeated, or (3) excessive in amount and de- gree, or (4) too long continued, as (1) a narcotic or ir- ritant or acro-narcotic poison, (2) light to the eye, elec- tric shocks, etc., (3) heat or its absence—cold, (4) men- tal work, etc., the result is a depression or exhaustion of the normal irritability—a lowering of tone, a derangement of potential energy. This condition may be temporary, or may continue for some time, or may be permanent. The consequences of this depression or derangement of the normal irritability (paresis) of the sympathetic system can be readily enough educed from a knowledge of the conditions of the various physiological functions and processes controlled and maintained by what is usually termed healthful innervation. IRRITABILITY OF THE NERVOUS SYSTEM. 59 It has been said that some of these processes (nutri- tion, for instance,) are not due to any special influence of the nervous system, since they take place in the plant. This is readily conceded as regards that func- tion or process in the plant (in vegetable growth), but it is entirely incorrect as regards nutrition or any other function in the adult human organism. For illustrations and examples of pathological con- ditions, primary and secondary, resulting from pare- sis of the sympathetic centers, the reader is referred to the article on " Symptoms and Pathology." (See also Carpenter's "Principles of Physiology," 464 to 468.) 60 THERMAL PARESIS. CHAPTER XVI. EXCITATION PARESIS. Excitation of the nervous system, (1) by excessive heat, applied from without, (2) by too great retention of the heat generated normally in the body, and (3) by too rapid loss of animal heat by radiation and vaporization and convection, produces paresis or ab- normal irritability of the sympathetic centers. For illustrations we have (1) sunstroke (insolation), "ardent" fevers, nausea and vomiting, (2) syncope, neuralgia, headache, loss of appetite and the various derangements which are usually placed in the list, said to be due to living in overheated rooms, although such overheated rooms have temperatures scarcely as high as 80° F., and (3) chill, drowsiness, catarrhs, pneumonias, etc. (See Hanfield Jones, Clinical Obs., p. 33. Carpenter's Principles of Phys., 603-677.)1 Anaemia, hydrsemia, chlorosis, inanition, etc., great- ly favor the production of heat-paresis, etc., inducing this condition far more readily than when the system is in a healthy state. Excitation of the nervous sys- 1. The fact that the heat generating power is not equally energetic in all individuals, nor in the same individual at all periods of the year, nor of a single day, has so important a bearing on the question under consideration that it will be well not to lose sight of it. (Ibid 676-6. Dalton 304.) EXCITATION PARESIS. 61 tern by heat is modified in a very interesting manner, and to a great degree, by the amount of moisture, the degree of temperature and the quietness or mobility of the atmosphere. These facts are more strikingly apparent when presented in a condensed tabular form. 62 THERMAL PARESIS. CHAPTER XVII. CONDITION OF AIR—EFFECT. Hot, dry still air—radiation rapid, vaporization free, convection low. Hot dry wind—radiation good, vaporization very free, convection free. Hot, moist still air—radiation very low, vaporization low, con- vection low. Hot moist wind—radiation low, vapor- ization low, convection low. Cold, dry still air— radiation good, vaporization very moderate, convec- tion low. Cold dry wind—radiation fair, vaporiza- tion very low, convection good. Cold, moist still air—radiation very low, vaporization very low, con- vection good. Cold moist wind—radiation very low, vaporization zero, convection rapid, chilling. This table furnishes the basis for a comparative idea of the effects of differences in degrees of heat, moisture and mobility of the atmosphere.1 After long continued high heat, the heat-generat- ing power is found to be very feeble (see Carpenter's Principles, 676), which is due to the paresis or lowered irritability of the temperature centers. This is the explanation of chilliness so readily experienced upon even slight depression of temperature under those circumstances. The sensation of chill does not indi- 1. Tyndall, Heat as a Mode of Motion, 425-432. SYMPATHETIC DISTURBANCES. 63 cate, necessarily, a low temperature, for the same rea- son. It may be present when the temperature of the body is above the normal standard. This is a paradoxical phenomenon quite common in thermal paresis of the sympathetic.1 Sympathetic disturbances from sensory impressions are among the most complex yet interesting and im- portant subjects. A tap upon the abdomen may dan- gerously interfere with the action of the heart. Pinching the skin is sufficient to kill some animals. Dysmenorrhoeal pain will cause extreme lowering of the temperature.2 Anatomical structure and chemical characteristics of the skin have a modifying influence upon the recep- tion of heat by the body and its escape therefrom. The thick, black, sooty, oily skin of the negro transmits heat much less readily, although it radiates external heat much more freely than the skin of the white man. It is almost entirely due to the peculiar struc- ture and properties of the skin that the negro pos- sesses a comparative degree of immunity, under cer- tain circumstances, from thermal diseases.3 Degrees of dryness and moisture, as well as oili- ness of the surface, exert an important modifying in- fluence upon the action and effects of heat upon the skin and upon the organism generally. 1. Hanfield Jones, Clinical Obs., 288. Erb in Ziemssen, xi., p7. 2. Ott, Physiol. Action Medicine, 288. 3. Oldham, 73-77. 64 THERMAL PARESIS. The influence of clothing in protecting the body from sudden accessions and from sudden losses of heat, is a very familiar matter, but its importance and philosophy are far too commonly disregarded.1 By enveloping themselves in thick wadded coats at sunset, certain tribes of India escape, almost en- tirely, the injurious influences of abstraction of heat ind thereby avoid the so-called malarial diseases.2 1. Tyndall, Heat, etc., 202-3. 2. Oldham, What is Malaria ? pp. 171-372. EFFECT OF TOPOGRAPHY. 65 CHAPTER XVIII. EFFECT OF TOPOGRAPHY ON SOLAR HEAT AND THERMAL DISEASES. A low, level marshy surface in a hot region, has been long known as extremely subject to the pro- duction of thermal (malarial) diseases. It is this circumstance that gave rise to the term marsh miasm, palludal poison, etc. Erroneous as the theories are on which these terms are based, and misleading as these terms are, nevertheless, it is true that a level, marshy, hot region is peculiarly liable to those dis- eases.1 This topography favors in various ways the inju- rious influences of heat, (1) by an enormously in- creased accumulation and radiation of solar heat, above that of a rolling, broken, and hilly region, espe- cially if the latter is interspersed with bodies of deep water, (2) by a vast increase of moisture and aqueous vapor in the atmosphere, and in many other ways, that cause injurious effects, directly or indirectly. The temperature of level regions is invariably much higher than that of broken, hilly or mountain- ous regions of the same latitude and altitude,—the character of the soil and currents of air being alike in both regions. The differences in surface topography 1. Ziemssen, vol. ii, 566. Oldham, 96-101. 66 THERMAL DISEASES, are the main causes of inequalities of temperature at equal distances from the equator. Altitude has a marked influence upon temperature, but it is the broken character of the country that brings about in- creased altitude in many places, the valleys being as low as the "level regions " in question, the hills being higher. Temperature does not always correspond with lines of latitude parallel with the equator, owing, in great measure, to the topography of the earth. Ther- mal (so-called malarial) diseases are governed by iso- thermal lines of latitude. The rays of the sun strike a level surface, during the whole day, from the time of its rise to the mo- ment of its disappearance below the horizon. The daily period of sunshine is longer in a level than in a hilly or mountainous region, because there are no hills and mountains to project long evening and morning shadows. The rays fall more vertically On the one than on the other, and for a longer time each day. Rays falling vertically upon a surface, have an immeasurably greater heating power than oblique rays, as is well known from the fact that the former are the cause of summer, the latter of winter. Broken surfaces produce many changes in the angles of the rays in the course of a day, and consid- erable portions of such surfaces are even shaded for some time at one period or another, between sunrise and sunset. This produces many minor surface cur- EFFECT OF TOPOGRAPHY. 67 rents of air which have the effect of lowering and equalizing the temperature by means of convection. It has been calculated that the total amount of solar heat received by the earth in a year, if distrib- uted uniformly over the earth's surface, would be suffi- cient to liquefy a layer of ice 100 feet thick, and cov- ering the whole earth, or would heat an ocean of soft water, surrounding the whole earth, 66 miles deep, from the temperature of melting ice to that of ebulli- tion. But this calculation is based on the power of rays that are vertical, or nearly so. There can be no doubt, that if all the rays of the sun should fall ver- tically upon the whole surface of the earth, that is, if the surface of the earth were a uniform smooth sphere, like a ball, all its flora and fauna, and diseases would be widely different from those that exist now. The sudden increase in the prevalence of thermal disease which occurs at the beginining of autumn, is no doubt in part due to the cessation of vegetable growth and consequent cessation of consumption of solar heat, instead of being due to the supposed pro- ducts of vegetable decomposition.1 Low level surfaces are said be especially productive of the malignant influence called "malaria," and that this influence is most active near the surface and at night after a very hot day. These observations are based on facts, and are not fancy. Toward morning of a clear night, after a hot day, the thermometer 1. Tyndall and Sir John Herschel. 68 THERMAL PARESIS. will be 10° and 12° and even 20° F. lower on the surface of the earth than four feet above the surface.1 Marshy surfaces, shallow ponds of water, etc., in hot localities, vaporize rapidly, and saturate the atmos- phere with moisture, thus checking vaporization from the body during the heat of the day, but favoring the abstraction of heat by conduction and convection at night. In this manner over-excitation of the heat regulating centers of the body occurs, which finally results in exhaustion, altered irritability and paresis. Deep bodies of water are not so readily heated, on account of the multitude and mobility of their parti- cles; compare a thin sheet of water with the Atlantic ocean, which seldom attains a temperature of 70° F. A live swiftly running brook remains cool, while a sluggish, stagnant stream becomes hot and is evapo- rated. The extreme amount or power of heat, in low, level regions, is shown in the exuberant vegetation. A portion of this heat is consumed in building up the immense quantities of vegetable fiber, severing the carbon from the carbonic acid in the atmosphere, and the hydrogen from water, which by their union form vegetable fiber, etc., storing up a vast quantity of heat (potential energy), that again becomes manifest when we use it as fuel and food. Without solar heat there would be no rain, no dew, no springs and rivers, no clouds, no glaciers, no snow, no winds, no hurri- 1. Tyndall, Wells, Fownes, on Dew Points, etc. EFFECT OF TOPOGRAPHY. 69 canes. Is it reasonable to contend that so powerful an agent does not also cause derangements of the hu- man organism, and that such derangements must not necessarily be such as have heretofore been known as the malarial diseases ? 70 THERMAL PARESIS. CHAPTER XIX. THE THEORIES OF DECOMPOSITION, FERMENTATION, ETC. Vegetable decomposition, resulting in the forma- tion of noxious gases, etc., may be an auxiliary in depressing the general health, but has no primal in- fluence as a cause of these diseases. No doubt, there is also some evolution of heat, but it cannot be sup- posed to be sufficient to have any appreciable effect. Cities built upon sites that were formerly swamps pestilent with so-called malarial poison, have a fair degree of health, and very little of the former dis- eases, because evaporation from shallow sheets of water has been arrested, and the angles of the sun's rays have been changed, so as entirely to change the character of the solar heat. Animal and vegetable decomposition goes on to perhaps even a greater de- gree than formerly. Undoubtedly there is more bad or impure air, than when the locality was a swamp, yet there are not ''malarial" diseases. Louisville, Ky., is said to be an illustration. It is however entirely useless to consider the sub- ject of decomposition any further. The theory is no longer held, unless purely from habit.1 The theories of cryptogamic plants, algse spores, etc. 1. Ziemssen, Wood, et al. THEORIES OF DECOMPOSITION, ETC. 71 also belong to the speculation of the past; entertain- ing, brilliant and plausible, yet the miscroscope has demolished them. A peculiar kind of fermentation has been held to be the cause of the thermal (so-called malarial) fevers. But since there are many diseases allied to those fe- vers (but without fever), and since the fevers named, often pass into those allied diseases, or vice versa, or alternate with one another, and since they oc- cur in the same localities and at the same seasons, and are prevented and cured by the same means, they are evidently due to the same cause. Yet, fermentation is evidently not present in the allied diseases. Fermentation properly considered, is characterized not only by the formation of carbonic acid and alco- hol, or acetic acid or lactic acid, etc., but also, and especially by the development of a new growth of the fungous order. Any other chemical process is not properly fermentation, but should be termed decay when simple oxidation, or decomposition, or putrefac- tion takes place. In the living organism retrograde changes are continually proceeding, of the saccharine or fatty compounds, resulting in the formation of car- bonic acid and water; and the retrograde metamor- phosis of the albuminoid compounds resulting in the formation of the simpler ureides. This is, chemically, a decomposition and not a fermentation, and proceeds in health, although at a slower rate than in fever; but it takes place in other fevers as well as in the so- called malarial fevers, consequently it cannot be held 72 THERMAL PARESIS. as the cause in the latter, and not of the former. There have been no chemical compounds discovered in the so-called malarial diseases, whether accompa- nied by disturbance in temperature or not, that do not occur in the progress of other diseases. Toxaemia, septicaemia, pyaemia, puerperal fever, etc., are, no doubt, owing to a special noxious element in the blood, but they are characterized by pathological conditions, products and results, utterly different from those of the " malarial" diseases. The two classes of diseases have nothing whatever in common, so far as their etiology is concerned, and must be held as different in nature as Asiatic cholera is from gastro-enteritis. PATHOLOGY AND SYMPTOMS. T6 CHAPTER XX. PATHOLOGY AND SYMPTOMS. This branch of the subject is thus epitomized for the purpose of making its relation to the sympathetic centers more readily perceivable. With a view to clearness, precision, and at the same time a reasonable degree of comprehensiveness, it is deemed best to present this subject under the various heads to which the derangements belong—such as those of innervation, circulation, nutrition, tempera- ture, secretion, etc. NEUROTIC DERANGEMENTS. 1st. Mental Disturbances.—Mental confusion, dis- taste and inability for mental effort, mental apathy, weakened memory, drowsiness, wild screams, curses and blows, dizziness, headache, syncope, delirium, stupor, coma, roaring in the ears, seeing sparks, intox- ication, melancholy, hypochondriasis, psychical dis- turbances, hallucinations, maniacal attacks, sleepless- ness, distressing dreams, irritability, periodic wake- fulness. 2nd. Sensory Disturbances.—Headache, darting pain in the eyes; chilly, creeping sensations over the body; burning pain in the pharynx, oesophagus and over the region of the stomach; a feeling of lassitude 74 THERMAL PARESIS. and exhaustion; vague, wandering pains, shooting pains in the limbs, pain in the back and in the back of the head; disturbance of visual accomo- dation; marked sensitiveness to changes in temper- ature; cramp-like sense of constriction in the re- gion of the heart; photophobia; sensation of full- ness and tension in the epigastrium; nausea, stale, bitter or metallic taste; sensitiveness to changes of temperature, sensation of heat and cold running over the body; complete loss of consciousness and sensibil- ity; chill, and constriction of the chest; insensibility to the sharpest irritants; anxiety, oppression ; sensi- tiveness in the region of liver and spleen of an inter- mittent character; neuralgias of many different nerves; angina, cardialgia, colic, gastralgia, etc.; anaesthesia of various nerves; micropia, macropia, amblyopia; night-blindness, photophobia, deafness, hyperaesthesia of the surfaces; hallucination of the sight, hearing and touch, etc.; sensation of numbness, formication, tickling or burning pain in the back and over the coccyx of a dragging character; in the joints, char- acter of pain very various. 3rd. Motor Disturbances.—Twitching of the eye- lids; disinclination or inability to move; intermittent paralysis of certain limbs; disturbance of speech; apa- thy; hiccough; shivering and rigor; trembling of the lips, chattering of the teeth; twitching of the mus- cles; contraction of muscular fibers of the skin, caus- ing the cutis anseria, and a convulsive shuddering of PATHOLOGY AND SYMPTOMS. 75 the whole body; convulsions; contracted, dilated and immovable pupils; hand clenched, jaws set, stiff- neck, body bent either backward or forward, unable to move or utter a sound; tremors, convulsions in single limbs; clonic and tonic spasms and hysteriform and chorea-like seizures; mutism, aphonia, stuttering, opisthotonos, emprosthotonos, pleurosthotonos; pare- sis in some one or more of the limbs, more rarely mus- cular contraction; paralysis of tongue and organs of deglutition ; paralysis (partial and general), epileptic or tetanic spasms.^ 4th. Sympathetic Disturbances.—Diminished ap- petite ; disposition to stretch and yawn; profuse sweat- ing; malaise; sighing; chill and fever; nausea and vomiting; palpitation of the heart; neuralgia of the vagus with yawning, stretching, dyspnoea, cough, etc.; cardialgia, beginning with a feeling of unpleasant oppression, which gradually increases until it amounts to a most severe pain, frequently accompanied by a scarcely perceptible pulse; cold extremities; great anxiety; eructations; vomiting and thirst; neurotic disturbances of the great splanchnics, resulting in colic, diarrhoea or constipation, and affections of the bladder, urethra and uterus. It is claimed that the typical cramp of the vessels supplying certain ex- tremities has been observed; dilated pupils; coldness of the body, like that of marble; choleraic conditions of the body; colliquative sweats; insatiable thirst; great elevation of temperature; rapid tendency to col- 76 THERMAL PARESIS. lapse; tenesmus; appetitite normal, diminished, lost entirely or voracious ; involuntary evacuations of the bowels and bladder. Disturbances of Respiration.—Respiration short and rapid, often anxious and sighing, accelerated and noisy; becomes freer and easy, stertorous; dyspnoea; breathing rapid, and stertorous and frothing; respira- tion is shallow, as slow as ten in a minute; dullness on percussion; increased vocal fremitus; crepitant ronchi; bronchial breathing and bronchophony; cough, dry cough, friction sounds; shortness of breath upon exercising; irregular sighing, respira- tion ; respiration arrested in cases of apparent death; death with all the appearances of asphyxia. Disturbances of Nutrition.—Inflammatory dis- turbances of nutrition, as coryza, bronchial catarrh, swelling of the tonsils, tongue, liver and spleen; vari- ous skin affections, as erysipelas, purpura, urticaria and pemphigus; iritis and ophthalmia, which may lead to atrophy of the globe; gastritis, peritonitis, pneumonia; bronchitis; inflammation of spleen and liver; grangrene, jaundice, parotitis; enlargement of liver and especially the spleen; gastric or intestinal catarrh; diarrhoea ; dysentery; spleen and liver hard and sensitive; furuncles; renal diseases; amyloid and leucaemic conditions; tuberculosis; inflammation; thickening and ulceration of the intestinal glands; thickened capsule of the spleen. PATHOLOGY AND SYMPTOMS. 77 Disturbances of Temperature.—Skin hot and dry; fever and apyrexia; fingers cold; temperature of the remote parts of the body below the normal stand- ard ; in the mouth, armpits and rectum, above; dura- tion of stage of chill variable; the trunk becomes burn- ing hot and the temperature of the periphery is ele- vated ; nose stone cold; grows warm; burning heat diminishes ; temperature rapidly sinks to the normal point; chilliness followed immediately by glowing heat, etc.; the fever paroxysm may betray itself by a periodical sweat, during which the thermometer will indicate a rise of temperature of from one to two de- grees; hot stage lasting from twelve to thirty-six hours; chill and heat without sweat, interval of several hours between chill and heat, or between heat and sweat; chill following the heat and sweat, or beginning with heat, followed by chill, ending in sweat. If the an- ticipating or postponing process is frequently repeated it alters the rythm of the fever. In young children the skin grows cold; after a period of from ten min- utes to an hour the hot stage follows incomplete forms in which the chill is lacking, and the hot stage with a very light sweat constitutes the attack. Cold stage ending in death without fever. In marked cases which run their course without fever, or with only partial febrile manifestations, and as a rule of about two hours duration, preceding or following or alter- nating with the ordinary intermittent form, or other forms, death may result from high temperature; fever may intermit or remit regularly or irregularly, or be 78 thermal paresis. continuous. Algid intermittent; coldness of the sur- face, like that of marble ; temperature in the mouth from 86° to 88° F. and that in the axilla 84°; attack begins with the usual chill; it is not until after the hot stage that the patients turns cold, while at the same time he complains of a burning heat within, and of thirst, and is covered with a cold sweat. Attack usu- ally preceded by an ordinary intermittent, with im- perfect reaction. Fever may be of sthenic, typhoid or adynamic character. Death in the cold stage with- out reaction. In the malarial cachexia never found the temperature elevated, unless when it assumes an " intermittent or remittent or continuous type." Disturbances of Secretion.—Profuse sweating at night; mouth and gums dry; tongue and teeth often covered with a slimy coating; foul breath; constipa- tion or diarrhoea; skin hot and dry; urine scanty, dark colored and turbid, with abundance of urea; commonly sweating after fever. The urine is usually increased in quantity, clear and watery, of low speci- fic gravity, and without sediment, during the stage of chill. During the hot stage urine is scanty, red and of high specific gravity. In the sweating stage, urine is copious, of high specific gravity, rich in solid ingre- dients, and throws down a brickdust sediment of the urates; on moving about or making the least physical effort, he breaks into a sweat; urine is sometimes dark and throws down a brickdust deposit; chill and fever not followed by sweat, or chill lasts for a few pathology and symptoms. 79 minutes and the patient breaks out in a profuse sweat, or there maybe only a periodical sweat; irregular sweating stages; running of the nose; periodic diar- rhoea; sweating may be more or less well marked. Skin hot and dry; mouth and tongue also dry, and often covered with a fuliginous coat; patient comes to himself in the midst of a profuse sweat; streaming perspiration; skin of the body is hot and dry; chol- eraic discharges from bowels, becoming more and more watery, and sometimes resembling bloody wa- ter; skin covered with a cold sweat; muco-bilious vomiting; greenish-yellow stools; urine free from albumen, but scanty, etc.; copious dejections from the bowels; first of a serous character, afterwards consist- ing of blood and mucus, or of pure blood; vomiting of a brownish or bloody fluid, while at the same time there are copious watery passages from the bowels; vomiting of bile and bilious diarrhoea; urine scant; deep red color from abundunce of biliary coloring matter; urine yellow, staining the linen; urine in great abundance, dark brown and rich in blood; in- creased secretion of saliva; urine excessively abund- ant, clear as water, low specific gravity, without ab- normal constituents. derangement of circulation. 1st. Cardiac Disturbances.—The impulse of the heart is augmented; carotids throb; pulse rises in fre- quency, action becomes extremely rapid and feeble; pulse may be normal; in certain cases the heart's ac- 80 THERMAL PARESIS. tion is extremely variable both in size and frequency ; pulse may be feeble though not frequent, irregularity of pulse finally terminating in paralysis of the heart; sometimes fast, sometimes slow, sometimes full; the pulse is irregular, often much retarded, is slow as forty in the minute, small and thready; again quite small, even becoming entirely unrecognizable, palpi- tation and blood murmurs in the heart. 2nd. Arterial and Venous Disturbances.— Pulse regular, though small and frequent; carotids throb, pulse full and hard; now and then the pulse may become frequent, with imperfect intermissions; pulse small, scarcely to be counted; the pulse becomes softer, wave-like and regular, and diminished in frequency; distended jugular veins; external hyper- emia and swelling of the spleen; apoplexy of the spleen with rupture and escape of blood into the pe- ritoneum, or gangrene of that organ; extravasation of blood in the spleen; congestion of the bowels, serious hemorrhage from the stomach and bowels, endangering the life of the patient or leading to deep fainting fits; murmuring to be heard in the neck; a venous congestion of the lungs and pulmonary hemorrhages; pulse small and rapid to 140; spleen en- larged, pulse sometimes extremely slow, accompanied by deep collapse; enormous swelling of the liver and spleen; epistaxis, haemoptysis and haematemesis; ca- rotids and fontanelles pulsate strongly; hemorrhage from the kidneys, intestines and uterus. PATHOLOGY AND SYMPTOMS. 81 3d. Capillary Disturbances.—Skin shrunken and pale; eyes sunken, nose pointed, lips and nails blue, fingers white and cold; skin on them wrinkled and numb as if dead; the face becomes flushed; eyes red and fiery; grows warm; the natural turgescence of the skin returns; herpetic vesicles appear; the head is aglow, face red; oedema of the face, hands and feet; pale or livid countenance and lips; oedema of the lower extremities or of the mammae; ascites and anasarca, iritis and ophthalmiae; collapse; hyper- aemia of the various tissues; hyperaemia of the bron- chi ; congestions of the lungs ; infiltration of the lungs, congestion of the pleura; petechia; diarrhoea and dysentery; death from pigment embolism of the cere- bral vessels; complexion pale and muddy; ecchy- mosis. 82 thermal paresis. CHAPTER XXI. type—rythm—mode—form . In the text-books, the higher thermal (malarial) derangements are treated according to certain pecu- liar types, or other peculiar characteristics, frequent- ly manifested. This manner of presenting them is practically useful for the purpose of discussing and impressing upon the mind their more prominent phenomena, rather than to convey a truthful and oomplete knowledge of their cause and nature. That these peculiar, striking phenomena are main- ly incidental, and by no means essential, features of the disease, will be apparent from the following in- teresting quotations from Hertz, in Ziemssen's Cyclo- pedia : " The entire paroxysm generally lasts from 4 to 12 hours, more rarely from 18 to 24, or even longer, 50 to 36. * * * Certain deviations from the course above indicated may occur, but they are of such a na- ture that while they modify the features of the dis- ease they do not alter its essential character. There are cases, usually of the quotidian or tertian type, in which at a given hour of the day a slight feeling of chilliness is experienced, followed immediately by heat, etc., lasting for several hours, and not succeeded by sweat; or the chill lasts for a few minutes and the patient thereupon begins to sweat profusely; or chill TYPE—RYTHM—MODE—FORM. 83 and heat may both be absent, and the fever par- oxysm betrays itself only by a periodical sweat, etc. Such instances are not rare among people living in a malarious region, etc. " They also occur as a species of relapse during recovery from fever. The intensity of the several stages may differ widely in the same individual in successive paroxysms, etc. "Even in severe cases of intermittent fever some stages may be very short, or entirely lacking, etc. The disease may begin with the period of heat, the missing chill being replaced by some severe brain symptom, as d lirium, etc. Chill entirely absent, or consists of a slight shudder, and the hot stage lasts from 12 to 36 hours, often accompained by the gravest symptoms, followed by but slight sweating." He then decribes some instances of what he ca\\a febris dissecta, and refers to some cases in which there is a "reversal of the order in which the stages follow one another," also to oth«r irregular conditions which he describes under the name of febris subintrans. He then gives the quotidian, tertian and quartan types. " Such are the fevers which occur every fifth, sixth, seventh,eighth or even every thirteenth day." In addition to the sim- ple types, double types may also occur. " Two par- oxysms may appear daily, at different times of the day, and of different intensities (int. quotidian, duplicata), or one attack may appear daily, but of such form that the paroxysms of the first and third, and those of the second and fourth days, correspond with one another 84 THERMAL PARESIS. as to time of day and intensity, presenting not the quotidian type of fevers, but two tertians combined, (int. tertiana duplicata)." He also refers to double quartans. This brings two successive fever days together and leaves every third day free. " To these may be added one more form, which is the semi-tertian intermittent, and consists of a quotidian and tertian combined, so that on the first and third days there are two attacks each, while on the second day there is but one." He then refers to the antic- ipating and postponing attacks : " If the anticipat- ing or postponing process is frequently repeated, it alters the rythm of the fever; thus by antici- pating, a quotidian is changed into a remittent or a subcontinued form, a tertain into a quotidian, and a quartan into a tertian. The reverse of all this being accomplished by postponing." " In other and rarer instances, especially among persons who have suffered repeatedly from malarial disease, it is liable to show the greatest irregularity and variety in the occurrence and character of the paroxysms (intermittens erratica)." Under the heading " masked fevers " he describes "attacks of disease, which, bearing the type of ordi- nary intermittent, present symptoms foreign to this malad}^, which ordinarily run their course without fever, etc. These fevers either appear as independent dis- eases in persons otherwise well, or they are associated with other forms of sick.'ess, or they may precede or follow ordinary intermittti.t fevers or alternate with TYPE—RYTHM—MODE—FORM. 85 the latter in the regular manner, so, for instance, that the first day shall present a regular attack of fever, the second the masked form, the third again the regu- lar paroxysm, and so on, assuming the character of double tertian. They usually show themselves as typi- cal neuralgias, etc. The character of the pain isverj* various; it may break forth suddenly in its fullest vio- lence, or it may for several days give warning of its approach and gradually increase in intensity." He describes farther anomalous types and forms under the head of masked fevers. Then, the various, almost indescribable phenomena of "pernicious" attacks, and closes the " pathology" with malarial cachexia and the remittent and continued forms. There is certainly no lack of symptoms and patho- logical conditions in these hyper-thermal diseases. They are so numerous and various in character as to produce, in the mind of a careless or inexperienced observer, confusion and bewilderment. The student of the old text-books, and diligent attendant of regular courses of lectures, cannot fail to be impressed with the idea that the different pathological conditions manifested are so many distinct diseases, produced by different causes, or by a different degree of activity of the same cause, or are owing to a greater or less degree of susceptibility of the individuals af- fected, and that the cause is some organic or inor- ganic material substance, or that the cause is unknown. In the light of established facts, relating to the etiology and pathology of these derangements, the 86 THERMAL DISEASES. theory of an organic or inorganic material substance (miasm or malaria) is entirely untenable. The derangements produced by substances of this character, are recognizable by their well-defined and unvarying train of symptoms, courses and termina- tions; they are governed by certain immutable laws of their organization or nature, while the hyper- thermal derangements disregard and contravene all laws of organic and inorganic material nature. This fact, which is incontestably established, but unfortun- ately sadly overlooked, is freely and fully apparon upon an attentive study of the verities of their pathol DIAGNOSIS. 87 CHAPTER XXII. DIAGNOSIS. It is impossible to determine with certainty from the prodromal symptoms, whether a thermal or some other disease is impending. When a chill has occurred with or without the ordinary prodomata, followed by the stages of fever and sweat commonly manifested in the simpler intermittent firms, and succeeded by freedom from any special manifestations of disease, a diagnosis is easily made. Complications arising from derangements of the respiratory organs, chylopoietic viscera, kidneys and other organs, however, frequently obscure the character of cases that would otherwise be simple intermittent, so completely that what is simply a complication may be mistaken for the primal disease, or rather be regarded and treated as the only disease present. Physicians well acquainted and very famil- iar with the thermal diseases have but little dificulty in detecting the primal nature of the attack, but are in danger of erring in the opposite direction, that of overlooking or disregarding the complications entire- ly ; so that the patient may succumb to the complica- tions, while the practitioner is aiming all his efforts at the supposed chief enemy. The greatest danger from this source is in overlooking hepatitis, gastritis and nephritis. These precautionary remarks apply as 88 THERMAL PARESIS. well to the remittent and continued forms as to the intermittent, but an oversight of the kind alluded to, or a failure to diagnose clear the complications as well as the primal disease, is more likely to be followed by disastrous results in the severer than in the milder forms. The graver the character of the primal attack the greater the probability of secondary complica- tions and the greater the likelihood of overlooking the latter. An uncomplecated case marked by a paroxysm of chill, fever and sweat, occurring every day, every se- cond or every third day, is readily recognized, because of its well marked phenomena and frequent occur- rence in hyperthermal regions of country. So, also, of uncomplicated cases in which there is no complete abatement of fever. If there is a regularly recurring exacerbation and decline of fever with or without a preceding chill or a succeeding sweat, there need be no hesitation in announcing the case to be one of thermal fever. But here the practitioner frequently finds himself in a dilemma; if he pronounce the case to be one of the remittent form he will often have cause to change his opinion before he gets through with it, and if he diagnose the case to be one of a con- tinued form—typhoid—he will find himself in an equally unpleasant predicament. For a change in diagnosis in the progress of a case adds nothing to the reputation of a practitioner, nor to the standing and dignity of his profession. There is no means of distinguishing the more sthenic )remittent) from DIAGNOSIS. 89 the more asthenic (typhoid ) forms in the first three or four days, unless by a careful, diligent use of the thermometer, by which the sthenic forms will show a more sudden—a shorter, but more rapid—exacerba^ tion, a more uniform high-fever line, and a more rapid decline than the asthenic (typhoid). Even this test sometimes misleads. Herein lies the cause of so much variance in statistics. Some practitioners diagnosing nearly all cases of this character as "remittents," while others class them as "typhoids." It is quite a common thing to find practitioners " who cure nearly all their cases of " typhoid " or " typho-malarial" fever in from one to two weeks! The whole mystery lies in their diagnosis. The reason for it exists in the facts that it is safer and better for their reputation to cure typhoid fever inside of two weeks than to wrestle with a case of "remittent" for a period of four or five weeks, or longer. The truth is, there is no distinguishable difference between these distinctively named conditions, but the difference in degree of severity. The distinctive names referred to have a mischievous effect, in impart- ing the idea that they are diseases of essentially dif- ferent natures; and they also at least arouse a suspi cion that they result from different causes. The most important matter, then, to determine in cases of continued fever, is the grade, whether sthenic or asthenic. If the exacerbation be prompt, the high- fever line well maintained, the decline well marked, accompanied with moisture of the surface, and if at 90 THERMAL PARESIS. the same time a decided quieting of nervous dis- turbances, as headache, pain in the back and limbs, and restlessness takes place, the case is one of the more sthenic grade, and will prove more promptly amenable to treatment. If the reverse of these conditions be present, we are justified in consid- ering the case to belong to the asthenic grade. At the outset, the condition of the tongue and urine give no indications of the grade. The former is usu- ally more or less coated with a white or yellow-white coat, and the tip and borders more or less increased in redness. If the case be one of the asthenic grade the mouth and tongue will begin to show signs of dryness, usually as [early as the first week, but may not until later, and if not suitably treated will in- crease in dryness, so that the tongue becomes hard, much impaired in its natural mobility, while its coat turns a darker color, until it sometimes is black. The urine is highly colored from the beginning, and as the case progresses usually becomes more and more scant. Cases in which the intellectual and sensory functions are much depressed, with a marked degree of stupor, are frequently obscured by the bladder being distended by long retained urine, which disten- tion adds to the depression and irritability of the ner- vous system. There is nothing connected with the urine, nor in the manner of its secretion and evacua- tion, by which the thermal diseases can be known from many others, but its quantity, color, increase or decrease of normal constituents, presence of abnor- DIAGNOSIS. 91 mal ingredients, and the manner of its secretion and evacuation furnish important indications in regard to the form and grade and complication of each particu- lar case. The same holds true in regard to the ac- tion of the bowels and the character of the dejections. There is in many cases a decided bilious condition of the stools in consequence of derangements of the hepatic and duodenal secretions; commonly the bow- els are inclined to constipation, yet this symptom is of little value for purposes of diagnosis, as the oppo- site conditions may be present instead. From the symptoms alone present at any particular time, it would often be extremely difficult and sometimes even impossible to make a differential diagnosis be- tween some cases of thermal fever, meningitis, hepa- titis, gastritis, gastro-enteritis and nephritis. How- ever, the symptoms in connection with the history of the case relative to residence, mode of living, occu- pation, previous condition of health, season Of the year, etc., should invariably lead to a correct diagno- sis. Milk-sick is sometimes mistaken for a somewhat low form of thermal fever (remittent or typho-mala- rial). This has happened in the practice of gentle- men of fair attainments and many years' practice. Such oversights may be deemed inexcusable. Yet so long as no more definite and scientific knowledge in regard to the cause and nature of these diseases pre- vails, such blunders will continue to occur. One of the most dangerous forms of thermal dis- 92 THERMAL PARESIS. ease, dangerous because of the insidious manner of its attack, and the quietness and apathy of the pa- tient, is that commonly known as congestive diar- rhoea or dj^sentery. The attack comes on in many of these cases without any rigor; there is simply a sense of weakness and shortness of breath on making any exertion, followed by looseness of the bowels with thin watery discharges, sometimes more or less mixed with blood. After a few hours the attack abates and the patient feels, in many cases, about as well as before its advent. He will assume it to have been an attack of diarrhoea due to some indiscretion in diet, or to having taken a cold. But in a day or two, or three days, or in week there will be another and a severer attack lasting longer, but he may pass through this also, and again suppose himself well or getting well; but there comes another and probably a fatal relapse or attack. During the attack the patient com- plains but little, many times apparently because he has not enough energy to do so. He is lethargic, apathetic to a remarkable degree, in fact, in many cases, semi- unconscious, and is then in an extremely critical con- dition, being in danger of fatal syncope upon the slightest exertion. There may not be any marked depression of temperature, nor any appreciable rise after the attack, should it not prove fatal. In some of these the diarrhoea or dysentery is attended with pain, while in others it is as painless as in cholera. In the severer attacks, at least before death, more or less nausea and vomiting occurs. DIAGNOSIS. 93 It is highly important to remember that these dis- eases occur at all ages, from earliest infancy to ex- treme old age, and that in the very young, the deli- cate and the old, they do not present the usual and more distinctly marked features of cases occurring in vigorous adults. In the very young drowsiness, coma and convulsions, even when there is no rise of temperature, are commonly the chief symptoms. Feeble middle-aged persons, and the aged, are gen- erally more subject to the masked forms of the dis- ease. Thermal paresis of the sympathetic centers seems capable to produce or rather to open the way for the production of almost every known patholgical con- dition, not due to some specific infectious or contagious cause. And it frequently modifies, to a very impor- tant extent, pathological conditions due to other causes. It can scarcely be necessary or advantageous to dis- cuss the diagnosis of the pernicious forms, and the thermal cachexia; because the former present fea- tures of so striking a character as to be readily dis- cerned, unless perhaps from cases of poisoning from some narcotic or acronarcotic agent. The latter can hardly he mistaken for any other form of cachexia, especially when the history of the case is kept in view as a guide. Indeed, it is by this guide that all forms of the disease are to be examined, else there will be much doubt and hesitancy, and many grave mistakes. In hyper-thermal localities, cholera mor- bus and cholera infantum should be classed with the 94 THERMAL PARESIS. thermal diseases. Thermal paresis of the sympathetic centers from excessive excitation by solar heat being the primary pathological condition, it is an impor- tant matter in its bearing upon successful treatment. TREATMENT. 95 CHAPTER XXIII. TREATMENT For the sake of convenience in setting forth the treatment of the thermal fevers, and all the other thermal diseases, there is a temptation to divide them into several forms and types, as has heretofore been the custom. But, as such divisions convey the idea, at last bjT inference, that they are essentially distinct diseases, and as all division of these diseases is based upon purely conventional or imaginary grounds, so far as their essential nature and cause is concerned, it is deemed preferable to give the treatment on broader grounds, based on general principles. The chief pathological condition, the paretic and abnormally irritable condition of the sympathetic nervous system, is what needs to be kept most prom- inently in view. In some cases it maybe aeomewhat perplexing matter to decide whether this condition is due to disease of the nerve-centers primarily, or whether it is a secondary condition depending upon a diseased state of the blood. As a rule, all derange- ments of the blood, and of the functions of the vari- ous organs, as also structural changes, are results, effects, and not causes, of the disease. These second- ary conditions, of course, modify the phenomena 96 THERMAL PARESIS. present, and commonly require therapeutic, dietetic, and hygienic attention. The most valuable and reliable medicinal agent in the treatnent of this multifarious disease is cinchona and its alkaloids, quinia, quinidia, cinchonidia and quinoidine. The three first named are those most generally in use, and of about equal value and power, although their actions, and the sensations they pro- duce, are not exactly identical. The action of quinia is more energetic upon the brain, as is evinced by greater cerebral disturbance, headache, photophobia, tinnitus aurium, deafness, etc., while that of cinchonidia is more energetic upon the spinal cord, as shown by tremors of the hands, etc., and is decidedly more energetic as a cardiac sedative, acting frequently so strongly as to cause dizziness and even syncope (when the patient assumes tho erect position), from cerebral anaemia; with quinidia I have not had sufficient experience to state any specific differences in effect. Quinoidine has power equal to that of the others, but is not so well borne by the stomach and bowels, frequently causing nausea, vom- iting and diarrhoea. Their powers to arrest the pro- gress of thermal diseases (to restore tone to the pa- retic sympathetic centers) is decidedly superior to any other known agent. But their efficiency depends very greatly upon the manner in which they are pre- scribed. Agents so positive in their effects for good when properly administered may also be injurious when misapplied. The contraindications to their uso TREATMENT. 97 then, are matters of the highest importance, and their disregard has cast a certain degree of reproach upon the profession. They should not be administered in the stage of chill with actual reduction of temperature. In cerebral and spinal irritations, hypera^mia or in- flammation as shown by severe throbbing pain in the head and back, severe headache, with flushed face and injected conjuctiva, photophobia, great active restlessness and convulsions, they should be withheld until these conditions have been removed by other measures. Neither should they be administered when there is high irritation or inflammation of the stom- ach, as indicated by a red and swollen, or red and dry tongue, with great thirst, nausea or vomiting and ten- derness upon pressure upon the epigastrium, and es- pecially not in the form of a dry crystalline powder. In this form, dry crystalline powder, the cinchona alkaloids are obnoxious to many healthy stomachs. Whenever given in the form of powder»the crystals should first be broken as thoroughly as possible, by complete trituration, either alone or with the addi- tion of pulverized extract glycyrrhiza or some other powder of this character. A very good plan i& to triturate together the alkaloid, pulv. ipec, pulv* zingiber and pulv. ext. glycyrrhiza in proper pro- portions, depending somewhat upon the special con- ditions present. The conditions of the head, spinal cord and stomach mentioned as contraindicating the use of the cinchona alkaloids constitutes an objection to their use in every grade of the disease from the mild- 98 THERMAL PARESIS. est, simplest intermittent to the most severe conges- tive or so-called "pernicious." They can be given to the youngest infant (although they are frequently not necessary in the very young), to the adult and the aged. The very young and the very old do not bear, neither do they require, so large proportional doses as adults. From my own observation I must say that the al- kaloids of cinchona have in certain cases the action of abortifacients, and contrary to the observations of some, that they all have this power alike. It is proba- bly due to abnormal irritability of the cerebral and spinal reflex centers. That they have the power of ex- citing and strenghtening uterine contractions at full term in women who suffer from thermal paresis there can be no doubt. The best form for the administration of the cincho- na alkaloids is in combination with hydrobromic acid and syrup of licorice or some other suitable ve- hicle tending to disguise the taste. The hydrobro- mic acid influences in a very favorable manner the unpleasant effects upon the brain and spinal cord. It is unfortunate that there is no officinal preparation of this acid. It is therefore usually necessary to indi- cate in the prescription what preparation is desired— Fothergill's, Squibb's, or some other. No doubt in the coming revision of the pharmacopoeia this subject will receive the necessary attention. The dose of the cinchona alkaloid will, within cer- tain limits, have to be regulated by the severity of TREATMENT. 99 the case and the period of time open to its adminis- tration. From my experience I must say a five grain dose is the most suitable for an adult male pa- tient. When there is sufficient time for the administra- tion of* the medicine in five grain doses at intervals of from two to four hours, to give from 20 to 60 grains before the recurrence of dangerous symptoms, this is the best method to adopt. It is safer, more perma- nent and less disagreeable in its effects. It is how- ever sometimes necessary on account of want of time to prevent the recurrence of a dangerous attack, or owing to the urgent necessity of reducing a danger- ously high temperature, to give larger doses. I have never given more than 30 grains of quinia or cincho- nidia at one dose. Such doses often give rise to very well marked phenomena, such as sensory disturbances, depression of the circulation, fainting, hallucina- tion, etc. Beyond these unpleasant manifestations I have not observed anything that should cause hesi- tancy in prescribing such doses when there is a clear indication therefor. According to my experience, relapses occur more frequentl}' after the administration of 30 grs. in one dose than after 30 grs. administered in six doses three hours apart. But the relapse is more commonly not in the form of the original attack, that is, an inter- mittent will manifest itself in its relapse as a frontal neuralgia or some other form of a periodic character, or be devoid of anything typical, but show itself as a jaundice or as anaemia. The use of the remedy should 100 THERMAL PARESIS. be continued for a length of time, (even after the acute symptoms have abated) proportionate to the de- gree of paresis present, from one to four weeks. So long as the skin has not assumed its healthy hue and function, the tongue is not clear and of natural size, the appetite, digestion, assimilation and nutrition, tissue change and secretions not normal, and there is shortness of breath and an unusual sense of fatigue upon slight exertion, the alkaloid should be contin- ued. During this stage of treatment, it is commonly advantageous to combine the alkaloid with other ton- ics, as iron and strychnia or arsenic, and with altera- tives, or with diaphoretics, certain cathartics, and diuretics. Iron preparations are generally not well borne in large doses nor in concentrated form, under these circumstances. The tine, of the chloride of iron must be given in small doses well diluted; so of the subcarbonate; solution of dialysed iron is a good prep- aration, usually well borne by the stomach. The syrup of the iodide is also a very useful preparation in 20 drops doses, well diluted. The alkaloid in combination with fluid extract of eucalyptus globulus acts very well in the chronic catarrhal forms. Eucalyptus globulus, picrate of ammonia, the sulphites, as that of soda, tincture of iodine, arsenic, chloroform, opium, the bromides and a multitude of other agents have been announced as possessing equal specific power with that of the cin- chona alkaloids. After a rather extensive experience I must place these agents in the list of auxiliaries. TREATMENT. 101 Some of them have but a slight tonic effect upon the paretic nerve-centers, at least in the doses usually advised, while the others have no such effect at all; they act mainly upon the secondary pathological con- ditions and not upon the primary nerve center pare- sis, or if so, in an indirect and uncertain manner. It may be well to remark, and to bear in mind, that the action of the cinchona alkaloids, and other agents also, no doubt, is frequently prevented ©r neu- tralized by the condition of the stomach or its con- tents, preventing its ready absorption, or, perhaps, even sometimes changing it in its chemical character- istics so as to effect its therapeutic value. I am impelled to make this statement from having ob- served a much more decided effect after the action of an emetic or cathartic than before. A somewhat acid state of the secretions of the stomach favors the ac- tion of the alkaloids; when this is not present it is advisable to give them in combination with an acid, as hydrobromic or sulphuric acid. The practice of giving them in combination with alkalies or the alka- line salts, as bromide and nitrate of potash, necessi- tates a larger quantity of the alkaloid.1 In all forms of this disease there are quite com- monly present, conditions of the secretions of the skin, liver and kidneys, which seem to indicate the administration of diaphoretics, cholagogues and diu- retics. It will, however, be found upon trial, that the 1. H. C. Woods, Jr., Therapeutics, etc. 102 THERMAL PARESIS. action of such agents will be very imperfect and un- satisfactory so long as the primary lesion of the sym- pathetic centers has not been removed. After the removal of this primary lesion by a sufficient quantity of the cinchona alkaloids, the organs and functions referred to, it will be discovered, have also regained their normal condition, and this will usually be first noticed in the perspiration. A simple intermittent requires no other medicinal agent than a suitable quantity of one of the alkaloids named, given for a sufficient length of time. Complica- tions must, of course, be treated in accordance with their indications. Dietetic and hygienic measures are of great importance, and should be strictly insisted upon in every case. It is an anomalous matter that patients cannot understand why they should suffer from relapses when they continue to expose them- selves to the same conditions that gave rise to their first attacks. They are quite apt to imagine, very foolishly, that twenty or thirty grains should not only cure them but should keep them well for that year, at least, although they continue subject to the same influences as before the first attack. In the somewhat severer cases, in which the fever abates, but does not disappear, the alkaloid requires to be used in the same manner, and will have an equal- ly beneficial effect. It is generally necessary to con- tinue its use for a longer period, until the exacerba- tion ceases to appear, and then for several days longer in smaller doses, or at longer intervals. In these TREATMENT. 103 cases it is frequently useful to give a dose of hydrag» chol. mit., five to twenty grains at the outset, in the chill or exacerbation, to be followed in two or three hours by a saline cathartic, which must be repeated in two hours until free evacuation of the bowels has been secured. If the case is not seen until the remis- sion has commenced the cinchona alkaloid should be administered at once, and given in full doses with the view of preventing another exacerbation. If not suc- cessful, the cathartic may be given during the follow- ing exacerbation, and when the remission sets in the alkaloid should be resumed. In these cases there fre- quently is much suffering from nausea and vomiting, and restlessness, especially during the stage of high fever. Cold water or cold acidulated water drinks with cool bathing of the head gives great relief. A small dose of morphia often produces a good effect. Bathing the surface of the body with water of a grateful temperature is of the utmost importance in all cases and at whatever stage, provided the surface is hot and dry, or either one or the other. The skin should under all circumstances be kept soft and moist, unless there is depression of temperature, whether the case be of the asthenic or sthenic grade. When there is obsti- nate vomiting or distressing nausea, effervescing pow- ders given every half-hour or hour almost invariably give relief. Aromatic spirits of ammonia with pepper- mint water, also, frequently answer a very good pur- pose. Sinapisms may also be applied over the epigas- trium, and in the event of a high grade of fever, cloths 104 THERMAL PARESIS. wrung out of cold water may be thus applied. A dis- tressing headache of a neuralgic character is often present in such cases, which, however, does not pro- hibit the use of the alkaloid, but on the contrary is benefitted by it. In this disease, and especially in the severer cases, active, irritating cathartics are injurious, frequently complicating the case with troublesome irritation and even inflammation of the stomach and bowels; old, hardened, drastic pills are especially con- traindicated. The sulphates of magnesia, soda and potash, or the citrate of these bases, are the best prep- arations in all cases that are not greatly debilitated. In such, castor oil is the best, per orem, but in the ex- tremely typhoid cases, if it becomes proper to move the bowels, it should be accomplished by means of eneinata of castor oil emulsions. If there is persistent deficiency in the sudoriferous and renal secretions, spir. etheris nitrosum or liq. ammonia acetatum should be given with the alkaloid. If the deficient secretions be accompained by much active restlessness and a high grade of fever, tinct. of gelsemium may be added to the article just named, or given alone1. When there is much dryness of the mucous surfaces, in the more sthenic cases, small doses of hyd. chlor. mit. can be prescribed with advantage, combined with suitable proportions of opium or pulv. ipecac, compound, when necessary to restrain the action of the bowels. The latter agent can also 1. Ott, Physilog. Action of Med., etc TREATMENT. 105 frequently be given in combination with the alkaloid to promote perspiration and rest. The administra- tion of twenty-grain doses of sodium sulphite four times daily almost invariably prevents dryness of the mouth and the browning and blackening of the coat- ing of the tongue, and should be administered through- out the course of every case of any considerable de- gree of severity, and especially in cases of a low or typhoid character. Ten-drop doses, in emulsion, of oil of turpentine, given every three hours, is the promptest agent for the removal of a dry brown or black coat from the tongue. High irritability and inflammation of the stomach, however, forbid its use. The application of sinapisms or oil of turpen- tine over the abdomen should be persevered in during the whole course of the case, if there is any indication of enteric complication. In conditions of high or acute inflammatory action of the peritoneum, or intestines, cloths wrung out of cold water applied over the abdomen answers an excellent purpose. Hemorrhagic complications from the nose, mouth, stomach or intestines can be generally promptly controlled by the use of ergot, opium, acetate of lead, and persulphate of iron, etc. If the sodium sulphite is administered from the beginning of the case, hemorrhages seldom ensue. For diarrhoea, opi- um, lead acetate, tannic or gallic acid, meet all the requirements. In cases of violent seizure and extreme depression of some or all of the vital functions, such as those 106 THERMAL PARESIS. usually described under the terms "pernicious," con- gestive, algid, etc., the most useful and prompt agents are atropia and morphia administered hypodermic- ally; of the former one-hundredth to one-sixtieth grain, and of the latter one-tenth to one-fourth grain in combination. This measure can be repeated every fifteen to thirty minutes. In the meanwhile other suitable measures can also be instituted, as diffusible stimulants, ammonia or alcoholic, artificial warmth and rubbing. In case of excessive heat, the cold water douche, or a cold water bath and in the event of not too great cerebral or spinal congestion, one of the cinchona alkaloids should be freely administered. In all cases, unless there is an unmanageable com- plication present, the fever can be controlled within the limits of safety by means of free ventilation, bathing of the surface, cooling drinks and the proper administration of a cinchona alkaloid. These means should be diligently and judiciously employed until convalescence is fully established. A suitable diet is of importance and requires the strictest attention of the physician. Many cases have been permitted to perish for want of nourishment. Of course, in the acute stage at the onset of an attack, active feeding is not only not required, but would be a source of dis- comfort to the digestive organs of the patient. But when the active sthenic stage has passed, which is the case at an earlier period in the young, the feeble and the old, active and positive measures for the nourish- ment of the patient should be instituted. It must al- TREATMENT. 107 ways, under such circumstances, be borne in mind that the patient is incompetent to determine what nourishment he requires. The appetite and sense of taste are lost or perverted. Nothing is palatable and he generally objects to taking nourishment of any kind. It is as necessary and important that others should determine when he shall take food, and what he shall take, as it is in regard to medicine. And after the case has continued for several days, food is as important an agent for his recovery as medicine, and often more so. The choice of the kind of food, and the period of its administration, can in no event, under such circumstances, be left to the patient. He is utterly incompetent to decide whether he needs food or not, or what should be its character. At times he may have a peculiar craving for special articles of food, which it is safe to indulge to a moderate extent, provided there is no well marked contraindication. Iodine is useful in the treatment of the sequelae and cachexia of whatever form, glandular enlargements, anaemia, etc. It should be given in the form of the compound tincture, or compound solution, or the syrup of iodide of iron; the condition of the stomach must be good, otherwise it will not be accepted. The use of iodine in the form of tincture, especially to be given in water, cannot be commended. During the past ten years, at least, it has however been published in numerous medical journal reports as a remedy in intermittent fever. The action of iodine as an alter- ative and tonic is no doubt useful in many cases of 108 THERMAL PARESIS. this disease, yet it cannot, nor can any other agent be compared, for efficiency, with the cinchona alkaloids, as special tonics. Arsenic holds about the same rank as iodine, in regard to its worth as a remedy, in this disease. The other agents named at the beginning of this article have more or less power for good if judicious- ly applied, but they do not compare in therapeutic value and range of applicability with the cinchona alkaloids. In fact, any agent, material or immaterial, capable of making or communicating a stimulating impulse upon the nerve-centers, produces more or less effect upon the disturbed innervation arising from the paretic condition of the sympathetic temperature and circulation regulating centers. Strychnia, as an excito-motor and stimulant of the cardiac and respira- tory centers, is an agent of positive value. In case of a continued fever, and in fact in all cases where there is dryness of the mouth and skin, defi- cient urinary secretion, jaborandi, in from 5 to 18 gr. doses every 3 or 4 hours, exerts a most excellent effect. Great enfeeblement of the cardiac systole is however a positive contraindication to its employment. There are temporary conditions of feeble circula- tion, in many cases, that can be relieved by alcoholic stimulation, but the greatest indication for its use is in prolonged attacks resulting in inanition, feebleness of circulation and sleeplessness from cerebral anaemia. Blood-letting, one of the first measures formerly had in mind for the management of the thermal fevers is TREATMENT. 109 not often neccessary, but in certain conditions of sud- den high sthenic fever, with active congestion or in- flammation of the brain, liver, stomach or other vital organ, threatening early disorganization or fatal lesion, it affords the most prompt and efficient means of averting grave consequences. In such conditions it has greater power to calm the abnormal irritability of the sympathetic nerve-centers than any known agent, and should be resorted to in a prompt and fear- less manner. The blood should flow freely and co- piously from a large orifice, otherwise no good may result therefrom. Conditions requiring blood-letting arise most commonly in cases described by the late Prof. J. K. Mitchell, under the name of the " summer remittents," by some called the" ardent fevers." They occur generally during the hottest months, and are characterized by violent disturbance of all nerve- centers, from the direct effect of excessive solar heat. Thermal diseases, whether accompanied by aberra- tions in temperature or not, should not be treated without the intelligent use of the fever thermometer. It is impossible to form a reliable estimate or judg- ment of the character of the case without the infor- mation it affords. There is no other mode of ascer- taining whether the temperature is within safe bounds and when to adopt measures for its reduction or ele- vation. When it indicates 96° or 105° F., there is ur- gent need of instituting suitable measures for its elevation or reduction, as continuance for any con- siderable number of hours of those degrees of tem- perature will bring about the gravest consequences^ During convalescence it is generally necessary to regulate the diet and to assist the impaired digestion. For the latter purpose pepsin and the various prepa 110 THERMAL PARESIS. rations of this agent, and ingluvin, possess valuable properties. Their powers are enhanced in some cases by the addition of hydrochloric or lactic acid. Patients occasionally die from inanition, due to impairment of digestion and assimilation. Troublesome abscesses, especially of the parotid, are liable to occur. Their management must be based on general principles. They constitute a dangerous complication, yet are not necessarily fatal. Nothing will be said on the subject of prognosis for the reason that this depends so greatly on the previous condition of the patient and the treatment— therapeutic, dietetic and hygienic. There is probably no other disease more certain of producing fatal re- sults if left to itself, although often in a very indirect manner, nor is there another disease that is more amenable to treatment. The low or typhoid grades of fever continue for four or five weeks, under the best directed management, and a simple intermittent or simple paretic depression, may continue for years, if neglected, or until it brings about a fatal result by way of a pneumonia, an incurable disease of the liver, or phthisis. Occasionally the disturbances of one or more of the vital functions is so sudden, and violent, as to produce death before any measures can be brought to bear for the prevention of this result. In order to overcome the paretic condition of the nerve-centers, whether there has been any marked disturbance of one or more of the vital functions of the system or not, it is sometimes necessary to abandon all active mental and physical work, and to bring to bear the invigorating influences of travel and change of climate. LOCATION OF SICK ROOM, ETC. Ill CHAPTER XXIV. LOCATION OF SICK ROOM, THE BED, THE LINEN, AND POSTURE OF THE PATIENT. The first floor is generally unsuitable because of its proximity to the surface, especially if it has not a well ventilated, clean, dry basement or cellar underneath. The second story rooms of two-story houses are generally too hot during the middle of the day, unless well shaded and ventilated. A well ventilated room on the second story of a three or more storied house is the best. Unfortunately this is a matter not always subject to control. The mattresses should be clean and pure, and thor- oughly aired every second day. Feathers and other imperfect conductors, in cases of fevers, are to be condemned. Feather pillows under such circumstan- ces are especially obnoxious. The patient's linen should be renewed daily. The posture should be strictly attended to, in order to avoid hypostatic pneumonia and bedsores. He should be moved at least every hour, to prevent the injurious effects of gravitation and pressure, especially when the circulation has become much enfeebled. Chilling currents of air must also be guarded against under such circumstances. 112 THERMAL PARESIS. CHAPTER XXY. ONE OF THE CAUSES WHY NEW VIEWS ARE SO SLOWLY ACCEPTED. The remarks upon " What can be learned without the aid of the special senses," at the beginning of this work, are the result of experience in the difficulties met with in attempts to convince the minds of men of erroneous ideas long entertained, and perhaps often repeated in thought and word. Under such circum- stances the mind can hardly be convinced, unless by ocular demonstration. An idea long prevalent in the mind, whether erroneous or true, becomes almost as firmly fixed as though the impression had been made by actual sight of the object itself—a definite image having become very clearly and almost indel- ibly fixed in the mind. Such as cannot efface the old " malarious " images unless by ocular demonstration, will go on in their search for a " material specific something," and will arrive at the end of their lives without having found it, as many generations of " blind men with good eyes" have done in the past. The search for, and belief in, a specific material cause of the thermal dis- eases, reminds me, forcibly, of the search of the an- cient alchemists for the philospher's stone. INDEX. Abscess of the parotid............... ...................................110 Acid, hydrobromic......................................................... 98 Air, influence of......................................................35, 62, 63 Algid forms, treatment of................................................105 Arsenic, use of...............................................................107 Arterial disturbances...................................................... 80 Authors, views of........................................................... 51 Blood-letting............................................................108,109 Cause of so-called malarial diseases.....................31, 40, 41, 49 Cachexia, tropical and polar............................................ 25 Cardiac disturbances....................................................... 79 Capillary disturbances..................................................... 81 Cathartics, in treatment:...........................................103,104 Central nervous system, disturbances of.......................... 10 Chill, causes of............................................................33, 34 Cinchona alkaloids, action of........................................... 96 " \" best forms for administration.......97-100 " " contra-indications............................. 97 " " as abortifacients................................ 98 " " want of action...........................100,101 Complications................................................................ 87 Conditions necessary to good health................................ 43 ^Conduction of heat........................................................ 11 Confusion from abundance of symptoms.......................... 85 Deductions of Mr. Tyndall, incomplete........................14, 15 Derangement of circulation............................................ 79 Diagnosis....................................................................... 87 Diagnosis of peculiar forms............................................. 93 Diagnosis, caution in...................................................88, 89 Diarrhcea........................................................................105 Diet in treatment......................................................106, 107 Difference in body temperature....................................... 38 Digestion in regard to treatment......................................109 Disturbances of nutrition................................................ 76 " " respiration............................................. 76 " " secretion.............................................. 78 Eflect of stimulation of nerve-centers..............................107 Eucalyptus glob.............................................................100 ii INDEX. Excitation paresis........................................................... 60 Fever, temperature centers disturbed in............................ 9 Fermentation................................................................. 71 Health, how restored, etc,............................................... 33 Heat, abstraction of........................................................ 68 Heat, animal source of.................................................... 29 Heat, condition of..................................................11, 12,13 Heat, conversion of................................................12,13, 28 Heat, effect of on living human body.............12,13, 28, 29, 62 Heat, enurination of.......................................................50 Heat, increased supply not the cause of nervous disturb- ances.......................................................•................ 10 Heat, how regulated....................................................... 29 Heat, in regard to vital action...................................... 13 Heat, production.........................................................15, 29 Heat production, how regulated...................................28, 29 Heat, regulated by a special center...........................9,10, 31 Heat, solar..................................................................... 28 Heat, solar effects of........................................................ 36 Heat, theory of............................................................... 46 How to avoid thermal paresis.......................................41, 42 How the body protects itself against external heat........... 13 Hughes, Dr., on insolation...........................................50, 51 Hyperthermia...............................................................35,36 Ideas in regard to the wood-malaria................................ 35 Influence of air on action and effect of heat..................63, 64 Importance of correct diagnosis....................................87, SS Inflammatory complications..............................................S7 Insolation.........................................................24, 26, 50, 87 Irritability of nervous system.......................................55, 57 Irritability of nervous system, abnormal.......................58, 59 Irritable nerve centers, results of.................................... 36 Iodine.......'.....................................................................107 Jaborandi.......................................................................108 Kirchner, Dr..............................................................24-26 Liebermeister, temperature in fevers................................ 9 Littell, Dr., theory of...................................................... 52 Malaria, so-called, effects of..........................................20-22 Malaria, so-called, between insolation and tropical ca- chexia...................................................................... 26 Malaria, so-called, what is it?.......................................... 48 Malaria, so-called, seasons of greatest prevalence............. 49 index. iii Malarial diseases, etiology of........................................51-55 Malarial diseases, cause of.............................................31-35 Malarial diseases, not due to a material substance.............. 86 Masked fevers..............................................................84, 85 Mental disturbances........................................................ 73 Milk-sick........................................................................ 91 Motor disturbances.........................................................74 Modes of acquiring knowledge....................................... 27 Moisture, effects of............................................21, 22, 62, 63 Nausea and vomiting in treatment....................................103 Nerve-oenters, effects of.................................................. 36 Nerve-centers, sympathetic, effects of............................... 29 Nerve-centers, excitants of............................................... 50 Nerve-centers, results of over-excitation........................... 40 Nerve-force, exhaustion of............................................... 26 Nervous system, excitation of......................................60, 61 Nervous system, irritability of.......................................55-59 Nervous system, tone of.................................................. 58 Oldham, Dr., etiology by..............................................48-50 Pathology..................................................................... 73 Pathological conditions................................................20, 21 Paresis, results of........................................................19, 58 Paresis, causes of...........................................17, 19,42, 53, 54 Paresis, how to avoid........................................41, 42, 43, 64 Paroxysms, character of.............................................82-84 Paths to the truth........................................................20,23 Periodicity, cause and nature of....................................32, 33 Pernicious forms, treatment......i......................................105 Perspiration, function of.................................................. 13 Phenomena in tlrermal paresis of sympathetic................. 63 Posture of sick............................................................. 112 Potential energy...........................................31, 33, 40,55, 57 Quinoidine..................................................................... 96 Quinoidine, animal.......................................................... 47 Quinia. action of............................................................. 96 Radiation of heat................ .'.......................................... 39 Reasons for a correct pathology...................................33, 41 Refrigeration...............................................................24-26 Rhythm, cause of...................................................32, 33,82 Sensoiy disturbances...................................................... 73 Sodium, sulphate, use of...........................................100, 104 Solar heat, effects............................................................ 68 IV INDEX. Solar heat, modified by topography..............................65, 67 Sick room.......................................................................Ill Spinal nerves, function of................................................ 57 Stimulants.......................................................................108 Sympathetic centers.....................................................44, 47 Sympathetic centers, disturbances of.............................. 75 Sympathetic centers, functions of...................................... 57 Strychnia........................................................................108 Sudden increase of thermal diseases................................. 67 Temperature, extremes of.......................................24, 26, 27 Temperature, human.....................................30, 31, 38, 40, 42 Temperature centers.......................................................... 9 Temperature centers, where located................................... 31 Temperature centers, how associated................................ 32 Temperature, disturbances of............................................... 77 Theories of decomposition.............................................70-72 Thermal diseases..................................................................65, 66 The human body as a conductor and radiator.................... 17 Thermal diseases, dangerous forms..............................91, 92 Thermal diseases, accurate, all ages.................................. 93 Thermal diseases, relapses.................................................... 93 Thermal diseases, treatment of.....................................*,. 95 Thermal diseases, results of.............................................110 Thermometer......................................................55, 89, 109 Tonics on nerve-centers.................................................... 33 Topography, influence of............................................ 65-69 Types................................................................................................82, So Tone of nervous centers........................i......................31-33. 40, 55 Vaporization...............,.................................................................... 13 Vegetable decomposition.......................................................... 70 Views, undergoing development.........,...............,............., 51 Vital processes............................................................14, 15, 38 Venous and arterial disturbances......................................... 80 Why new views are so slowly accepted................................112 Errata.—On page 17, third line from bottom, read gland- ule for glandular; on p. 26, eleventh line, read overleaping for overlapping; on p. 5(5, twenty-first line, read nutrient for nutriment; on page 88, third line, read clearly for clear. 'l:iv>37$»:.«s. •*■...■ £'•£%;*&.. ■-■''■' l#L&■:*■?: ■■■■ — ; ••^■^; ?¥-*■■ ■,-;. ■•" .•■jet ■•.'' :.iv?-.;-^ '■• --'. '-'•*»-js.<|*~ <,t-, ■ --, hSf*«f ii *'■■-. - ' ' ' TTL-Jt** -*v r«'. * •.... •w r jCZ! • •• ■ ,l - **-':' <-i ■■ '^tflTjKV fcVv *, ,' NLM001222402