Volume 1 — GENERAL DISEASES. (continued 4)

The death-rate of typhoid fever is found to vary very considerably in different years and in the different seasons of the year, as will be seen from the two following tables. Statistics as to the mortality of the disease to be reliable must therefore be based upon a large number of cases extending over a series of years.

The following table shows the number of cases admitted into the Pennsylvania Hospital during each of the twenty years ending Dec. 31, 1881, and the ratio of mortality among them:

TABLE NO. 1.

YEAR. Number of cases. Number of recoveries. Number of deaths. Number of deaths within 48 hours of admission. Average stay in cases ending in recovery. Average stay in fatal cases. Percentage of deaths. Percentage of deaths after deducting cases fatal within 48 hours of admission.

1862 89 68 21 7 54¹/3 8 23.6 17.7

1863 36 33 3 2 32¹/5 3¹/3 8.3 2.9

1864 43 35 8 1 38¹/2 8 18.6 16.3

1865 36 31 5 1 38¹/2 5¹/2 13.9 11.4

1866 23 17 6 0 45²/3 9 26.0

1867 24 20 4 0 37¹/3 6¹/2 16.6

1868 27 23 4 0 44³/4 10 14.8

1869 21 16 5 1 35¹/2 14 23.8 20.0

1870 24 19 5 1 47¹/2 11 20.8 17.4

1871 32 26 6 1 37³/4 13¹/2 18.8 15.0

1872 21 16 5 3 37¹/2 4¹/2 23.8 11.1

1873 12 8 4 2 34 9 33.3 20.0

1874 16 12 4 0 54¹/2 9³/4 25.0

1875 20 18 2 1 48 4¹/2 10.0 5.3

1876 30 21 9 2 45¹/2 11 30.0 25.0

1877 48 34 14 4 48¹/2 12¹/2 29.2 22.7

1878 8 5 3 0 49 5²/3 37.5

1879 17 15 2 0 53¹/3 8 11.8

1880 40 35 5 2 47 10¹/2 12.5 8.0

Totals, 621 500 121 28 43¹/2 8³/4 19.5 15.7

Out of the 621 cases admitted, 121 were fatal. This gives a death-rate of 19.5 per cent.; but if we deduct the 28 cases in which the patients died within forty-eight hours of their admission, it falls to 15.68 per cent., or about the same ratio as Murchison found to exist among the cases treated at the London Fever Hospital. Other observers have obtained slightly different results. Thus, the mortality was 11.16 per cent. in 197 cases analyzed by Dr. Hale, and 13.5 per cent. in 303 cases collected by Dr. James Jackson. Dr. Cayley⁹³ found the death-rate of the several hospitals in London to be 17.8 per cent., and Geissler⁹⁴ that it was in all the German hospitals 12.8 per cent. in 1877, and 13.5 per cent. in 1878. Flint had 18 deaths in 73 cases, or 24.4 per cent. According to Liebermeister, the ratio of mortality at the hospital at Basle during the twenty-two years from 1843 to 1864, or before the introduction of a systematic anti-pyretic treatment, was 27.3 per cent., and only 8.2 per cent. during the six years immediately following its adoption. As the results obtained at the Pennsylvania Hospital are apparently not so favorable as those reported at some of the continental hospitals, it is only proper to state that a large proportion of the cases were severe, that many of them were far advanced in the disease when admitted, and that very few of the patients were under twenty-one years of age. These are all circumstances which influence very decidedly the prognosis in typhoid fever. In no other city are the laboring classes able to surround themselves with so many comforts as in Philadelphia. This fact, fortunate as it is in the main, often operates to the disadvantage of the patient by enabling his family to indulge for a time the reluctance which it naturally feels to part with a member when sick. In the case of the young this reluctance is so hard to overcome that children with acute affections are rarely brought to hospitals for treatment. There were also special causes for the large mortality in certain years. This was particularly the case in 1862, when a large number of soldiers fresh from the battlefields of Virginia, and suffering from the typho-malarial form of the disease, were admitted into the hospital. Many of them were moribund upon admission, and others, exhausted by the fatigue incident to transportation here and by previous hardships, soon succumbed to the disease.

⁹³ Med. Times and Gaz., 1880.

⁹⁴ Schmidt's Jahrbuch.

Table 2 gives the number of cases, with the number of deaths occurring in each season, at the Pennsylvania Hospital during the last twenty years:

TABLE NO. 2.

Spring. Summer. Autumn. Winter.

Number of cases 89 259 182 91

Recoveries 73 191 163 73

Deaths 16 68 19 18

Percentage of mortality 18.0 26.2 10.4 19.8

It will be seen from this table that the highest death-rate occurred in the summer and the lowest in autumn, while there was only a slight difference between the death-rate of spring and that of winter. Murchison's experience, based on a much larger number of cases, has led him to conclude that while the disease is a little less fatal in autumn, the difference in the mortality at different seasons is very inconsiderable. Chomel believed that the percentage of deaths was highest in France during the winter months, and Bartlett held the same opinion as regards America. Epidemics of great severity have undoubtedly prevailed in winter, as the in Lowell, Mass., referred to by Bartlett, but there can be little doubt that the death-rate is highest in this country during the warm months of the year. Dr. Cleemann⁹⁵ found that the monthly average mortality in Philadelphia for the ten years from 1866 to 1875 was highest in August, and next highest in September, confessedly the two months of the year when the heat in this city is most exhausting. I feel very sure I have lost patients with typhoid fever in these months and in July who would probably have recovered if the weather had been cooler. With a temperature often rising above 90° F. at midday, and sometimes for several days at a time never falling below 80°, all radiation of heat from the surface of the body is arrested, and death frequently occurs as the result of hyperpyrexia.

⁹⁵ Transactions of the College of Physicians of Philadelphia, 3d S., vols. ii. and iii.

The stage of the disease at which efficient treatment is begun has a manifest influence upon the result. This is strikingly shown by some observations of Jackson: 90 cases were admitted into the Massachusetts General Hospital during the first week—of these 7 died, or 1 in 12.85; 139 cases were admitted in the second week—of these 16 died, or 1 in 8.68; 46 cases were admitted in the third week—of these 10 died, or 1 in 4.60; and 21 cases were admitted in the fourth week, and of these 5 died, or 1 in 4.20. Convalescence also occurred much earlier in those who were admitted early.

Murchison found that in a large number of cases the death-rate varied at different ages as follows: Under ten years it was 11.36 per cent.; from ten to fourteen years it was 12.86 per cent.; from fifteen to nineteen years it was 15.48 per cent.; from twenty to twenty-nine years it was 20.46 per cent.; from thirty to thirty-nine years it was 25.90 per cent.; from forty to forty-nine years it was 25 per cent.; and above fifty years it was 34.94 per cent.

According to Liebermeister, among the 1743 patients treated for typhoid fever in the hospital at Basle from 1865 to 1870, inclusive, there were 130 who were more than forty years old; of these 39, or 30 per cent., died, while the mortality among the patients under forty amounted only to 11.8 per cent. Among the cases of typhoid fever in individuals over forty years of age collected by Uhle, more than half proved fatal. According to Friedrich,⁹⁶ there were, among 16,084 children treated in the Children's Hospital at Dresden, 275 cases of typhoid fever, of which 31, or not quite 11 per cent., proved fatal. Age, therefore, exercises a positive influence upon the mortality of typhoid fever. Its influence is less decided in this disease than in typhus, in which the death-rate does not reach 4 per cent. until after the age of twenty, when it rapidly rises from 12.34 per cent. until it reaches 57.03 per cent. in patients above fifty years of age. The comparatively slight mortality of typhoid fever among children is probably due to the fact that the temperature is less often continuously high in them than in adults, and that while hyperpyrexia is frequently present, it is generally better borne and less likely to produce paralysis of the heart. Liebermeister says that the only case which he has seen recover after the temperature had repeatedly risen to 107.5° F. was that of a girl fourteen years of age. It is also said that the intestinal lesions are not so severe, and the liability to complications and sequelæ less marked, in children.

⁹⁶ Quoted by Liebermeister.

Typhoid fever appears to be a slightly more fatal disease in women than in men, for while in some local epidemics the percentage of deaths is greater among the latter than among the former, the reverse is found to be the case when the records of a large hospital for a number of years are carefully examined. According to Murchison, the mortality at the London Fever Hospital was about 1 per cent. higher among the female than among the male patients, and about the same difference in the death-rate of the two sexes has been reported by continental physicians. A greater disparity even than this has been observed by Liebermeister at the hospital at Basle, where the death-rate for women was 14.8 per cent., and only 12 per cent. for men. Murchison says that this excess of mortality among the former cannot be accounted for by the influence of child-bearing upon the course of the fever, since it is much more decided between the ages of five and fifteen than in the period of child-bearing.

The rich are not only as liable to contract typhoid fever as the poor, but the disease is also quite as fatal among them. Murchison found from the statistics of the London Fever Hospital that the mortality is not greater among the destitute than among the better class of patients, and expresses the opinion that in private practice enteric fever is probably more fatal among the upper classes than among the very poor. Chomel and Forget seem to have reached a similar conclusion.

All authors agree that the prognosis is unfavorable in corpulent persons, not only on account of the diminished power of resistance to disease generally which such persons exhibit, but also because the febrile movement is often intense in them, and the degenerative changes of the muscles and organs of the body which it induces are generally early developed and of high grade. Liebermeister goes so far as to say that even in the case of ill-nourished, anæmic, or chlorotic individuals the chances for life are better than in the corpulent. Murchison has also expressed the opinion that a large, muscular development is likewise an unfavorable element in prognosis, having seen the strong and robust succumb to the disease oftener than the feeble. The mortality from the disease appears to be greater in certain families than in others. This has been ascribed by some writers to peculiarities of constitution, but it may be due to other causes, as, for instance, difference in the intensity of the poison. The disease is also often very fatal among the intemperate, who usually bear the disease badly in consequence of the presence of various degenerations of one or more of the important organs of the body caused by the excessive indulgence in alcoholic stimulants; paralysis of the heart being not an infrequent cause of death among them.

Certain epidemics have been exceedingly fatal, while in others the percentage of deaths has been very small. There can be no doubt that in most of these cases there has been a difference in the virulence of the poison. Recent residence in an infected locality has been shown by Murchison and other writers to have a decided influence in increasing the fatality of the disease. Second attacks are, on the other hand, usually mild. Some diversity of opinion exists among authors in regard to the effect that pregnancy has upon the course of the disease. Murchison believes that it is a far less formidable complication than is usually thought, while Liebermeister, on the contrary, holds a directly opposite opinion. He also regards the prognosis as unfavorable when the disease occurs in childbed or a short time afterward. Individuals with disease of the heart, emphysema, or bronchial catarrh who contract typhoid fever are said to be more liable to paralysis of the heart than others, hence the existence of these diseases materially diminishes their chances of recovery.

TREATMENT.—Inasmuch as the spread and propagation of typhoid fever may be prevented to a great extent, if not entirely, by the employment of judicious sanitary measures, it is proper, before entering upon the discussion of its curative treatment, to devote a few words to the prophylaxis of the disease.

Whether the physician accepts the theory so ably advocated by Murchison, that typhoid fever may arise from exposure to the products of the fermentation of healthy feces, or adopts the view now held by a large number of investigators, that the disease is never generated in the absence of the specific germ, he will admit the great importance of an efficient system of sewerage, with a thorough flushing of the sewers at regular and frequent intervals, for disposing of the fecal discharges of the population of all towns, no matter how inconsiderable in size. No less important is it that the drains of every dwelling should be well constructed and kept in good order. They should be trapped just before they empty into the sewer, and should be provided with the means of thorough ventilation between the trap and the walls of the house by a free communication with the outer air. The soil-pipe should be carried up three or four feet above the top of the house, and every water-closet, bath-tub, stationary washstand, and sink should have its own separate trap, and none of them should be placed in rooms unprovided with a window or with some other sufficient means of ventilation. Physicians should, as sanitarians, urge upon the authorities of all cities and towns the importance of deriving their water-supply from a source unpolluted by sewerage or by any other substances likely to be deleterious to health. They should also see that when water is stored in a tank inside of a house the overflow pipe does not communicate directly with the drain, since if this is allowed to occur the water may very soon become contaminated with sewer gas, and consequently unfit for internal use.

In the case of isolated country-houses and of small villages some other means of disposing of the fecal discharges of the inhabitants than by sewers has to be found. In the great majority of instances no better way presents itself than by the ordinary cesspool. Care should, however, be taken that this is so constructed and situated that there can be no filtration of its contents into wells from which water for drinking is obtained.

As the alvine dejections of the sick are beyond question the medium by which typhoid fever is most frequently communicated to others, the importance of thoroughly disinfecting them before they have acquired the power of imparting the disease cannot well be overestimated. Liebermeister recommends that the bottom of the bed-pan should be strewed, each time before being used, with a layer of sulphate of iron, and that immediately after a passage crude muriatic acid should be poured over the fecal mass, as much as one-third or one-half of the bulk of the latter being used. He also urges, whenever it is practicable, that the contents of the bed-pan should be emptied into trenches dug anew every two days and filled up when discarded, care being of course taken that they are not located anywhere in the vicinity of wells. Murchison seems to prefer carbolic acid to other chemical agents as a means of preventing fecal fermentation. For this purpose the liquid carbolic acid may be diluted with water in the proportion of 1 to 40 to 1 to 20, or it may be mixed with sand or sawdust. I have myself employed as a disinfectant with success the solution of the chlorides sold under the name of Platt's chlorides. As the discharges must in cities, in the great majority of instances, be emptied into water-closets, these should be freely flushed with water after every time they are used; and it is well to impress upon the attendant on the sick the importance of doing this. The bed-linen of the patient and his clothes, if they are soiled by his discharges, should be removed as soon as possible, and subjected to a high degree of heat (248° F.) or soaked in a solution of the chlorides or of carbolic acid for several hours before being washed. If these precautions are observed, cases of typhoid fever may be treated in the wards of general hospitals without danger to the other patients.

In the doubt and obscurity which generally envelop the diagnosis of the disease when the physician is first called upon to treat it, it is impossible to lay down any positive rules for the management of typhoid fever at its commencement. But even in those cases which begin insidiously, if the patient is carefully examined enough of the early symptoms of typhoid fever will be detected to put the physician on his guard. The thermometer will show the existence of fever, which has a tendency to increase at night. There will generally be found to be a little diarrhoea, or at least an increased susceptibility to the action of purgative medicines; perhaps a little tympany and tenderness in the right iliac fossa, and moreover a prostration which is out of all proportion to the other symptoms.

These symptoms, it is true, are not infrequent concomitants of many diseases besides the one under consideration; but when their presence cannot be otherwise satisfactorily explained, especially if they have continued for several days, it is a safe rule in practice to regard the case as one of typhoid fever, and to regulate the treatment accordingly. The patient must be put to bed at once, and not allowed to leave it on any pretext, not even to empty his bladder, after the first week. This is a rule which should be rigidly enforced in every case, no matter how mild the symptoms may be. Its non-observance, either through the neglect of the physician or the ignorance or wilfulness of the patient, has been the cause of some disastrous results; in illustration of which it is only necessary to refer to the frequency with which perforation of the bowel occurs in walking cases of typhoid fever. Perfect quiet should be maintained in the sick room. Visitors should be excluded from it, and the attendants limited in number to those actually necessary to carry out the directions of the physician. All unnecessary talking is to be avoided, and especially conversation carried on in a low tone of voice, which is always annoying to the sick.

There is only one condition under which I should be disposed to break the rule of absolute quiet and rest laid down above, and that is when called upon to treat typhoid fever in the built-up portion of our large cities during the summer season. If the patient were still in the first week of the disease, if his circumstances were sufficiently affluent to enable him to surround himself with every comfort, and if it did not involve a journey of more than a few hours, I should unhesitatingly send him to the sea-coast. I have so often seen cases prove fatal in summer in consequence of the great heat of the city—a heat, too, which is sometimes almost as great at night as in the day-time—that I should feel that I was giving him an additional chance of life by sending him where the heat was, at least occasionally, tempered by cool breezes from the ocean. During the late war numbers of soldiers were frequently sent in the early stages of typhoid fever from the camps in the South to their homes or hospitals in the North, and it is fair to say that they did at least as well as those who remained behind. But when the journey may be accomplished by means of Pullman cars and the other appliances of modern travel the risk, and even discomfort, it involves to the patient is reduced to the minimum.

As the disease is usually one of long duration, the patient being rarely able to leave his bed under four weeks, and more frequently being obliged to keep it for a much longer time, the sick room should, wherever practicable, be large, airy, and provided with an open fireplace, which is a much more efficient means of securing thorough ventilation than an open window, while it is not liable to the objection sometimes applicable to the latter of causing a direct draught upon the patient. It is well, however, for the physician to remember that the danger from this source is very much exaggerated by the laity, and that patients in the febrile stage of typhoid fever do not readily take cold. Still, the same end may generally be attained without the least risk to the patient by opening a window in an adjoining room. The temperature of the sick room should be steadily maintained at between 65° and 68° F.

The careful regulation of the diet is also a point of great importance in the management of typhoid fever; for in this disease there are not merely the high fever and other exhausting symptoms, speedily inducing excessive prostration, loss of strength, and emaciation, common to many fevers, but there is also the peculiar ulceration of the bowels, which gives rise to danger of its own and demands special consideration in treatment. The food must therefore be not only nourishing, but also readily digestible, and not likely to create irritation in its passage through the intestines. All solid food should therefore be excluded from the dietary of the patient as long as the fever lasts. Indeed, it is better to continue this prohibition even after the subsidence of the fever if rose-colored spots are still to be seen on the abdomen or elsewhere, or if there exists a tendency to diarrhoea or any other symptom indicating that the disease has not fully run its course. Having myself seen some rather disastrous results from a too early return to solid food, I have been accustomed in my own practice to interdict its use until at least two weeks after the beginning of convalescence. Jaccoud also lays much stress upon this point, saying that the early administration of meat always gives rise to fever, to which, from its cause, he gives the name of febris carnis. On the other hand, Flint⁹⁷ and Peabody have recently advocated the giving of solid food immediately after the cessation of fever, in the belief that recovery is thereby promoted. Milk as an article of diet is unquestionably to be preferred to all others in typhoid fever. It is open, it is true, to the objection of occasionally forming tough curds in the stomach, but this may generally be prevented by giving the milk in small quantities at a time, diluted with lime-water or barley-water or mixed with some farinaceous substance. No positive general rule can be laid down as to the amount to be given. This will be found to vary not only in different cases, but also in the same case at different times. Indeed, in those cases which begin abruptly with symptoms of gastro-intestinal irritation, if it is forced upon the patient in large quantities it is not only usually rejected, but also causes an aggravation of the symptoms, while after this irritation is allayed it will be digested without difficulty. As a general rule, most adult patients will be able to take from a quart and a half to two quarts of milk daily, given in quantities of from four to six ounces every two or three hours. It should be remembered, however, that if more is taken than can be assimilated it will act as an irritant and increase the diarrhoea. If, therefore, the stools contain undigested milk, the quantity should be diminished. Patients are occasionally met with, but not in as great number as is often asserted, with whom milk habitually disagrees. In these cases it must of course be replaced in whole or in part by some other article of food. Under these circumstances some one of the liquid preparations of beef may be given with advantage, although it may be objected to them also that they sometimes occasion an increase of diarrhoea. Beef-tea or beef-essence, made from the fresh meat whenever this can be obtained, is to be preferred to all others; but when it cannot, that made from the preparations of Johnston or Brand is the best substitute. When the stomach is very irritable, Valentine's meat-juice, in consequence of the smaller bulk in which it is given, often answers an admirable purpose.

⁹⁷ Medical News, Mch. 29 and Apl. 5, 1884.

Various farinaceous substances, such as farina, corn-starch, and arrowroot, are also occasionally given in typhoid fever, and, although the last named would seem to be indicated in cases in which diarrhoea is a prominent symptom, their tendency to cause flatulence is so great that their use in the acute stage of the fever has not found favor among physicians generally. In convalescence, on the other hand, they are generally perfectly well borne.

The subject of the administration of alcoholic stimulants in typhoid fever may be conveniently considered in this connection. Some difference of opinion exists in regard to the quantity in which they should be given, and indeed in regard to the necessity for their use at all in many cases, as, for instance, in those of young persons whose health and habits had been good previously to the attack. I have myself treated several such cases without alcohol, and have not been able to perceive that their duration was longer and the result less favorable than in cases in which it was given in the usual amount. It is, moreover, not necessary to prescribe it always, even in very severe cases, at the beginning of an attack. When given at this time, it not infrequently does harm by increasing the fever. It should be reserved, therefore, until the action of the heart grows feeble and the first sound becomes indistinct. It is not possible to lay down any general rule as to the amount to be given, even in severe attacks. This will vary in different cases, and to a certain extent will be determined by the effects it produces. If the pulse grows stronger and the delirium diminishes under its use, it is doing good and should be continued; if, on the other hand, there is increase of delirium and restlessness, the quantity should be diminished.

In cases in which only a gentle stimulus is required wine in the form of wine-whey will often be found to meet the indication fully. Generally, however, it will be necessary to have recourse to whiskey or brandy. The choice between these may usually be left to the patient's fancy; brandy is, however, to be preferred in cases in which diarrhoea is a prominent symptom. These stimulants should be given in small quantities frequently repeated. In many cases a dessertspoonful every two or three hours, either diluted with water or, when the stomach is irritable, with carbonic acid water or given in the form of milk punch, will be sufficient. In others a tablespoonful every two hours, or even at shorter intervals, will be required, but it will rarely be necessary to exceed eight ounces a day for more than a few days at a time.

Although the physician will not often be called upon at the present day to encounter and combat the prejudice so common formerly against the free administration of water in the febrile condition, he will frequently find nurses and others not sufficiently alive to the importance of supplying it when the patient, having fallen into the typhoid state, ceases to ask for it. The high temperature which is generally present in this condition, and the rapid combustion of tissue which it causes, make a full supply of liquid an urgent necessity which it is dangerous to disregard. Water is the best of all diuretics, and it is important in this disease, as indeed it is in many others, that the functions of the kidneys should be kept active, so that the products of the combustion of the tissues may be eliminated with their secretion. Care, however, should of course be taken, as pointed out by Da Costa,⁹⁸ that water is not given in such quantity that the desire for and capability of digesting food is destroyed by it.

⁹⁸ Preface to Wilson's Treatise on the Continued Fevers.

In the few cases which begin abruptly with symptoms simulating those of a so-called bilious attack the practitioner will usually content himself with the administration of medicines calculated to allay the irritability of the stomach and bowels. For this purpose I have found the bicarbonate of potassa in solution, to which lemon-juice is added at the moment it is taken, so as to produce an extemporaneous effervescing draught, often an admirable remedy. In other cases I have used with advantage small doses of calomel or blue mass, followed, if necessary, by a gentle saline purge. When the symptoms have occurred soon after a hearty meal, or when there is evidence that the stomach is overloaded, it will occasionally be necessary to have recourse to an emetic. Usually, the indications for treatment at the beginning of an attack are much less definite, and even in the class of cases just referred to they become so after the subsidence of the gastro-intestinal symptoms. Indeed, the treatment in the larger number of cases must be purely symptomatic until the nature of the disease has fully declared itself. The presence of fever will suggest the use of the neutral mixture, effervescing draught, or spirit of Mindererus, combined, if there is decided tendency to evening exacerbations, with sulphate of quinia in full doses. If there is much diarrhoea, Hope's camphor mixture or opium in some other form may be given; if delirium is a prominent symptom, ice or cloths wrung out of cold water should be kept constantly applied to the head.

But even after all doubt in regard to the diagnosis has been dispelled and the existence of typhoid fever has been recognized, the treatment most in favor with physicians is in large measure symptomatic in character. It is true that various specific treatments, to which fuller reference will be made hereafter, have been lately proposed, but the results obtained by them up to the present time where they have been fairly tested are not so favorable as to induce the body of the profession to adopt them to the exclusion of all other methods. It is certain that no remedy or plan of treatment has yet been discovered which has the power of cutting the disease short, although this power has been claimed at different times for several. Thus, at one time quinia in very large doses was believed to possess it, at another venesection, and at another cold baths. But experience has shown that these and other perturbating remedies often do harm, and there is good reason to believe that the apparent good which has followed their use in a comparatively small number of instances may be better explained by supposing that an error of diagnosis has been made than by attributing to them the power of arresting the progress of the disease. Medicines are, however, by no means useless in the treatment of typhoid fever. There is no question that the disease is not only generally conducted to a favorable issue, but that its duration is often materially shortened, by their judicious use. It is evident, however, that the treatment must vary with the severity of the attack. In a few cases it is scarcely necessary to interfere with the course of the disease by the administration of medicines. In others, on the contrary, it is necessary to act promptly and energetically in order to save life.

When called upon to treat typhoid fever, if the case is a mild one with no bad symptoms, such as excessive diarrhoea, delirium, tremors, and the like, and especially if the temperature does not rise higher than 102° F., I am accustomed, after giving minute directions as to the diet and general care of the patient, to prescribe from two to three grains of sulphate of quinia four times daily. No great power in reducing the temperature of the body can, of course, be claimed for these doses, but experience has shown that the impression which they make is useful, and they do not interfere with the administration of the drug in larger quantities should this become necessary. Their action, too, is tonic, and, as they rarely produce cinchonism, the objection often made to the use of larger doses does not apply to them. I am also in the habit of adding to each dose of quinia from ten to fifteen drops of one of the mineral acids. These acids were originally prescribed in typhoid fever under the impression that they neutralized the cause of the disease, which was supposed to be an alkaline poison. Although the results of recent research, which tend to show that the cause of the disease is an organized germ, give no support to this theory, they continue to be used by a large number of physicians of experience. I do not know that any satisfactory explanation of their action in typhoid fever has ever been given. They are certainly tonics, and are therefore indicated, if not in the beginning of the disease, as soon as the strength begins to fail. If, as the disease progresses, the tongue becomes dry and fissured, and if there is much tympany, it will be well to give, in addition to the quinia, ten drops of the oil of turpentine in mucilage every two hours. This was a favorite remedy of the late George B. Wood, the distinguished professor of the Theory and Practice of Medicine in the University of Pennsylvania, who attributed the improvement in the symptoms which generally follows its use to a direct influence of this medicine upon the ulcers in the intestines. Although inclined to believe that the correct explanation of this improvement is its stimulating action upon the circulation and secretions, I fully agree with him in regard to its usefulness in many cases. Under its use I have often seen the dry, fissured, and shrivelled tongue grow moist and throw off its coating much earlier than in all probability it would otherwise have done.

No other than this simple treatment is required in a large number of cases, but even in mild cases symptoms occasionally arise which render necessary some modification of it. It will, however, be more convenient to postpone the discussion of this part of the treatment of typhoid fever until after the treatment of the more serious forms of the disease has been considered.

When typhoid fever assumes a severe type, the success of the physician in the management of the disease will depend largely upon the readiness with which he detects indications for treatment and the promptness with which he meets them. Usually, one of the first symptoms to demand attention is the high temperature. This is not only an early symptom in many bad cases, but may continue throughout the attack; or it may suddenly supervene in cases in which the fever has previously been moderate in degree, and when excessive may be the direct or indirect cause of death. The reduction of the temperature is therefore an indication the importance of which cannot well be overestimated. Fortunately, there are several methods by which this end may be accomplished. It will, however, be necessary for our purpose to consider only two of them in detail: 1, the cold-water treatment; 2, sulphate of quinia in full doses.

The cold-water treatment is not new, since it was practised in the form of cold effusion in the treatment of fevers as long ago as 1787 by Currie of Liverpool, who may be said to have introduced it, and who asserted that it had the power not merely of moderating the symptoms of these diseases, but also, in many cases, of cutting them short. It enjoyed at first a high degree of popularity, which lasted for from twenty to thirty years, but finally fell into disuse, probably in consequence of the exaggerated character of the claims which were made for it by its advocates. Although resorted to from time to time in various parts of the world, the merit of having brought it again into notice seems to be due to Brand of Stettin, who published a work on The Hydrotherapy of Typhoid Fever in 1861. Still more recently, the recorded observations of Bartels, Jürgensen, Ziemssen, and Liebermeister in Germany, and of Wilson Fox and others in England, have so far restored the treatment to professional favor that there are few physicians either in this country or abroad who do not occasionally have recourse to it.

The cold-water treatment may be applied in several different ways: 1, the cold bath; 2, the graduated bath; 3, cold affusions; 4, the cold pack; 5, cold sponging; 6, cold compresses; and 7, frictions with ice. They all act in the same manner, and depend for their efficacy upon their power of abstracting heat from the body, and are useful just in proportion as they do this. There is no reason for believing that they have the power to modify the conditions upon which the production of heat depends, but there is, on the other hand, no doubt that under their use distressing and dangerous symptoms, such as coma, stupor, subsultus, and the like, are often much relieved. They probably act, therefore, by diminishing the metamorphosis of the tissues, and the consequent loading of the blood with excrementitious products which the hyperpyrexia has a tendency to promote.

The cold bath is the most effective of all the methods of applying the cold-water treatment. Liebermeister recommends that the bath for an adult should be at the temperature of 68° F., and its duration should be about ten minutes; if, however, the patient shows signs of great weakness, it should not exceed seven. After the bath he should be wrapped up in a dry sheet or light blanket and put back in bed. If the pulse should then show signs of failing, or if there should be shivering or any other evidence of weakness, he should be given a glass of wine or brandy or a dose of some other diffusible stimulus, and bottles containing hot water should be applied to his feet. The process of cooling goes on for some time after the patient's removal from the bath, for while a thermometer placed in the axilla will show that the external temperature is immediately affected by it, the same instrument placed in the rectum will indicate a gradual fall, which will continue in many cases for at least half an hour. Shortly after this the temperature will be observed to rise, and in many cases it will not be more than two hours before it has attained its former height. Liebermeister therefore recommends that the thermometer should be frequently used, and that the baths should be repeated as often as the temperature rises to 103° F. or above it. He has himself given them as often as every two hours, or as many as two hundred during an entire illness, but usually finds that not more than six or eight a day are required. It often requires some persuasion to overcome the repugnance which most patients feel at first for these baths, and the shock of being suddenly immersed in cold water is agreeable to very few. Later, this repugnance, he says, entirely disappears. Intestinal hemorrhage, perforation of the bowel, and great weakness of the heart's action are all contraindications to the use of the cold bath. They are especially to be avoided, according to Liebermeister, when the force of the circulation is so far reduced that the surface of the body is cold while the interior is very hot. On the other hand, the advocates of this plan of treatment contend that the existence of pneumonia or of hypostatic congestion of the lungs is not a sufficient reason for abandoning it, the congestion often disappearing under its use.

The graduated bath possesses some advantages over the cold bath, as its use involves less of a shock to the system. It is therefore more suitable than the latter for nervous and excitable patients, for persons of advanced age or of general feebleness of constitution, or for very young children. In it the temperature of the water, which at the time of the immersion of the patient should be at or above 95° F., is cooled by the gradual addition of cold water until it is reduced to 72°, or below this point. These baths, to produce the same effect as the cold baths, must be of longer duration. They are contraindicated in the same conditions as the latter, but to a less degree.

Although fully willing to admit the good effects of the cold bath in many cases, having been, of course, myself a witness of them, I am indisposed to have recourse to it except in cases of hyperpyrexia of such intensity that death seems imminent and only to be averted by energetic treatment, or in cases in which other antipyretic remedies have failed to reduce the temperature; and for the following reasons: 1. In the first place, it is generally possible to produce a decided effect by the other methods of applying the cold-water treatment, with much less discomfort to the patient. 2. In a private house it is not always practicable to have a bath brought to the bedside of the patient, and in a general hospital to do so often would occasion a good deal of annoyance to the other patients in the same ward, and I have seen ill result from carrying him some distance to the bathroom. But even where the bath is brought directly to his bedside, it involves so much movement, and is sometimes the cause of so much excitement, that its good effects are more than neutralized by its bad.

Cold affusions, while not nearly so efficacious in reducing the temperature of the body as the cold bath, are open to many of the objections which may be urged against the latter mode of treatment. They are, therefore, rarely employed at the present time. Liebermeister, however, thinks that they may sometimes be resorted to with good effect for their brisk stimulating effect on the psychical functions or the respiration.

The cold pack possesses the advantage over the cold bath and cold affusions of involving less movement on the part of the patient and of being less terrifying to children, and may therefore be resorted to in cases in which the latter method of applying the cold-water treatment is contraindicated, as, for instance, in persons of feeble circulation. It is, however, inferior to either of them in its cooling effects, and must be longer applied to produce the same effect. Liebermeister estimates that a course of four consecutive packs, of from ten to twenty minutes' duration apiece, is about equivalent in effect to a cold bath of ten minutes.

Cold sponging is assigned a very low place among the methods of abstracting heat from the body by many writers. It has, however, often been in my hands of much service, and its easy application and the comfort which patients derive from it are certainly strong recommendations in its favor. I have employed it frequently in cases of intestinal hemorrhage, and even in cases of great debility, and have never yet had any reason to repent my having done so. The addition of a little vinegar to the water has seemed to me to increase the effect of the sponging.

Cold compresses, either in the form of cloths wet with cold water or bladders filled with ice, can only produce a local fall of temperature, and therefore, except when applied to the head, can be of little service.

Frictions with ice are a powerful means of depressing the temperature of the body, and may therefore be resorted to in cases of intense hyperpyrexia when for some reason the cold bath cannot be obtained, and when there are no contraindications to the latter.

Liebermeister classes cold drinks, the internal administration of ice, and the injection of cold water among the means of cooling the body in fevers; but it is doubtful if any great reduction of temperature can be brought about by any of these remedies in the quantities in which it would be safe to use them. The first two, and to a less extent the last, meet a very important indication, that of supplying water to the system. Their free use, therefore, forms a very important part of the treatment of typhoid fever.

Luton of Rheims⁹⁹ extols the Diæta hydrica in the treatment of typhoid fever. The patient receives absolutely nothing else to drink but water, which is given in large quantities, for from four to six days. No nourishment is given until the beginning of the third week, and first of all milk. If fever returns, the water is given again. Medicines such as quinia and eucalyptus are given in adynamic conditions, which Luton says are rare under this treatment. He believes that the increase of the typhoid germs is prevented by absolute diet and abundant supply of water.

⁹⁹ Journal de thérapie, Oct., 1880.

Quinia to produce a decided antipyretic effect must be given in large quantities. Murchison says that a dose of from fifteen to twenty grains causes within an hour or two a fall of the temperature, and, to a less extent, of the pulse, which may last from twelve to eighteen hours, and that he has never known any other disagreeable symptoms result from its use than noises in the ears, temporary acceleration and irregularity of the respiration, and occasional vomiting. This quantity will often, however, be found to be insufficient to produce a notable reduction of the fever, and it is therefore necessary occasionally to increase it. Liebermeister usually gives to adults from twenty-two to forty-five grains of the sulphate or the muriate of quinia, and this dose must positively be taken within the space of half an hour, or, at the most, an hour, as it is useless, he says, to expect the full benefit of this dose to appear if the dose is divided and its administration is extended over a longer time. He never repeats it in less than twenty-four hours, and, as a rule, does not give it again under two days. Jürgensen has exceeded the dose of forty-five grains without observing any bad effects from it. When these large doses are taken the fall of the temperature usually begins a few hours after the administration of the medicine, the minimum being reached in from six to twelve hours, and it is usually not until the second day that the temperature attains its former height. It is found in practice that the most decided results are obtained when the medicine is given in the evening, so that the time of its fullest antipyretic effects will coincide with that of the morning remission. When these large doses produce vomiting, as they occasionally will, the quinia must be given by the rectum or hypodermically.

Quinia possesses the great advantage over the cold bath that it may be given in conditions in which it would be dangerous to resort to the latter. The existence of great cardiac weakness, of perforation of the bowel, or of intestinal hemorrhage do not usually constitute contraindications to its use. In my own practice I have not often found it necessary to have recourse to much larger doses than those recommended by Murchison, preferring to repeat them if necessary rather than to give a single dose of even half a drachm.

It will be well, in this connection, to allude briefly to a few other remedies which have been given for their antipyretic effect. One of these is digitalis, which has been administered for this purpose in very large doses. Thus, Liebermeister recommends that from eleven to twenty-two grains should be given in the course of thirty-six hours. I have never used this drug in these doses, and therefore cannot speak of its effects from personal knowledge of them. I have frequently had recourse to it, however, in more moderate doses, and I think with advantage.

Another is sodium salicylate. This remedy has been used largely in England and Germany, and to a less extent in this country. It has been claimed for it that it has the power of destroying the germs of typhoid fever, but Stricker¹⁰⁰ finds it difficult to accord it this property in the face of the fact that he has had three cases of typhoid fever under his observation which occurred in patients just recovered from rheumatism, which had been treated by this drug. My own experience with it in the treatment of this disease is small, but has been unsatisfactory. While it is undoubtedly an antipyretic, the pulse becomes weak and the inspiration less strong under its use. The brain symptoms do not diminish under its use. Indeed, it is said to produce narcotism in some cases. Dr. Jahn¹⁰¹ and Dr. Jh. Platzer¹⁰² speak more favorably of it, but admit that its administration is occasionally attended by the inconveniences above referred to. The verdict of the profession in regard to it, tersely expressed by one who had given it a fair trial, appears to be that it is a remedy that brings nothing but disappointment to the physician and disaster to the patient.

¹⁰⁰ Deutsche Milit.-arztl Zeitsch., 1877.

¹⁰¹ Deutsches Arch. f. klin. Med., 1877.

¹⁰² Bayr. Arztl. Intell. Bl., 1877.

Eucalyptus, in the form of the tincture, is also a favorite remedy with many practitioners. Dr. Benj. Bell¹⁰³ is in the habit of giving a teaspoonful every three or four hours in a wineglass of water, and asserts that it diminishes the tendency to diarrhoea and the duration of the illness.

¹⁰³ Edin. Med. Jour., Aug., 1881.

The different varieties of typhoid fever require slight modifications only of the treatment laid down above. In the typho-malarial form, especially in those cases in which the malarial element predominates, and in which there is a marked tendency to remission, the early administration of quinia in full antiperiodic doses is urgently called for. In some cases which he had the opportunity of observing in the army, A. L. Cox¹⁰⁴ found great advantage from the use of arsenious acid in rather large doses. When the disease attacks elderly people, an early resort to alcoholic stimulants is usually necessary, in consequence of the excessive prostration it induces in them. Henoch and Steffen¹⁰⁵ assert that cold baths are not so well borne in children as in adults. Their influence is transitory only, and their use has sometimes been followed by fatal collapse. In the renal form dry, and in some cases cut, cups should be applied externally and saline diuretics given internally.

¹⁰⁴ Outlines of the Chief Camp Diseases of the United States Armies, by Joseph Janvier Woodward, M.D., Philada., 1863.

¹⁰⁵ Jahrb. f. Korhde, 1880.

SYMPTOMS REQUIRING SPECIAL TREATMENT.—Vomiting, when it occurs early in the disease, is usually checked by the administration of an emetic and by the application of sinapisms to the epigastrium. The use of emetics is no longer advisable when it occurs after the first week. It is better then to trust to small doses of hydrocyanic or carbolic acid, aromatic spirit of ammonia, or bismuth. It will often be found that lime-water and milk will remain upon the stomach when every other article of food or medicine is rejected. In some severe cases which have been under my care the symptom was permanently relieved by the frequent administration of small quantities of brandy in iced soda-water. When vomiting is a consequence of peritonitis it usually resists every form of treatment.

Diarrhoea, if the number of the stools does not exceed two or three in the course of twenty-four hours, does not need special treatment. When, however, it is more severe, prompt measures should be taken to check it. Under these circumstances laudanum injections have seemed to me to be by far the best remedy. It is not necessary that these injections should always contain a large amount of laudanum or that they should be repeated frequently. In many cases twenty drops once a day will be found to be sufficient, and it is rarely necessary to exceed forty drops twice daily. Opium given by the mouth or in suppository in equivalent quantity does not act with anything like the same efficacy. If the laudanum injections fail to restrain the diarrhoea, it will be well to have recourse, in combination with opium, to the subnitrate of bismuth or the acetate of lead. Nitrate of silver was at one time much employed in the treatment of typhoid fever, especially by the late J. K. Mitchell of this city, but was afterward suffered to fall into neglect. Its use has been recently, to a certain extent, revived in consequence of the recommendation of William Pepper,¹⁰⁶ who claims for it the power of modifying the course of the disease. I have given it in a number of cases, but have never been able to satisfy myself that it possessed this power. I have therefore ceased to prescribe it except in the later stages of the disease, when the symptoms indicate that the intestinal ulcers are in an atonic condition. Under these circumstances it has appeared to me to promote their cicatrization. It is important, however, to remember that diarrhoea is occasionally caused and kept up by more food being given to the patient than he can assimilate, and it is therefore a good rule to examine the stools from time to time to see whether they contain curds of milk or other undigested food. If such is found to be the case, the amount of nourishment should be diminished, and it will be well also to prescribe pepsin either in powder or in solution.

¹⁰⁶ Philadelphia Medical Times, Feb. 12, 1881.

Tympanites also occasionally requires treatment, for in addition to interference with the descent of the diaphragm and other discomfort it produces, the distended condition of the bowels directly increases the risk of perforation. It is usually sufficient to employ embrocations or stupes of equal parts of sweet oil and oil of turpentine, or of camphor liniment. If the tympanites coexist with constipation, enemata, either with or without a small quantity of oil of turpentine, may often be used with advantage. If it is extreme, an intestinal tube should be introduced very carefully into the rectum and the gas drawn off. Charcoal has occasionally been administered in this condition with a view of preventing decomposition of the intestinal contents. Tympanites occasionally rapidly supervenes upon the occurrence of perforation, and must then, of course, be treated with due reference to the latter condition.

Intestinal hemorrhage is a symptom which always demands prompt attention, no matter how slight it may seem to be, for it is to be remembered that not only is there a danger of its recurrence, but that the quantity of blood which appears in the stools is by no means a reliable measure of that actually lost, as more blood frequently remains in the intestines than appears externally. In estimating its severity, it is therefore proper to take into consideration the gravity of the other symptoms which attend it, such as the fall of temperature, feebleness of the pulse. In many cases the enforcement of absolute rest, with the administration of cold drink and a small amount of opium to diminish peristaltic action, is all that is needed. In cases in which the symptoms are graver it will be necessary to have recourse to more energetic measures. Under these circumstances the hypodermic injection of from three to five grains of ergotin, repeated if necessary, has seldom in my experience failed to check the hemorrhage. Dilute sulphuric acid, oil of turpentine, and acetate of lead have also proved themselves useful remedies in my hands. The application of ice to the surface of the abdomen has also been said to be attended with good results, but the objections to the use of this remedy in the condition of collapse, which is so apt to accompany profuse intestinal hemorrhage, are so evident that it is unnecessary to discuss them here. Monsel's solution, tannic acid, and various other mineral and vegetable astringents have been recommended for their direct effect upon the bleeding surface, but, even admitting that they can, when administered by the mouth, reach this unaltered or in a sufficient state of concentration to be active, it is evident that they could only do so after the loss of valuable time.

When perforation occurs, it is obvious that the indications for treatment are to preclude the extravasation of the contents of the intestine into the cavity of the peritoneum, and to prevent the peritonitis which is a consequence of this accident from becoming general. Both of these indications are met by the administration of opium, which diminishes, and, if pushed, arrests, the peristaltic action of the intestines. By means of it the bowels may be kept as free from movement as if "placed in splints." A grain of solid opium may be given every hour until a decided effect is produced, or if it is found to disagree with the stomach an equivalent quantity may be given by the rectum, or it may be substituted by morphia administered by the mouth or hypodermically. With the same view, food is to be allowed in small quantities only at a time, and of a character capable of digestion by the stomach. A light poultice, or, if there is much evidence of inflammation, ice should be applied to the abdomen. It has been recommended also, in cases in which the peritonitis has become general, to apply leeches to the abdomen, but few patients in this condition will readily bear the loss of much blood. It is very important not to interfere with the constipation which results from the above treatment, and which it is one of its objects to promote, until all inflammatory symptoms have been absent for at least a week, when a simple enema may be administered. Peritonitis resulting from other causes than perforation of the intestine does not require any modification of the above treatment.

Severe abdominal pain, when it occurs independently of inflammation, is best treated by the application to the abdomen of light poultices, to which two or three teaspoonfuls of laudanum may be added.

Constipation is an occasional symptom, but it rarely calls for active interference. When it is present so early in the course of the disease that the diagnosis is still uncertain, and has continued for several days, it is best to prescribe a small dose of castor oil; a dessertspoonful is generally sufficient. The late Dr. Gerhard was in the habit of giving a tablespoonful of sweet oil in this condition. The inordinate action which frequently follows the administration of these mild purgatives will often dispel all uncertainty as to the nature of the disease we have to do with. When it occurs in a more advanced stage of the disease it is best met by the administration of enemata, which may contain, if there is much tympanites present, a small quantity of oil of turpentine. Under all circumstances it will be well to remember the advice given by Baglivi two centuries ago, to avoid the use of active cathartics in this disease.¹⁰⁷

¹⁰⁷ "Fuge purgantia tanquam postem," Opera Omnia Medico-Practica et Anatomica, Georgii Baglivi, 1788.

The headache which is sometimes a distressing symptom in the beginning of the disease is usually relieved by the application to the head of cloths constantly wet with ice-water or by that of a bladder filled with ice and lard. If it is very severe and does not yield to these remedies, a few leeches applied to the temples often have a very happy effect in moderating the pain. Murchison recommends that the cold affusion should be administered by simply placing the patient's head over a basin at the edge of the bed and pouring water on it from a height of two or three feet. He also says that warm fomentations are to be preferred to cold in aged and infirm persons of feeble circulation. Sleeplessness will often disappear under the use of remedies presented for the relief of the headache and other nervous symptoms. It is occasionally so persistent as to call for special treatment. If it occur early in the disease, it will generally be sufficient to prescribe at bedtime ten grains each of potassium bromide and chloral, repeated once or twice during the night. Later in the disease this combination ceases to produce any effect, besides which chloral cannot be administered with safety after the action of the heart becomes feeble. It is therefore necessary to have recourse to opium in some form or other. There are, it is true, theoretical objections to its use in typhoid fever, such as its interference with digestion and its tendency to lock up the secretions; but these will hardly weigh in the balance against the fact that the patient will die of exhaustion if the insomnia is allowed to continue, and that under certain circumstances opium is the only drug which will procure the needed sleep. The form in which it is given is not a matter of much importance. I prefer the deodorized tincture, twenty or thirty drops, repeated if necessary in an hour or two, but I have seen good results from the solid opium and from the hypodermic injection of morphia. When the insomnia is attended by much tremor and muttering delirium, camphor may be added to the opium, and given throughout the day as well as in the evening. Violent delirium is sometimes also relieved by administration of opium and alcoholic stimulants, and by the application of cold to the head. It is also much lessened by the cold-water treatment. When the delirium is so violent that restraint is necessary, it is better that this should be mechanical than that it should be left wholly in the hands of ignorant and untrained nurses. A folded sheet passed over the chest of the patient and fastened to the sides of the bed is frequently all that is needed. Stupor requires very much the same kind of treatment as that suitable for the other forms of nervous derangement. If it is extreme, counter-irritants should be applied to the nape of the neck and cold to the head. The late Dr. Wood was in the habit of shaving the hair and applying a blister to the scalp of a patient in this condition, and I have seen good in more than one instance result from this treatment. The urine should also be examined, and if the quantity be insufficient diuretics should be given. If it contain albumen or blood, counter-irritants and even cut cups should be applied to the loins. It is also important, if the patient be in this condition, that the physician should not rest satisfied with the nurse's assurance that the urine is passed freely, but should from time to time examine the supra-pubic region himself. It is not infrequently found under these circumstances that there is really retention, and that the wetting of the bed upon which the nurse has based her assurances is really the consequence of the dribbling of urine from an over-distended bladder. I have known of serious results, such as cystitis, paralysis of the bladder, having followed the neglect of this very simple precaution. Convulsions when they occur are to be treated by the application of cold to the head and counter-irritants to other parts of the body.

Epistaxis is rarely so severe as not to yield to the use of simple remedies, such as the application of ice to the forehead or back of the neck, or of styptics locally. In a few cases, however, it is profuse, and it will then be necessary to have recourse to hypodermic injections of ergotin, as in the case of hemorrhage from the intestines, or to plug the nostrils.

TREATMENT OF COMPLICATIONS.—Hypostatic congestion of the lungs, as it is usually the consequence of feeble action of the heart, is best treated by frequently changing the position of the patient, and by remedies calculated to increase the power of the organ, such as alcoholic stimulants, ammonium carbonate, oil of turpentine, and digitalis. Recent German authors, however, regard digitalis as a dangerous remedy when the heart has undergone the granular degeneration peculiar to fevers. It had, therefore, better not be given if the congestion occurs late in the disease. I have myself always found advantage from the application of turpentine stupes to the chest, and occasionally from the application of dry cups. Pneumonia when it occurs as a complication does not render necessary a material modification of the above treatment. It may sometimes be well, if it occur early in a robust subject, to take blood locally, but it can rarely be justifiable to do so by venesection.

Bed-sores may generally be prevented by frequently changing the position of the patient, by scrupulous attention to cleanliness, and by bathing prominent parts of his body with whiskey and alum. These parts should also be protected from pressure by the judicious arrangement of pillows and cushions. When redness or abrasions appear the part should be covered with soap plaster smoothly spread upon kid. This application may be continued even after the formation of sloughs. As soon, however, as these show a tendency to suppurate poultices should be applied, and the resulting ulcer treated as if occurring under other circumstances.

Thrombosis of the femoral vein is best treated by elevating the affected leg and enveloping it with flannel cloths saturated with hot vinegar and water. Thrombosis of other veins is to be treated on the same general principles. When an artery becomes obliterated, whether from embolism or thrombosis, the part which it supplies should be surrounded with cotton wool and every effort made to favor the establishment of the collateral circulation. If sphacelus occurs, it should be treated on general surgical principles.

TREATMENT OF CONVALESCENCE.—The importance of a strict adherence to a liquid diet in the early part of the convalescence of typhoid fever has already been alluded to. The ulcers in the intestines often remain unhealed for some time after the subsidence of the fever, and errors in diet may therefore readily cause recrudescences of fever, if not true relapses. These recrudescences are sometimes produced by very slight causes. I have seen them follow undue mental exercise or worry, or sitting up too early or too long. It is therefore important to guard our patients at this stage of the disease from undue fatigue or excitement of any kind. Medicines calculated to build up the strength and to improve the nutrition are clearly indicated at this time. If the diarrhoea should persist, nitrate or oxide of silver, sulphate of copper, and subnitrate of bismuth in appropriate doses, given with a little opium, will all be found to be useful remedies. When, on the contrary, constipation exists, it is still necessary to avoid the use of drastic cathartics; indeed, even mild laxatives should be given by the mouth only after enemata have failed to produce a movement of the bowel.

SPECIFIC TREATMENT.—The search for a specific remedy in typhoid fever is not new. It is as old as the theory that the disease is generated by a specific cause. The hypothesis that this is an alkaline poison led many years ago to the use of the mineral acids, and it was only after experience had shown that they were without power to cut the disease short, or even to control many of its symptoms, that they ceased in a measure to be prescribed. Calomel also, which was occasionally resorted to formerly for its antiphlogistic effects upon the intestinal lesions, has been lately recommended in Germany in the treatment of typhoid fever on account of its supposed antidotal properties. Seven and a half grains of the drug, and in some cases a much larger dose, are given four times daily on alternate days as soon as the nature of the disease is fully recognized. It is claimed for this treatment that when it is begun early the rate of mortality and the duration of the disease are much less under it than under any other. Its advocates admit, however, that the latter is not always the case—a variety in the action of the medicine which is attributed to a difference in the way in which the poison of the disease has been taken into the body. Salivation is rarely produced by the calomel. The diarrhoea, which is at first increased by it, subsequently diminishes, and the administration of each dose is followed by a decided although temporary reduction of temperature.

A diminution in the rate of mortality is also said to have been obtained by the administration of iodine in typhoid fever, although the results of its use are on the whole less favorable than those of calomel. Liebermeister recommends that three or four drops of a solution of one part of iodine, two parts of iodide of potassium, and ten parts of water should be given every two hours in a glass of water.

Number treated. Number died. Percentage of mortality.

Non-specifically treated 377 69 18.3

Treated with calomel 223 26 11.7

Treated with iodine 239 35 14.6

Total 839 130 15.5

The preceding table, which is taken from Liebermeister's article on typhoid fever in Ziemssen's Cyclopædia, is based upon the results of treatment in 839 cases, a part of which were treated with iodine, a part with calomel, and a part with neither, the rest of the treatment being exactly alike in all of them, and consisting in the employment of a partial antipyretic method.

James C. Wilson¹⁰⁸ has recently used with great success in the treatment of typhoid fever the following prescription, which was originally suggested by Roberts Bartholow: Rx. Tinct. Iodinii fl. drachm ij.; Acid. Carbolici liq. fl. drachm j.—M. Of this, one, two, or even three drops is given in a sherry-glassful of ice-water after food every two or three hours during the day and night. In addition to this prescription his patients were given a dose of calomel varying in amount from seven and a half to ten grains, which was repeated on every alternate night until three or four doses had been administered in the course of the first six or eight days. Of sixteen cases so treated, none proved fatal, although eight of them were severe, the temperature reaching or exceeding 104° F. Da Costa¹⁰⁹ has used carbolic acid in this disease, and has found it useful in controlling the diarrhoea and in lowering the temperature, but suggests the use of thymol in doses of from half a grain to one grain as a substitute, on account of its greater acceptability to the stomach. C. G. Rothe¹¹⁰ recommends a mixture of carbolic acid, tincture of digitalis, tincture of aconite, brandy, and tincture of iodine. Its use causes a decided fall of temperature and diminution in the frequency of the pulse.

¹⁰⁸ Transactions of the College of Physicians of Philadelphia, 3d Series, vol. vi., Philadelphia, 1883, p. 221.

¹⁰⁹ Ibid., p. 234.

¹¹⁰ Deutsche Med. Wochenschr., 1880.

My own experience does not enable me to speak with positiveness of the value of this plan of treatment. Indeed, it has been used in so few cases, to the exclusion of all other remedies, that it is difficult to decide how far the result attained in cases treated by them is due to them, and how far to the other therapeutic means employed. With the testimony of such competent observers as those above named it is only proper that the treatment by iodine and carbolic acid should have a further trial. More caution, it seems to me, is required in the use of calomel. While it is probable that in a few cases the intestinal lesions may be favorably modified by the purgation which it induces, the indiscriminate use of the drug is, I am sure, calculated to do more harm than good.

TYPHUS FEVER.

BY JAMES H. HUTCHINSON, M.D.

DEFINITION.—Typhus fever is an acute contagious disease, usually occurring epidemically, lasting from ten to twenty days, and characterized, among other symptoms, by an abrupt commencement, great prostration, profound derangement of the nervous system, and a peculiar eruption which appears between the third and eighth days, and which, disappearing at first under pressure, soon becomes persistent, and in severe cases may be converted into and be associated with true petechiæ. When it proves fatal, it generally does so at or near the end of the second week. The lesions found after death are not specific in character, and consist mainly of a marked alteration of the blood, congestions of internal organs, softening of the heart, and atrophy of the brain.

SYNONYMS.—Petechial Typhus, Putrid or Malignant Fever, Camp, Jail, Ship, or Hospital Fever, Spotted Fever, Irish Ague, Contagious Typhus, Brain Fever, Adynamic or Ataxic Fever, Ochlotic Fever, Catarrhal Typhus.

The term typhus was first applied by Sauvages in 1760, and afterward by Cullen, to certain forms of fever, characterized by marked prominence of the nervous symptoms, to distinguish them from another group of cases to which they gave the name synochus, and is derived from the Greek word [Greek: typhos], which literally means smoke, and which is employed in the treatise on internal affections attributed to Hippocrates for a similar purpose. According to Murchison,¹ Hippocrates used the word to define a "confused state of the intellect, with a tendency to stupor." The appellation typhus, therefore, as indicating a very prominent symptom of the disease about to be described, is perhaps the best that could be given to it. It has been generally adopted by the physicians in England and in this country to denote this disease, but on the Continent, and especially in Germany, it is applied also to typhoid fever, the two fevers being usually designated there as typhus petechialis and typhus abdominalis, respectively.

¹ A Treatise on the Continued Fevers of Great Britain, by Charles Murchison, M.D., LL.D., F.R.S., etc., second edition, London, 1873.

HISTORY.—As human want and misery and the evils which follow in the train of war have never been wholly absent from the world, and as these are the conditions which are now known to be favorable to the spread, if not to the generation, of typhus fever, it is highly probable that this disease was the cause of some of the epidemics to which allusion is made by the sacred and profane writers of antiquity. Yet their descriptions are too vague to justify us in assuming that such was positively the case. The records of the first fifteen centuries of our own era are similarly wanting in details, for, with the exception of a brief notice of an outbreak of the disease in the monastery of La Cava, near Salerno, in the year 1083, by Corradi² it may be said to have been practically undescribed before the year 1546, when Fracastorius³ published his work, De Contagionibus et Morbis Contagiosis. From the description which this distinguished physician gives there of the epidemics which prevailed in Verona in the years 1505 and 1508, there can be no doubt that the disease he had the opportunity of observing was really typhus fever. Not only are the principal symptoms succinctly described, but its contagiousness and tendency to early prostration fully recognized. We learn also, from the same work, that the disease, although previously unknown in Italy, was one with which the physicians of Cyprus and the neighboring islands were perfectly familiar. According to the same authority, it again made its appearance in 1528 in Italy, and from there extended to Germany.

² In Chron. Cavense Annali, p. 1, 101, quoted in Handbuch der Historish-Geographischen Pathologie, von Dr. August Hirsch, Stuttgart, 1881.

³ Quoted by Murchison.

During the last half of the sixteenth century epidemics of typhus fever would seem to have been of more frequent occurrence than before it, since many of the medical authors of this period not only refer to it very fully, but also give accurate descriptions of the disease. There is also abundant evidence of the same kind that it frequently prevailed epidemically in almost every part of Europe during the seventeenth and eighteenth centuries, following generally in the wake of famine and of war, and often attaining a high degree of virulence in besieged towns. The histories of many of these epidemics are exceedingly interesting, especially those of the so-called Black Assizes which occurred at different times in several of the towns of England, and which derived their name from the fact that the disease was communicated from the prisoners on trial to the judges and other persons in attendance upon the court; but to give these in detail would be beyond the scope of this article. Although many of the authors of these two centuries boldly advocated copious venesection as the only rational method of treating the disease, there was a not inconsiderable number who recognized its essentially typhoid nature, its tendency to early prostration, and the fact that patients suffering from it bear bleeding badly, as fully as is done by physicians of the present day. They were also unquestionably quite aware of the circumstances under which typhus fever generally arises, for in 1735, Browne Langrish⁴ wrote that it originated from "the effluvia of human live bodies," and that its principal cause was overcrowding with deficient ventilation, as a result of which "people were made to inhale their own steams;" and a similar opinion was expressed a few years later by Sir John Pringle,⁵ J. Carmichael Smyth,⁶ and others.

⁴ The Modern Theory and Practice of Physics, by Browne Langrish, p. 354, London, 1764.

⁵ Observations in Diseases of the Army, London.

⁶ Quoted by Murchison.

Epidemics of typhus fever have frequently occurred in various parts of Europe during the present century, although they have, on the whole, shown a greater tendency than before to confine themselves to the place in which they first appeared. The most severe of these began in 1846, and after committing great ravages in Ireland extended to England, and subsequently to the Continent. The disease proved much more fatal than the sword in the armies of Napoleon in the towns besieged by him in the early part of this century, and was the cause of an immense loss of life in the Russian and French armies in the Crimea after the fall of Sebastopol.

In our own country typhus fever has appeared several times during the present century, but the outbreaks have rarely attained the magnitude of epidemics, such as are seen in Europe, and have usually been distinctly traceable to importation from abroad. It was first met with, according to Wood,⁷ in New England in 1807 and in Philadelphia in 1812, continuing to lurk, this author says, in the lanes and alleys of that city until the winter of 1820-21, when, as a student of medicine, he had an opportunity of studying it. Another outbreak of the disease occurred in the same city in 1836, and is the subject of an admirable paper by the late Wm. S. Gerhard.⁸ Since then epidemics of moderate severity have repeatedly occurred at different times in several of the American cities, and have been described, among others, by Flint, Da Costa,⁹ and Loomis. A large number of cases of typhus fever (1723), with 572 deaths, were reported to the Surgeon-General's office during the late Civil War, but doubt has been thrown upon the correctness of the diagnosis of many of these cases by Clymer¹⁰ and Woodward,¹¹ and by other army surgeons, who, as the result of their investigations of this subject, have reached the conclusion that typhus did not prevail as an epidemic, however limited, among our soldiers at dépôts for returned prisoners of war. A like immunity from this scourge may be assumed to have been enjoyed by the Confederate forces, since Joseph Jones,¹² one of the most eminent of their medical officers, has stated positively that no case of true typhus fever came under his observation during the war in any army, in any field hospital, general hospital, or military prison, and that the experience of all of his associates whose opinions on this question he was able to obtain, either personally or by letter, was the same. It is therefore most probable that the cases entered upon the sick reports of both armies as typhus fever were in almost every case, if not in all, cases of typhoid fever occurring in scorbutic subjects.

⁷ A Treatise on the Practice of Medicine, by George B. Wood, M.D., etc., Philada., 1855.

⁸ The American Journal of the Medical Sciences, February and August, 1837.

⁹ Ibid., January, 1866.

¹⁰ The Science and Practice of Medicine, by William Aitken, M.D., Edin.; 3d Amer. ed., p. 462, Philadelphia, 1872.

¹¹ Camp Diseases of the United States Armies, by Joseph Janvier Woodward, M.D., Philadelphia, 1863.

¹² United States Sanitary Commission's Memoirs—Medical, p. 600, New York, 1867.

From the foregoing sketch of its history it is evident that typhus fever has prevailed from time to time in almost all the countries of Europe. Indeed, it is probable that no one of them has wholly escaped its ravages, while in others—as, for example, Ireland—it has been more or less constantly present until within the last few years, when its visitations have been less frequent as well as less severe. Even in countries which are popularly supposed to enjoy an immunity from it there is evidence of an incontrovertible character that it has occasionally occurred. Such an immunity has been claimed for France, but in the works of Riverius,¹³ Ambrose Paré,¹⁴ and others will be found descriptions of the disease which leave no doubt upon the mind of their entire familiarity with it; and Hirsch, in his work on Historico-Geographical Pathology, is able to give references to several writers who describe outbreaks that have recently occurred there. The disease has also been observed in Iceland. Typhus fever is of much less frequent occurrence in the other divisions of the eastern hemisphere than in Europe. According to Murchison, there are no authentic records of its having been met in Africa, or, with the exception of India, in Asia, such as it is seen in England and Ireland. There are, however, reports of its occurrence in Asia Minor, Syria, Persia, Egypt, Nubia, Tunis, and Algeria, which Hirsch,¹⁵ on the other hand, believes place the occasional presence of this disease in these countries beyond doubt. The same difference of opinion exists between these two distinguished observers in regard to the accounts which have been published of typhus fever occurring in Mexico, Central America, and South America, the latter holding that they are entirely reliable, the former that the cases described in them were really cases of malarial or typhoid fever. The disease has never been met with on the continent of Australia, in New Zealand, or in the valley of the Mississippi and the States bordering on the Pacific Ocean in our own country.

¹³ The Practice of Physick, being chiefly a Translation of the Works of Lazarus Riverius, London, 1678.

¹⁴ Traité de la Peste, de la Petite Verolle et Rougeolle, par Ambrose Paré, Paris, 1568.

¹⁵ Loc. cit.

While Hirsch's researches go to show that the tropical zone has not been so wholly exempt from the visitation of typhus fever as some authors have asserted, they establish the fact that it is of much less frequent occurrence there than in the colder portions of the temperate zone, where the modes of life are certainly much more favorable to its extension. Natives of warm climates are as liable to be attacked by it as others upon coming to places where it is prevailing, and in the Philadelphia epidemic of 1836, which Gerhard¹⁶ has described, negroes and mulattoes suffered from it more severely than the whites.

¹⁶ Loc. cit.

ETIOLOGY.—The etiology of typhus fever will be best studied under the heads Predisposing and Exciting Causes.

PREDISPOSING CAUSES.—It may be stated, generally, that whatever impairs the health or reduces the strength of an individual, even temporarily, or acts depressingly on his nervous system, predisposes him to typhus fever. But there are among the predisposing causes some which exert a more special influence on its production than others. Among the more powerful of these is the overcrowding of human beings, with deficient ventilation. Indeed, there are some authors who consider that this has been in many cases alone sufficient to occasion the disease; and although this opinion, as it involves the admission that it may be generated de novo, is contested by others, there is great unanimity among authors in attaching great importance to it. Of the patients admitted into the London Fever Hospital with typhus fever, a large proportion came from the more crowded districts of the city. The disease has always been most prevalent in the poorer quarters of Glasgow, Dublin, and Edinburgh, and when epidemic in Philadelphia in 1836 it was confined to a portion of the town which has always been noted for the squalor and misery of its inhabitants. Among those admitted during that year to the Philadelphia Hospital were seven negroes, said by Gerhard to be "the entire population of a cellar." It is probably largely due to the fact that the better social condition of the poor in this country prevents the degree of crowding which often exists in European cities that the disease is comparatively rare here. The effect of overcrowding is of course much increased by want of cleanliness, either of the person or of the clothes.

Poverty, not merely from its own depressing influences, but also from the fact that it leads to overcrowding, is a powerful predisposing cause of typhus fever. Insufficiency of food, which is one of its many consequences, by impairing his nutrition and thus diminishing his vital resistance, renders the individual more susceptible to the action of the specific cause. Gerhard says that of the patients seen by him in 1836 a very small proportion came from the better class of mechanics, and Tweedie¹⁷ and Sir William Jenner¹⁸ state that it is rare to meet with instances of the disease, except in the case of medical practitioners and students, among those in comfortable circumstances. Bateman¹⁹ goes so far as to assert that "deficiency of nutriment is the principal source of epidemic fever;" and there is certainly a remarkable coincidence in time between outbreaks of this fever and seasons of want and distress. But, as Murchison has shown, destitution is not essential to the production of typhus, for the Dundee epidemic of 1865 was due to overcrowding of the town, brought about by the inhabitants of the surrounding country flocking into it in consequence of labor being unusually abundant and wages good.

¹⁷ Lectures on the Distinctive Character, Pathology, and Treatment of Continued Fevers, by Alexander Tweedie, M.D., F.R.S., London, 1842; and Clinical Reports on Fever, by same author, London, 1830.

¹⁸ On the Identity or Non-Identity of Typhoid and Typhus Fevers, by William Jenner, M.D., London, 1880; also Lancet, November 15, 1879.

¹⁹ A Succinct Account of Typhus or Contagious Fever of this Country, by Thomas Bateman, M.D., F.R.S., London, 1820.

Similar in its action to the above cause is intemperance. Not only is the habitual drunkard more likely to suffer from typhus fever than the temperate man, but a single debauch has been followed by an attack in individuals who had previously resisted the contagion. On the other hand, the most rigid temperance will not afford in all cases a complete immunity from its effects. The debility left by an illness is also a condition favoring the occurrence of an attack of the disease in those who are exposed to its exciting cause. Fatigue of all kinds renders the body less able to resist the causes of disease, and typhus fever is not an exception to the general rule. Overworked nurses are specially liable to contract it. The depressing emotions also favor its occurrence. It has been observed during epidemics that those who exhibit an excessive fear of the contagion are much more likely to suffer from it than the cheerful and courageous.

No age enjoys an immunity from the disease. In fact, it is probable that all ages are equally liable to it. Buchanan²⁰ has seen it at the London Fever Hospital in an infant a fortnight old and in a man of eighty, and attributes the prevailing opinion that children rarely suffer from it to the fact that they are not often taken to hospitals, but are retained in their own homes for treatment. Gerhard²¹ says that no children in the asylum attached to the Philadelphia Hospital were attacked with the disease during the prevalence of the epidemic there, but the distance of the asylum from the wards in which the cases were treated was probably the reason of their escaping. In the few cases which have come under my own observation the patients were young men, varying in age from twenty-five to thirty-five. The sexes also suffer from it equally. In some epidemics there may be a preponderance of one sex over the other, but in others the reverse has been the case.

²⁰ A System of Medicine, edited by J. Russell Reynolds, M.D., F.R.C.P., etc., vol. i., article "Typhus Fever," London, 1866.

²¹ Loc. cit.

Occupation, except so far as it brings the individual into immediate contact with the sick, as in the case of physicians, nurses, and clergymen, does not predispose to the disease. There would seem also to be no difference in the susceptibility of the different races to the contagion. Acclimatization affords no protection from the disease, as it does in the case of typhoid fever, and change of the habits of life does not appear to exercise any influence upon the liability to it. On the other hand, the susceptibility of different individuals, and of the same individual at different times, varies considerably. Thus, while in many persons a single exposure to the contagion is followed by an attack, in the case of an engineer mentioned by Murchison it did not occur until after fifteen years of continuous service at the London Fever Hospital. A person who has once suffered from typhus fever is not likely to contract it again, but this protection is not complete, as there are a few well-attested instances of a second attack on record.

The disease prevails most frequently during the winter and early spring, principally because the cold weather of these seasons leads to the closing of windows and all other avenues of ventilation, thus intensifying its exciting cause. Still, some epidemics of great severity have occurred in the warmer months of the year, as, for instance, the one described by Gerhard. It is also doubtful if there is any relation between variations in temperature and the amount of moisture in the air and the prevalence of epidemics of typhus fever, although Hirsch regards a low and damp situation as powerfully predisposing to the endemic and epidemic prevalence of the disease. It is usually met with in towns on the sea-coast or on navigable rivers, but it has also been observed frequently in country districts, and even in regions at a considerable elevation above the level of the sea.

EXCITING CAUSE.—The principal if not the only exciting cause of typhus fever is a specific contagion developed in the bodies of the infected and transmitted from them to the healthy by actual contact, by fomites, or through the atmosphere. The nature of this contagion is unknown. A careful study of its peculiarities seems to justify the opinion that it depends upon the presence of a minute organism in the emanations given off by the sick, which is capable of indefinitely multiplying itself in the human body. But this is only an hypothesis, which rests principally upon the analogy between typhus and some other diseases, as, for instance, relapsing fever and diphtheria, in which such a growth is thought to have been discovered, and upon the fact that the contagious principle whatever it may be, is destroyed by a temperature over 204° F.

The evidence in favor of the contagiousness of typhus fever is conclusive, and may be briefly stated as follows: When it breaks out in a community the disease not only attacks those persons who have been subjected to the same influence as the sick—as, for instance, members of their own families, occupants of the same house, etc.—but also those who have come from healthy localities to visit them. In fever hospitals it is rare for any member of the household who has not already had the fever to escape an attack, and the probability of his suffering is in direct proportion to the intimacy of his relations with the patients. Thus, the nurses are far more likely to be attacked than servants whose duties do not take them into the wards, except those employed in the laundry, who are so often affected by it that Murchison says it is difficult to find women who are willing to take the position. The spread of the disease may often be promptly arrested by the complete isolation of the first few cases, while free intercourse between the sick and the well is invariably followed by its extension, not only in the locality in which it first appeared, but to other localities. But the strongest argument in favor of its contagiousness is found in the fact that patients taken into a previously healthy place have frequently become the starting-point of an epidemic. In this way the disease has often been introduced by Irish immigrants into the cities on our seaboard, and even into some of our interior towns.

Actual contact is not necessary for the communication of typhus fever from the sick to the well. The contagion may be transmitted through the atmosphere. How far it will be transmitted in this way will depend upon many circumstances. In a spacious and well-ventilated ward it is probable that the presence of one or two patients with this disease does not seriously endanger the safety of the other patients, and that the only persons who run much risk of contracting it are the physicians and nurses, who are often compelled in the performance of their duties to inhale the emanations from the bodies of the sick. At the Pennsylvania Hospital, where cases of this disease are occasionally admitted, it has been usual to isolate them by placing them in a room a few feet distant only from the dining-room of the men's medical ward and separated from the ward by a short corridor. The steward of the hospital informs me that during his connection with it, which extends over a period of more than sixty years, he has never known the disease to extend to other persons, except on two occasions. One of these was during the epidemic described by Da Costa, when an unusual number of cases was received, and when one resident physician and two nurses contracted the disease. On the other occasion, which happened during my own term of service in the spring of 1881, a young Danish sailor appeared to have taken the disease from two British seamen. As it was ascertained positively that he had not entered the room in which these two seamen were isolated, and as his bed in the ward was one of the farthest removed from the room, and he had not therefore been more or as much exposed to the contagion as the other patients, it was difficult to understand why he alone of all of them should have suffered from it. The explanation was, however, found in the fact that he had been taken over to the women's ward to act as interpreter for a countrywoman who was not known at the time to be suffering from typhus fever, and that he had remained there some time in conversation with her. Murchison and Buchanan both assert also that typhus fever has never extended from the London Fever Hospital to the inmates of adjacent houses, even when it was itself one of a row of houses. If, on the other hand, several patients with typhus fever are placed in a crowded and ill-ventilated ward, the contagion will then be found to have acquired so much more virulence that few of the other patients will escape its effects.