Typhoid Fever.

Synonyms.—Typhus abdominalis; Typhus nervosus; Ileo-Typhus and Autumnal Fever, are the most common terms, although Murchison's list includes forty others.

Definition.—An acute, infectious disease, derived from a specific cause and characterized pathologically, by inflammation and generally by sloughing of Peyer's glands, swelling of the mesentery and engorgement of the spleen.

Clinically, by a slow fever of gradual invasion, lasting from three to six weeks, a rose-colored eruption, diarrhea, tympanites and a characteristic delirium, typhomania.

History.—This is the most universal of all fevers. It is not confined to any country or climate; to any age, sex, or condition. Wealth has no power to bribe or beauty to charm this insatiable foe. Wherever civilization has made its way, there typhoid fever has been an unwelcome guest. Although its authenticity does not date back of the present century, we have every reason to believe that it can be traced to prehistoric times.

In 1813, Bretonneau of Tours recognized this fever as differing from other continued fevers and termed it Dothinentérite, while Petit termed it Enteromesenteric fever. In 1829, Louis offered the-name Typhoid, but it remained for Gerhard, of Philadelphia, a student of Louis, to distinguish between typhoid and typhus as separate and distinct diseases. He published his views in the February number, American Journal, 1837. Drs. E. E. Hale and James Jackson, Jr., of Boston, also students of Louis, corroborated the observations of Gerhard, and typhoid fever was recognized, especially in America, as a distinct disease. In Europe, however, there was still doubt as to its identity, many believing that the two were only different phases of the same disease.

Stille, of Philadelphia, who was house physician to Gerhard, assisted largely in making clear to the people of France the distinction between the two diseases, during his careful study of typhoid while in Paris.

Shattuck, of Boston, visited the London fever hospital, studied the disease in all its minutiae, which he carefully tabulated and presented to the Societe Medicale d'Observation. These observations were accepted by prominent writers from various countries, and since 1850 there has been a general acceptance of the truth, that typhoid fever is a distinct disease. It will be observed that to America belongs the honor of isolating one of the most common and prevalent of all fevers.

Etiology.—The predisposing causes are twofold. On the one hand are all the conditions that favor the growth of the infective material and its accumulation. On the other hand are all the conditions that impair the vitality of the individual, rendering him susceptible to the poison.

Age.—One of the most frequent predisposing causes is age, over seventy-five per cent of its victims being between fifteen and thirty years of age. It was formerly believed that children were exempt, but since Murchison, in 1864, presented to the London Pathological Society the intestines of a child six months old, who had died from the disease, all doubt has been removed, and nearly every physician of experience can bring his own evidence to substantiate the fact, that from infancy to old age there is no exemption.

Sex.—Some have tried to prove that males are more prone to the disease than females, but the cause is rather to be found in the fact that men are more exposed to the infection than women, and not to any difference in the sexes.

Season.—Typhoid fever prevails most frequently in the fall, hence the term Autumnal Fever. Hirsch found that of five hundred epidemics twenty-nine occurred in the spring, one hundred and thirty-five in summer, two hundred and fifteen in the fall, and one hundred and forty in the winter.

Weather.—The condition of the weather plays some part as a predisposing factor in this disease. Hot and dry seasons favor it, while cold and wet seasons tend to check it.

Exciting Cause.—The exciting cause is now generally recognized by the medical world as being due to the entrance into the system, of one susceptible to the poison, of a specific germ, the bacillus of Eberth, which he has termed the bacillus typhosus. These micro-organisms, taken into the system through the digestive tract, when not destroyed by the acid of the stomach, pass into the alkaline constituents of the intestine, where the conditions are favorable for their multiplication and development.

The bacilli penetrate the solitary follicles and Peyer's patches, and there form colonies. These migrate by way of the lymphatic vessels to the mesenteric ganglia, and by way of the radicles of the superior vein to the liver, to be finally distributed by the blood current to the spleen and other organs. Such is the view held by a large part of the profession. That these bacilli are found in the contents of the intestine, the stools, in the urine, in the mesenteric glands and spleen, none can deny, although many contend that they are the result, rather than the cause, and that the toxins are not generated from the micro-organisms. Of these doubters the most prominent authority on fevers is Murchison. Unfortunately they are unable to furnish a tangible substitute to take the place of the specific germ. The life of this bacillus is very tenacious. (See frontispiece.)

Pruden found that after being frozen for over three months it was capable of growth, and that it maintained its vitality after being heated to a temperature of 132 C., and that after repeated freezing and thawing its vitality was unimpaired.

Modes of Conveyance.—While it is possible to receive the poison by inhalation, by far the most frequent mode of entrance is through the digestive tract in eating and drinking. Contaminated water ranks first as a carrier. Of two hundred epidemics that were studied, polluted water was found to be the source of infection; only two will be named, however, to show the direct relation to this source.

In 1885, in Plymouth, Pa., twelve hundred persons, out of a population of eight thousand, were attacked with the fever. The water supply was taken from a reservoir which received its supply from a mountain stream, upon the side of which resided a typhoid fever patient. During the months of January, February, and March the stools were emptied near the banks of the stream that supplied the city with water. Typhoid fever at the rate of fifty cases per day broke out, and did not cease until the number reached twelve hundred.

In 1898, at Maidstone, England, an epidemic occurred, in which eighteen hundred cases out of a population of thirty-five thousand could be traced directly to contaminated water.

Milk.—Milk is also a common carrier of the infective material, although nearly always the result of polluted water being used, either in diluting the milk or in washing the cans. Several epidemics have been traced to this source in France.

Oysters.—Articles of food may also contain the poison; notably, oysters, more than one hundred cases being attributed to the luscious bivalves, which had been fattened on contaminated water.

Dr. Conn, of Middletown, Conn., traced the cause of the epidemic which prevailed among the students of Wesleyan University in 1894 to this article of diet. The oysters came from a creek where they had been fattened by being kept in brackish water, the oyster-bed being only three feet from the mouth of a sewer which emptied the contents of two typhoid fever patients. Students from Amherst College, who received oysters from the same locality, also developed typhoid fever. The oysters were eaten raw in every case. Thus we find that polluted water, either directly or indirectly, is the common carrier of the infection, whatever that may be.

Pathology.—The lesions resulting from this fever may be divided into two parts. First, those which are primary and distinctly characteristic; viz., the lesion of the intestinal canal, Peyer's patches, the solitary glands of the ileum and cecum, and more rarely of the colon and rectum, the mesenteric glands, especially those opposite the ileum, and changes in the spleen. Secondly, those resulting from sepsis occurring during the long period of fever, and affecting the tissues and organs at large.

The lesions of the intestines are better described under four stages, infiltration, necrosis, ulceration, and healing. The first effect of the poison, typhotoxin, bacilli, or whatever it may be, is to cause hyperemia of the lymph follicles; the capillaries become engorged, cell infiltration proceeds till the glands extend from an eighth to a quarter of an inch from their base, the solitary glands varying from the size of a small bird-shot to that of a small pea. The follicles most involved are those in the lower third of the ileum and the upper part of the cecum, although the follicles of the entire tract may be involved. The infiltration reaches its height by the eighth or tenth day, when it terminates by resolution or death. In the milder cases, by resolution, the follicles undergo fatty or granular degeneration, and are carried away by the absorbents, during which process there may be slight hemorrhages. More frequently, however, the infiltration is so excessive that resolution can not take place, the capillaries become engorged and choked by infiltration, and necrosis and sloughing follow.

A gland may have several necrotic spots with mucous membrane intervening, or an entire patch may be involved. The necrosis is variable, depending upon the severity, sometimes involving only the mucosa or sub-mucosa, again extending to the muscular and serous coats. This stage occupies eight or ten days, and is followed by the stage of ulceration.

The ulcers are shallow or deep according to the amount of necrosis or sloughing. The ulcers of the solitary glands are round, while those of Peyer's patches are irregular and ragged. Where the ulcers extend to the deeper portion of the bowel, hemorrhages result. Perforation may follow, although a rare condition.

This stage is followed by healing or cicatrization; granular material forms in the bottom of the ulcer; the mucous membrane of the edges projects; the glands with their epithelium reform, and the bowel is restored to its normal condition.

The mesenteric glands undergo similar changes—viz., hyperemia, necrosis, and ulceration—those opposite the lower third of the ileum being more often involved. They vary in size from that of a pea to a walnut. The spleen in nearly all cases is early involved. Congestion early takes place, followed by softening.

It is difficult many times to separate the secondary from the primary lesion; in fact, in some cases we get the tissue changes first. The system is so profoundly impressed by the poison that there is very early a degeneration of tissue. The liver becomes hyperemic, swollen, and soft, which may be followed by abscess formation.

Cloudy swelling, with granular degeneration, takes place in the kidneys. There may be ulceration of the larynx, while the congestion of the bronchial mucous membrane is shown by an irritable cough.

Congestion of the lungs is a very common and serious complication. The heart shares in the general infection, although pericarditis and endocarditis are rare, myocarditis is not uncommon, the cardiac muscles become weakened, and the much dreaded heart-failure is to be early combated.

Symptoms.—Incubation—This stage is of several days' duration, from seven to twenty-one or more. The symptoms are those of depression; the patient feels languid, and complains of feeling tired, although there be no exertion. His rest is disturbed at night, and he rises unrefreshed, as weary as when he retired; the appetite is impaired, the tongue is generally coated, and the bowels are slightly constipated; he complains all the time of being tired and of having more or less headache. Bleeding from the nose may occur for several days. These symptoms increase from day to day until the period of invasion is ushered in.

Many times it is difficult to draw the line between the period of incubation and that of invasion, so gradually does the one run into the other. While the chill may be pronounced, at other times slight chilly sensations are the only evidence of its appearance. Epistaxis is common and affords slight relief to the headache so often experienced; the temperature has been slightly above normal for several days previous to the chill, but now reaches 101 or 102, and the patient is now fully entered upon his long siege of fever, which is to be characterized by daily remissions.

The pulse varies, is full and frequent, although soft, or quick and sharp, if there is much nervous irritation. There is evidence of depression even in the early stage; the face is slightly flushed, the eyes heavy and expressionless, the tongue is moist and dirty, the appetite is gone. The skin, at first, becomes moist and somewhat clammy, with an unpleasant odor. The bowels at this time are usually constipated, although if active cathartics have been used diarrhea early ensues; the urine is but slightly lessened in quantity, and as the disease progresses, it becomes slightly increased, and is pale and frothy, resembling new made beer.

The temperature gradually increases, during the first week being about one degree higher in the evening than in the morning. From the seventh to the tenth day the characteristic rash, rose-colored, appears on the abdomen and chest, and although this is regarded as one of the chief diagnostic symptoms, it may be absent altogether. The diarrheal, frothy, "pea-soup" discharges may begin as early as the sixth or seventh day, or it may be delayed until the third week, although usually the second week finds the stools frequent and offensive.

If there be much nervous irritation, the delirium may be active during the early stages, occurring mostly at night and disappearing with the approach of day; most frequently the delirium is of a passive character, and typhomania is a characteristic symptom.

The abdomen has been drummy from the invasion, with gurgling in the right iliac region, and by the second week tympanites is a marked feature. At this time there may be a temporary paralysis of the bladder, and the patient passes his water involuntarily; or, on the other hand, there may be retention, when the catheter affords the only relief.

From the tenth to the twentieth day the evidence of sepsis grows more pronounced; the tongue becomes dry, brown, and heavily coated, or sleek and glossy, while sordes appear on teeth and lips. The loss of tissue is rapid and emaciation marked. The pulse has now become dicrotic; the disturbance of the nervous system is complete, and we witness subsultus tendinum and carphology. If ulceration is severe, hemorrhages occur, followed by a drop in temperature and great prostration. The extremities are inclined to be cold, the heart feels the strain, and the depression is great. The position is dorsal.

In the more favorable cases, the disease has spent its force by the eighteenth to the twentieth day, the temperature declines, the stools are less frequent, the tongue becomes moist and clean, appetite ferocious, and the patient enters the convalescent stage. This may be delayed, however, to the twenty-eighth, thirty-fifth, or even forty-second day.

Temperature.—There is a gradual rise in temperature during the first week, and if the forming stage is of long duration, the patient goes to bed with a temperature of 100°. Each day, for four or five days, we notice a slight increase from one degree to a degree and a half, the evening temperature being higher than the morning. These daily remissions are pathognomonic of typhoid fever. From the fifth to the seventh day the temperature reaches 104° or 105°. During the second week it is quite uniform—103° or 103.5° in the morning; 104° or 104.5° in the evening. The temperature, gradually rising from the noon hour, reaches its maximum between six and eight, remaining there until midnight, when there is a gradual decline till six or eight in the morning, when it reaches its minimum, remaining thus till nearly noon, when there is a repetition of the previous day.

During the third week there is a slight decline, and by the twenty-first day, in the mild cases, the temperature is normal in the morning, although the rise in the evening temperature continues for several days. In severe cases the remissions are very slight, from the fifteenth to the twenty-fifth day the fever being very uniform, with an occasional increase of the morning temperature over the evening temperature. During the decline the remissions are more marked, there being a fall of from two to three degrees from morning till night, and where the emaciation and prostration have been extreme it is not uncommon to find a subnormal temperature in the morning for several days of the convalescent period. The severity of the disease and its duration is determined, as a rule, by the temperature range; when this is low the fever is mild, the disease increasing in severity as the temperature rises. We meet some cases where the temperature never rises above 102° or 103°.

A disease which shows as much systemic infection as typhoid, would naturally show more or less wrong of every organ and tissue of the body, and while this is true, there are some parts more frequently affected than others, notably the respiratory, nervous, and gastro-intestinal systems.

Bronchitis.—The toxin may early infect the bronchial mucous membrane, giving rise to bronchitis. The breathing is more hurried, and there is a sense of constriction of the chest, attended by a frequent hacking cough. Expectoration is at first scanty, and the mucus is raised with difficulty; but gradually the secretion becomes more free, often resulting in bronchial catarrh. The sibilant rhonchus, together with the symptoms already noted, enables us to recognize this lesion.

Pneumonia.—Congestion and inflammation of the lungs are not infrequent, and may occur during the second or third week, rarely in the first. The breathing is short and rapid, the oppression of the chest is marked, and the cough is harassing, greatly depressing the patient. The expectorated material is usually not so viscid and tenacious as in simple pneumonia, nor the sputum so rusty, being more of the prune-juice color.

The dark, dusky hue of the lips and tongue, the flushed face, oppressed circulation, dullness on percussion, and crepitant rhonchi, are symptoms that can not be mistaken. This is one of the most serious complications, causing great prostration, and rendering the prognosis problematical. The congestion is most frequently due to the dorsal position, and not from taking cold nor from germ infection.

Gastro-Intestinal.—In some cases we notice, at the beginning of the fever, marked wrongs of the stomach. The tongue is heavily coated with a dirty, pasty coating; there is loss of appetite, nausea, and weight in the region of the stomach. There is hyper-secretion of mucus, and food and medicine are not appropriated. The fever is of low grade, the pulse weak, and temperature not over 102° or 103°. Although the prostration is great, emaciation is not so marked. The extremities are inclined to become cold. In such cases convalescence is delayed to the fifth or sixth week.

In other cases there is great irritation of the stomach, and the enteric lesion is greatly aggravated. Diarrhea is a prominent feature, the stools being frequent and offensive. Tympanites is extreme and hemorrhage may be expected.

Cerebral Complications.—In some cases the nerve centers are the first to feel the effect of the poison, and the disease is ushered in with intense headache or neuralgia, and if the physician is not careful, he will overlook the real lesion. All the symptoms are increased in intensity; the skin, especially of the head and face, is intensely hot and pungent. The countenance is flushed; there is throbbing of the carotids; the pulse is rapid, full, and strong; the breathing is frequent and suspirous; the eyes are injected and suffused, or dry and burning. There is great irritability and restlessness, giddiness, intolerance to light and sound, with greatly increased sensibility.

Within forty-eight to seventy-two hours delirium of a wild and active character occurs, which is soon replaced by coma vigil, subsultus, and lastly by profound coma. At other times the cerebral affection is intense; profound stupor speedily makes its appearance, accompanied by a slow, oppressed, and intermittent pulse; or the patient is dull from the first, the pupils are dilated, the patient answers slowly, protrudes his tongue with difficulty, and is careless of the result. The pulse is feeble, skin cool, temperature not very high, delirium low and muttering, which is soon replaced by coma.

Laryngitis and Pharyngitis.—Occasionally we meet with these complications; the constriction of the throat, difficult deglutition, and change of voice enables one to recognize the lesion.

Heart.—We meet with cases where the circulatory apparatus feels the force of the poison, and, although rare, an endocarditis or pericarditis results. A myocarditis occurs more frequently.

A febrile Typhoid Fever.—This form is exceedingly rare. Some eight or ten years ago I treated one of our students with this form, the temperature being sub-normal the greater part of his three weeks sickness.

Typhoid in Children.—The disease as seen in children needs no especial description, except to say that the onset is frequently more sudden. There is a short forming stage, and the fever runs a shorter course, the patient often being convalescent the fourteenth day.

Diagnosis.—The diagnosis is usually not difficult, although in rare cases it may be uncertain for several days. Osler states that, in four or five cases in his series, the diagnosis was not made until autopsy.

The history of the forming stage: one, two, or three weeks of listlessness, languor, headache, loss of appetite, general depression, progressively increasing until the patient takes his bed, are the most characteristic symptoms of this fever, and the regular step-ladder rise in temperature with daily remissions, the peculiar dullness of intellect, the marked prostration and feeble pulse, are sufficient to render a most probable diagnosis. If to this we add tenderness and gurgling in the right iliac region, enlargement of the spleen, diarrhea, the presence of the rash and the cerebral disturbance, the diagnosis is complete.

The case difficult to recognize, is where the usual symptoms are masked by an early complication. A recent case serves as an illustration. The invasion was characterized by an intense headache and great irritation of the nervous system; his face was flushed, pulse full and hard, eyes bright and contracted, and his constant cry was for relief from the pain in his head. The symptoms were more of meningitis than typhoid.

Sometimes the respiratory complication is the first to attract the physicians attention, and if we are not careful we will give a mistaken diagnosis. In all such cases the physician must not be in too great haste to name the disease. If we examine our patient carefully, note the tenderness on pressure of the abdomen, the daily remissions in the fever, the evidence of sepsis as shown by the tongue, light will soon be forthcoming even in obscure cases.

I have but little faith or patience with the modern search for the bacillus typhosus as a means of diagnosis, nor with the serum test as proposed by Widal, which is as follows: To a drop of blood taken from the patient by pricking the finger with a needle, add a few drops of bouillon culture of the bacilli. In a short time, from a few seconds to five hours, the bacilli lose their peculiar movements and collect into heaps, and gradually into lumps, which, if examined in hanging drops, are visible to the naked eye. The blood serum of healthy persons, or persons suffering from any other disease, does not have this effect upon the typhoid culture.

Vaughan, in an article on ptomains, toxins, and leucomains, says of the Widal test: "There are reasons for believing that too much reliance has been placed on the Widal test, and that normal blood serum will often have a similar effect upon the typhoid bacillus, and that the difference in behavior between the typhoid and cholera germs toward the blood serum of typhoid patients is not so marked as has been generally believed." We thus see that we must depend upon the clinical examination of our patient, rather than upon the microscopic or chemical reaction.

Prognosis.—This is a disease that varies greatly at different times and in different seasons. Some years it assumes a mild character and but few die, while again it assumes a most malignant form. The mortality is usually larger in hospitals than in private practice. If modern Eclectic treatment be carried out, the mortality should not be over three to five per cent. If there be severe hemorrhages, pneumonia, or peritonitis, the prognosis should be guarded.

Treatment.—In the treatment of typhoid fever, Eclectics have been remarkably successful, the mortality having been reduced to five per cent or less, and, with the modern care in nursing, the mortality will be still further reduced.

Prophylactic.—While we believe that the direct or specific medication employed by our school shows the best results, we also firmly believe in using every known means to prevent the further spread of the disease, and at the same time minify the toxin that is destroying the vitality of our patient. Since the infection is conveyed most frequently through polluted water, our first care should be in this direction. If an epidemic is prevailing, the attention of the health department will be drawn to the water supply. This will not, however, release the attending physician from all responsibility. He must insist that all water be boiled before using. The milk should also be treated in the same way, as we have seen that this is a fruitful means for carrying the poison.

"Cleanliness is next to godliness" was a favorite saying of Dr. Scudder, and he would add, "In some diseases, better." This is certainly important in typhoid fever. Dirt is a fruitful soil in which the poison thrives and multiplies, and hence we must see that the patient be kept perfectly clean. The bed linen should be changed daily, as well as the night dress. After each stool the soiled parts should be sponged with an antiseptic solution. Platt's chlorides or a solution of carbolic acid 1 to 50 is very efficient.

The secretions, both urine and stool, should remain in a chloride-of-lime solution one hour before being emptied. The solution can be made by adding six ounces of pure chloride of lime to one gallon of water. The porcelain bed-pan should be thoroughly scalded after each using, and a cup of the lime solution placed in it to remain until it is again used. To each stool enough of the solution is added to completely cover it. After standing one hour, it should be emptied, if in the country, in a trench, dug for the purpose, being careful that it does not drain in any direction of the water supply. If vomiting occurs, the ejected material should be treated in the same way, as should the expectorations, unless cloths are used, when they should be burned. The soiled linen, after lying in some strong antiseptic fluid, should be thoroughly boiled before using.

These precautions may seem unnecessary to many, but as a school we have not paid as much attention to these matters as the times demand. This is an age in which antiseptics are demanded, and to fail in our attentions along this line is to court defeat. When possible—and I realize that many times it is not—the patient should be placed in a large room, where good ventilation can be secured, and where the sun can be admitted at some time during the day. An open fireplace is desirable. The temperature of the room should be maintained at sixty-five or sixty-eight degrees.

Much depends upon a good nurse, not necessarily a trained one, but one of good judgment, who will carry out instructions. The attendant should be gentle, but positive. Our patient must be put to bed early, and kept there. Much may be lost by allowing the patient to walk about during the early days. He is in for a long siege, and can not afford the unnecessary loss of a single ounce of his strength; hence a bed-pan should be used. He may object to it at first, insisting that he can not use it; but if the nurse be firm, he is soon convinced of his error. If impossible, which is rarely the case, he should be carefully assisted to the commode, which should be placed by the bed.

He is to be sponged daily with soda-water if the tongue be white and pasty, or acidulated water if it be red and dry. This is for cleanliness, not as a temperature reducer, which will be noticed later. The diet should be fluid, preferably milk, and should be given about every three hours, unless there be great prostration, when it may be given every hour. If the patient objects to sweet milk, it can be peptonized by adding essence of pepsin, or make a sherry whey by adding one-fourth of a cup of sherry-wine to three-fourths of a cup of hot milk, stir till it curds, strain, and add a little sugar. This is a favorite whey, and I find it acceptable to many; others prefer buttermilk, while again malted milk, which may be prepared in many ways, will answer better. Broths do better in the advanced stages of the disease; if used early they are apt to aggravate the diarrhea.

Sick people soon tire of one food, and it is a good plan to change the broth from time to time; say beef broth one day, lamb broth another; then change to clam or oyster broth, or chicken broth, when we may return to the beef broth. Give plenty of cold boiled water. If he does not ask for it, give it as a medicine; it will help nature wash out the poison by way of the kidneys. Do not allow any solid food until the temperature becomes normal and all tenderness disappears from the abdomen.

The position of the patient must be changed occasionally to prevent bed-sores.

In the giving of drugs in this disease, as in every other, it is well to bear in mind the object of our medication. We are to remember that our patient is to contend for weeks with a febrile condition that will tax to the utmost his vitality; that the fluids of the body and of every tissue and organ will be impressed by the poison; that every agent that is given must tend to conserve his vitality, and that every remedy that depresses it must be discarded. We are to guide our fever patient safely through the troubled sea of fever, render him as comfortable as possible, and so modify the morbid processes that may arise, that the voyager may safely reach the desired haven, health.

While we recognize that this is a true zymotic disease, with the intestines bearing the brunt of the attack, we do not treat it entirely by antiseptics. We most heartily concur in the teaching of Dr. Scudder in regard to the use of sedatives in this disease. An experience of twenty-five years convinces us of their beneficial action. We are aware of the fact that the fever is the result of a toxin in the blood, and that theoretically the treatment should be to give agents to neutralize or antidote this poison; at the same time we are satisfied that the fever may be modified, the irritation of the nervous system better controlled, and the secretions promoted by their judicious administration. We may not succeed in materially lowering the temperature, but we most favorably influence the heart's action and fortify it, so that it may withstand the strain that it is always called upon to bear. Sedatives may be given to improve the circulation.

Aconite.—This is the sedative where the pulse is small and frequent, an evidence that the heart's action is weak and is beating rapidly to make up for loss of power. Aconite in the small dose does not depress, but adds tone to the heart. In proportion as the circulation is controlled, the secretions from the skin and kidneys are increased. Echinacea possesses strong antiseptic qualities, and may be combined with it—thus:

Veratrum.—Although there is usually debility with this fever, we occasionally find the strong, full pulse, showing excessive heart's action, and here veratrum takes the place of aconite. With excess of the heart's power, there is generally great irritation of the nervous system, which gives us the flushed face and bright eyes calling for gelsemium. Here the prescription will read:

Rhus.—This is an agent to relieve irritation, either of the nerve centers or an irritable stomach. These conditions are present with the small, sharp pulse, and if the tongue be pointed with elevated papilla the indications are still more pronounced:

Lobelia.—This is an excellent drug where there is an oppressed pulse, as if there were some obstruction to the free flow of blood. In addition there is a sense of oppression in the chest, difficult breathing and unpleasant sensations in the region of the heart. These are symptoms often found with respiratory complications. Here specific lobelia, 10 drops, is added to the aconite solution above named.

Jaborandi.—Where the skin is dry and the temperature running high, Dr. Webster recommends Jaborandi:

Bryonia.—Where there is bronchial irritation, with harassing cough, with sharp chest pains, and where the pleura is involved. bryonia is especially valuable. With these conditions the pulse is usually vibratile:

Antipyretics.—For the high temperature, the temptation is to resort to some of the many antipyretics, chief among which are the coal-tar products, and quinine. These should never be used. The patient is being constantly depressed by the disease, and if to his depression we add remedies that are recognized by all medical men as heart depressants, our patient must necessarily suffer.

Baths.—To assist the action of the sedatives, baths are the safest adjuncts in reducing the temperature. The early Eclectics used the wet-sheet pack with great success, and we would do well to revive this practice. The Brand treatment, the submerging of the patient in cold water every time the temperature reaches 103, is not practical in private practice, but there are none so poor where the wet-sheet pack could not be used. Frequent sponging may take the place of the pack, and will be found very useful. Tepid water is the best.

Antiseptics.—Very early, antiseptics may be indicated. The dusky hue of the mucous membrane tells of the progress of the poison, and suggests echinacea and baptisia. Where the tongue is broad, full, slightly coated, and with a dusky hue, face and tissues full, give:

Baptisia.—Where the face is dusky and presents a frozen appearance, the tongue is dusky and the stools frequent, baptisia may take the place of echinacea, or, what would be better, combine them.

Sodium Sulphite.—Where the tongue is moist, dirty, and pasty, the face full, eyes dull, extremities inclined to be cold, emaciation not very rapid, a saturated solution of sulphite of soda will be found invaluable. Tablespoonful every two hours.

Potassium Chlorate.—This is the remedy for bad odors, offensive skin and breath, fetid stools; in fact, general cadaveric odor:

Hydrochloric Acid.—This is by far the most frequently indicated antiseptic used in typhoid fever. By the end of the second week, and sometimes earlier, the tongue becomes dry and brown, or, dry, sleek, and glossy, with sordes on teeth and lips. The tongue is protruded with difficulty, the emaciation is rapid, here:

Cider.—With these same symptoms, sharp, sparkling cider is not only very refreshing, but also curative. Buttermilk is another agent that is grateful in these conditions.

Sulphurous Acid.—The moist, dusky, red tongue, resembling spoilt beef, calls for sulphurous acid.

Nervous System.—We find that one of two conditions may be present. Where the patient is restless and irritable, gelsemium and rhus tox. will be called for; here the flushed face, bright eyes, hot head, and restlessness, calls for gelsemium. If the patient suddenly starts in his sleep, has a sharp stroke to the pulse, rhus has the preference.

Belladonna.—If there is more or less coma, the pupils will be dilated, the pulse will be small and the extremities inclined to be cold,—we will add ten drops of specific belladonna to a half a glass of water. Teaspoonful every hour.

Quinine.—We do not use quinine as an antipyretic, but where there is lack of innervation, with moist skin and moist tongue, quinine is an excellent agent:

Insomnia.—The patient who fails to secure sleep is doing badly, as the dry, brilliant eye, pinched features, and contracted nose will testify.

Passiflora. Passiflora in full doses will often secure the desired rest:

Diaphoretic Powder.—The old diaphoretic powder of the fathers, consisting of camphor, opium, and ipecac, is one of the most reliable remedies which can be used. The indications calling for it are, moist skin and tongue. From five to eight grains should be given every four or five hours. The second dose rarely has to be given.

Sulphonal and Trional.—These agents may be given in ten-grain doses, administered in very hot water. It is best dissolved in boiling water, then stir till cool enough to drink. The sulphonal should be given two hours before sleep is desired, as it is very slow in its action. Trional is much quicker, and should be given thirty minutes before bedtime. Before using any of these drugs, the nurse will have tried sponging the face in cologne-water, rubbing the spine, using the hot foot-bath, changing the pillows, etc., which will, very many times, secure the desired result, sleep and rest.

Gastric Complications.—Wrongs of the stomach should have been considered, perhaps, before lesions of the circulation: for many times treatment has to be directed to correcting this before any other medication can be carried out.

Irritation.—The irritable stomach will be easily recognized. The elongated tongue, reddened at tip and edges, tenderness over the epigastric region, the constant nausea with persistent retching, will be overcome by the use of specific ipecac and rhus tox.—five to ten drops of each to a half a glass of mint water. Tea-spoonful every thirty or sixty minutes; or sub-nit, bismuth, drachms 1 to water four ounces.

A cold pack over the stomach will assist materially in overcoming this condition. An infusion made from the bark of the young twigs of the peach-tree, and given in small doses, may also be very useful.

Atony.—At other times there is marked atony of the stomach with hypersecretion of mucus. Here the tongue is broad and pallid, with a heavy coating from base to tip. The patient is dull, and the tissues full.

Sodium Sulphite.—Until these conditions are changed, neither medicine nor food can be appropriated. With these symptoms, place sulphite of sodium, drachms 2, in a half a glass of water, and give a teaspoonful every two or three hours.

Diarrhea.—If mild, nothing will be required, but if profuse, bismuth subnitrate or bismuth subgallate will be useful, three to five grains every three or four hours; or specific epilobium, ipecac, or dioscorea may be given, ten to twenty drops in a half a glass of water. If the tongue be pasty, sulpho-carbolate of zinc will be found of great benefit.

Hemorrhage.—There will be few cases of hemorrhage if the doctor has carefully met the conditions from the beginning; however, we will sometimes have it even under the best of care. Gallic acid, five grains every three or four hours, will usually promptly arrest it. The decoction of erigeron cane is advised by Webster. There is usually great prostration following a hemorrhage, and stimulants will be called for, strychnia grs. 1/60 being one of the best.

Tympanites.—If the distention of the abdomen be great, the small dose of turpentine will be found useful. The tongue in these cases is dry and clean. An emulsion containing one drop of the drug at a dose, every two hours, will not disturb the stomach or kidneys, and will give good results. Specific xanthoxylum, 20 drops, to water four ounces, teaspoonful every hour. is good treatment. The common tincture of Prickly-ash berries, an ounce to a pint of warm water, and used as an enema, will also prove of marked benefit in stubborn cases.

Constipation.—I am not yet a convert to cathartics in typhoid fever, and I am persuaded that a little constipation is better than the irritating effect of a cathartic. I would allow the bowels to remain quiet twenty-four or forty-eight hours before resorting to means for an evacuation, when an enema of warm water and glycerine may be used. If unsuccessful, tablespoonful doses of pure olive-oil or broken doses of epsom salts may be given.

Bladder.—The condition of the bladder must be carefully looked after, for the patient may have retention and the nurse overlook it for several hours. If urine has not been voided for twenty-four hours, small doses of santonine may be used. Strychnia, 1/60 gr. every three or four hours is also an excellent agent. If there be much distention of the bladder, the catheter, of course, must be used.

Convalescence.—Great care must be exercised during convalescence; as the fever subsides and the tongue cleans, the patient develops a voracious appetite, and, if the nurse be not firm, will take more than can be digested. The nurse should give nourishment frequently and in small quantities, rather than the usual meals, three per day. As the strength is regained, the patient may be assisted about the room, but should not undertake to walk far till the stools become normal and the heart's action has regained its tone.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.