Typhoid Fever.


Synonyms:—Abdominal typhus (typhus abdominalis); enteric fever; ileo-typhoid; gastric fever; nervous fever.

Definition:—An acute continued infectious fever, characterized by the presence of the bacillus of Eberth. There is a constant lesion in Peyer's patches, and in the mesenteric glands and spleen. There is toxemia, diarrhea, tympanites, a rose-colored eruption and a tendency, in severe or badly managed cases, to intestinal hemorrhage and perforation. There is, following this disease, a proneness to the occurrence of acute inflammation in almost any organ, or part of the body, and local inflammation may set in during the course of this fever.

Etiology:—There is present in all of these cases a specific bacillus which was discovered by Eberth and subsequently studied by GafTky, who confirmed the opinion of Eberth. The specific infection of typhoid is introduced, almost invariably, through the medium of the drinking water. This is more readily proven in sporadic than in endemic cases.

The role played by the house fly in the spread of typhoid is important, especially in military camps where insufficient sanitary arrangements exist. The flies have access to the excreta of the camp and also to the food supply and the epidemic is thus rapidly spread. Our volunteer camps in the United States during the late war with Spain were striking examples of this mode of infection, which may be repeated wherever typhoid excreta is exposed, or not thoroughly disinfected, and where green grocers, milk and meat dealers and housekeepers do not properly protect their articles of food.

Predisposing Causes:—The disease occurs in youth and in early adult life. It occurs in the late summer and early autumn, especially if the summer has been hot and dry. It follows robust health, but results also from depressing causes, such as great sorrow, or mental overwork or excitement.

Symptomatology:—Typhoid fever is anticipated by a malaise, which may last for several weeks. A short time before the attack, there is severe headache each day, usually frontal, later it is of a bursting character, and it may then be occipital and increasingly severe. There is usually a tendency to dream wild, extravagant, or frightful dreams. There is anorexia, muscular aching, general dulness, and disinclination to exertion, some deafness, nasal hemorrhage, and increasing weakness. There may be nausea and vertigo, with diarrhea.

At the onset of the attack, there is a chill, though usually mild, or there may be a recurring chilliness, increasing for a few days, with heat flashes and increased headache and dulness, with some confusion of the intellect. There is, in some cases, severe muscular aching in the back and in the limbs. As the fever appears the prodromal symptoms are aggravated, with increased irritation of the gastrointestinal tract. There is abdominal tenderness, especially in the right side, with gurgling upon pressure in the right iliac region. The temperature increases, perhaps one degree, each day and the remissions are progressively less marked. The evening temperature will exceed that of the morning, perhaps two degrees. The pulse is frequent, but usually full, large, and soft, although not always rapid. The respiration quickens and becomes short and labored.

By the seventh day usually all above phenomena will have developed fully, with increasing diarrhea. There will be from two to five evacuations daily of a so-called "pea soup " character, or they will be described as watery, clay-colored, or yellowish, frothy and of an offensive odor. Usually at the end of the first week, or often in from seven to ten days, the characteristic rose-colored spots appear on the abdomen and chest. These appear in crops, which last perhaps four days, and then fade away and disappear. They are distinct elevated papules of a rounded or lenticular form. They disappear momentarily upon pressure. There is much disagreement as to the invariable appearance of these spots. They are certainly often absent in childhood, and occasionally absent in the aged.

In marked and severe cases there may be present a scarlet erythematous eruption, or there may be urticaria or purpura, with perhaps extensive ecchymoses, abscesses, boils or gangrene of the extremities. The gangrene may be due to an obliterating endarteritis, to a thrombosis or to an embolus.

During the second week the chilliness disappears. The morning remission in the temperature is slight, the pulse increases in rapidity and is easily compressible. There may be subsultus tendinum with increasing dulness or stupor, and a mild delirium, which may occur only at night or during an effort at sleep. There is an apparent increased enlargement of the spleen and increased tympanites. The diarrhea is now difficult to control, the tongue is brown and fissured, and sordes appear upon the teeth and lips.

At the end of the second week, if the condition has not been favorably influenced by treatment, a typhomania will appear in which the patient acts as if partially asleep, his mind wanders almost constantly, and he talks as if to himself in a despondent and discontented manner on all subjects. The tongue may lose its coating entirely and become red, glossy and dry, showing extreme atonicity of the digestive and intestinal organs and weakness of the nervous system. A bronchial irritation with a short, dry cough and bronchial rales, may now appear. The patient shows emaciation, is pale and there is a hectic flush on the cheeks.

During the third week there should be some amelioration of the symptoms, and toward the end of the week there should be a pronounced morning remission with a general slight reduction of the temperature and more mental clearness. The patient will be very weak, with a tendency to complications, and also to relapses, which are quite common at this point. Intestinal hemorrhage may now occur, especially if there be a relapse. In an unfavorable case there will be an increase of the diarrhea, with frequent dark, fetid, offensive and sometimes involuntary discharges. The coat on the tongue is almost black, there is offensive sordes on the teeth and there is marked prostration. The patient lies supine, with a constant tendency to slide down into the bed, with subsultus tendinum, and increasing coma, and, finally, death.

During the fourth week, if a favorable condition exists, all the symptoms will abate, the appetite will return and there will be a slow gain in the general strength, although there may be a little rise of the temperature during the latter part of each day for perhaps a week longer.

Diagnosis:—Unless pathognomonic phenomena are plainly apparent, a positive diagnosis of typhoid should not be made during the first week of the fever. Malarial fever, febricula, even, or remittent or relapsing fever, meningitis or the pronounced febrile symptoms, of some mild inflammation, may show some of the signs of typhoid development, and yet terminate more suddenly and more satisfactorily a little later on. The pyrexia of septicemia, of acute miliary tuberculosis, or of ulcerative endocarditis, may be mistaken for typhoid.

In a typical case there is the gradual development, languor, headache, pronounced and persistent anorexia and frequently recurring nose-bleed, chilliness and persistent slowly increasing temperature.

The enteric phenomena—diarrhea, tenderness in the ileocecal region, gurgling, tympanites, splenic enlargement, especially if accompanied with dry tongue, coated brown, and an increasing tendency to sordes—will all confirm the diagnosis. The appearance of the rose-colored spots at any time will remove all doubt.

There is a consensus of opinion in favor of the clinical value of the serum diagnosis of Widal. The reaction has occurred in 95 per cent of the cases in which it has been used, which fact confirms its reliability. Where typhoid develops after or during the progress of some local inflammatory development, this reaction may not take place early. On the other hand, the Widal test may show the development of typhoid when its presence is not shown by other characteristic phenomena.

Differential Diagnosis:—In acute miliary tuberculosis there is not the peculiar development of typhoid. Although the temperature is persistently high, it has not the regular remissions, nor are there the enteric symptoms, nor the rose-colored spots. The bacilli of tuberculosis may be found by microscopic examination of the sputum. The prominence of the cough and the cyanosis will assist in a correct diagnosis of that condition.

In septicemia the high temperature is very irregular and there are frequently recurring chills and periods of sweating. If there be an eruption it is by no means characteristic.

Typhus fever occurs in an epidemic form and is pronouncedly severe almost from its onset. It runs a short course and has a much more abrupt termination.

Fevers of a malarial origin are difficult to distinguish from typhoid, and malarial manifestations are common during the presence of typhoid, exhibiting either the remittent or a distinctly intermittent type. Laveran's hema-tozoa will be readily found in the blood if present.

In meningitis, with the persistent temperature, which is usually lower than typhoid, there is intolerance of light—contracted pupils—marked hyperesthesia, exaggerated reflexes and often muscular rigidity before the effusion. There is vomiting, constipation and great restlessness. All the nervous symptoms are prominent in the early stage of the disorder. The distinct typhoid symptoms are usually absent.

Trichinosis has been mistaken for typhoid in its evidences of blood degeneration, with great muscular soreness, but it lacks the persistent high temperature, enteric symptoms and rose spots.

Tubercular enteritis, tubercular peritonitis and tubercular meningitis have been mistaken for typhoid, but the presence of the tubercular bacilli, with the other characteristic phenomena, and the absence of the Widal reaction, will usually readily determine the exact condition.

Prognosis:—In an uncomplicated case the prognosis is favorable, but a guarded prognosis must be given if the cerebral or enteric symptoms are distinctly severe early in the case. When a high temperature occurs early and persists in spite of the treatment, with only slight or irregular or increasingly shorter remissions, the prognosis is not good.

If a temperature of 106° F. is maintained for two or three days, the case will probably die. Where there is severe and persistent diarrhea, with increasing tenderness, tympanites and frequent hemorrhages, or where coma and marked delirium occur early, the condition is threatening. Early and persistent nosebleed is not a good symptom.

If the high temperature is of short duration and the remission long or increasing on each day a little; if the pulse is good and the heart strong and there is but little delirium and the intestinal symptoms and diarrhea seem to be readily controlled, a more favorable prognosis may be given.

Treatment:—Is it possible to abort a case of typhoid fever when its etiological elements are implanted within the system and are enforced by a favorable environment? This question has had constant agitation for many years and is yet unsettled. There is no doubt, however, that avoidance of irritating measures, and the adoption of a rational and specifically indicated treatment, will greatly abridge the course of the disease and positively modify its manifestations in a very large proportion of cases if such a course be adopted from the onset in a positive and confident manner.

As soon as evidences appear which suggest the probability of a later positive diagnosis of typhoid, especial preparation should at once be made for the care of the patient in the most approved and scientific manner. These measures adopted, in a case of simpler fever or acute inflammatory manifestation, will do good and no harm, if the actual diagnosis of typhoid be not ultimately confirmed. The patient must be put to bed at once and kept in bed in a large, airy, easily heated and easily ventilated room, which is isolated as much as possible, and into which none should be permitted to enter but the nurses and attending physician. Both a night and a day nurse of skill and experience should be provided for the severe cases, or those which exhibit threatening premonitory manifestations. If a trained nurse is not accessible, all orders given by the physician should be written out in full, not alone those concerning the medicines, but those especially which concern the care of the patient, the preparation of the food, the disinfection and disposal of the excreta, and the ventilation and temperature of the room. Skilful nursing is of the utmost importance in typhoid cases.

The bed should consist of a hair mattress upon stiff springs. A thin cotton mattress over this, which can be readily changed, is advantageous. This is covered with a rubber sheet, with cotton sheet over all, changed frequently.

Any tendency in the early stages of the fever for the patient to lie continuously upon the back should be avoided. He should be turned from side to side gently and without disturbance, and every care should be taken that bed sores do not appear.

The clothes, both of the bed and the patient, should be changed at least every twenty-four hours and as often as soiled. All soiled clothes of whatever kind should be received in a sheet that has been dipped in the five per cent carbolic acid solution. These should be boiled in the washing from twenty to forty minutes and thoroughly aired before being returned to the patient or bed. There should be two or more rubber sheets, which should be changed each day, and the one removed dipped in the carbolic acid solution, washed and dried and aired for use later.

Most important in typhoid is disinfection of all the excreta. This is apt to be carelessly performed. The patient should not be allowed from the first to arise from the bed, but should use a urinal or bed pan. These should be sterilized and should contain a portion of the disinfecting fluid, and more should be added after the excreta (both urine and feces) are passed. A larger vessel should be provided, into which these should be poured, more of the solution added and allowed to stand from four to six hours before they are emptied into the water closet. The total mass should be well stirred and solid particles broken up.

As disinfecting fluids, a five per cent solution of carbolic acid is available, or Piatt's chlorides are of much service. A solution of chlorinated lime can be readily prepared by-adding five or six ounces of the lime salt to each gallon of water. This is a standard authorized solution.

When it is possible to devote two contiguous rooms to the use of the patient, one can be opened wide and aired, while-the patient is shut off in the other. This is of signal advantage always.

As auxiliary to our specific methods the use of water in sponge bathing or the Brand method of tub baths, is now conceded to be of much service and of great advantage.

Brand advised that the patient be kept in water at a temperature of 70° F. for twenty minutes. This is extreme and dangerous with very young, or aged patients, or with those of previous poor health and of rather feeble reactionary powers. A temperature of 90 degrees, slcwly reduced for from twelve to fifteen minutes, is cold enough for any but the sthenic cases, and with these a frequent repetition of the bath is not desirable.

I will not take it upon myself here to fully describe in detail this method, as I am an advocate of free sponging as more accessible and more readily adaptable to the individual peculiarities and necessities of the patient, and fully as efficacious, everything considered. In the sponging of a patient the water should be used at a temperature as low as possible, without producing discomfort to the patient. A little alcohol or ammonia may be added to the water, or 30 grains of the ammonium chlorid to the pint of water, may be used instead of water alone, two or three times daily. The arms, head and neck, legs, and then the trunk should be sponged in the order named, and each partially dried in succession before proceeding to the next. The sponging should be resorted to whenever the fever is on the increase and above 102° F. The sponging should be continued until the temperature has fallen from one and one-half to two degrees. If the patient becomes chilly or restless it should be discontinued. If it is decidedly opposed by the patient because of results unpleasant or distressing to him, it should be avoided entirely, except as applied to restricted localities.

In my earlier practice I became familiar with the application of the wet sheet pack at the onset of fevers and inflammations, and there is no doubt of the great efficacy of this method in the developing and early stages of typhoid. The temperature of the sheet may be adapted to the sensations of the patient. It may be cool, cold, at the body temperature or even hot, as the patient prefers. If applied hot the outer wet surface of the sheet should be exposed to the air until it cools to a point as low as desired, when the whole should be wrapped in a dry blanket. The patient may remain so wrapped for an hour, and will experience only comfort and rest. A perspiration often starts and may continue for some time. The patient may fall into a restful sleep in the pack, when extra covers should be applied to assist normal reaction and prevent too great depression. The sheet may be applied during the first week as often as every four or six hours and continued from half an hour to an hour, or even more. This method is readily adjustable to both the very young and the very old, with great benefit. Its application demands caution, and the exercise of the best of judgment.

In the feeding of typhoid patients many factors are to be taken into consideration. The extreme inactivity or actual suspension of operation of the digestive and assimilating functions makes the question of nutrition one most difficult of solution. From the onset of the fever solid foods in any form should be proscribed, and milk alone, always diluted, and usually with a trace of salt added, is the safest article of diet. Of this, from thirty to sixty ounces should be given within each twenty-four hours, and if there is any question of its digestion it should be prepeptonized. I have found patients, notably those where acids were indicated, where buttermilk, matzoon, or kumyss, suited the stomach better than milk in other form.

John Uri Lloyd has written some excellent articles on the food value of water, and there is no doubt, that with the reduction of the temperature—the lessening of the total number of hours of high temperature—there is a tonic, a strengthening effect from the free use of water both internally and externally.

During the course of a severe case of typhoid fever, especially if it be greatly protracted, there may be a time when the ingestion of food of any kind apparently does harm. There is increased nervous and intestinal irritation, a marked and sometimes abrupt rise in the temperature, and often delirium and increased diarrhea and tympanites. These conditions make it imperative that all food be discontinued, but water should be freely given. This course is now adopted by the leading clinicians. It is surprising how much benefit will obtain in even prostrate cases if this course be carried out for a few days. Later, as a substitute for solid food, I have obtained good results from the use of fruit juices prepared with the least possible amount of sugar. Where the juice from the fresh fruit cannot be obtained I have used diluted jellies. A teaspoonful or two of jelly may be added to a glass of water, which may be prepared as I have specified, with peroxide of hydrogen, and drunk ad libitum. It is very acceptable to the patient, does not disturb the stomach even in sensitive cases, does not ferment in the stomach, and shows evidences of considerable nutritional power.

Where there has been hemorrhage or where this condition threatens, it becomes necessary sometimes to substitute nutrient enemata instead of food per os. For these enemata, hot milk containing a little salt may be used, or an ounce of cream every three hours, or half an ounce of bovinine. Later, when the stomach will receive food, the white of an egg, dissolved in water, may be given in frequently repeated small doses, or where the prostration is very marked, and nutrition seems imperative, finely scraped raw beef may be administered. When the case has not assumed a severe form, and convalescence occurs early, or where we have reason to believe that the ulceration in Peyer's patches has not been severe, the patient may take the entire egg diluted, or thin custards, or may eat a little well cooked rice.

I have found ice cream, prepared by the nurse, of fresh milk with a very little corn starch and a minimum of sugar, with eggs if desired, to be received by many patients most gratefully, and to cause but little disorder of the stomach. This I have ordered administered quite freely during the high temperature, but always given in small quantities, and allowed to melt in the mouth.

When convalescence does not occur until the patient is greatly exhausted, the administration of eggs and raw meat, as above specified, is often of great service. Solid diet should be returned to very gradually and always with the advice of the physician. Some patients, for a beverage, do well upon the use of a little coffee or tea, and if the indications for an acid are present, lemonade or orange juice given cold and sweetened with a little glycerine will be of much service.

A thorough cleansing of the mouth and throat with a saturated solution of boric acid, or better yet, a strained infusion of white oak bark containing twenty grains of boric acid and ten drops of echinacea to the ounce should be frequently made day and night. If a little glycerine be added to the solution it will be gratefully received, if the mucous membranes of the mouth, and the tongue be dry and parched. The patient should be encouraged to drink freely of pure cold water throughout the entire course of the fever. If a tablespoonful of the peroxide of hydrogen be added to each quart of water without the patient's knowledge, there will be no taste of it in the water, and its influence as an oxidizing and disinfecting agent, steadily and persistently administered, will be of the most signal service, in preserving a benignant form of the disease, and in its ultimate abridgement. The use of a mild infusion of equal parts of marsh mallow and epigea repens or triticum repens, to which a little lemon juice is added, drunk cold, will be very pleasant to the patient and will act as a most serviceable diuretic.

The use of alcoholic stimulants in the earlier stage of typhoid is often harmful. The commonly accepted opinion that stimulants are necessary from the first is radically wrong. Stimulants are indicated by exhaustion, and need not be given until the indications appear. Then a little good wine or diluted brandy can be given during that period when the temperature is the lowest, but I am positive that harm results when given during the increase of temperature. We have recourse to remedial agents that are in every way superior to alcoholic stimulants. These will be named in their proper order.

When in convalescence fever has been absent about eight days the ordinary diet may be very gradually resumed, due attention being paid to the manner in which the food is received within the gastro-intestinal tract. Fresh vegetables have an especially rapid restorative influence when well digested, and fresh fruits in season are acceptable. The administration of an artificial digestive with the first solid food, and for the first few days, is an important precautionary measure.

Medicinal Treatment:—It may be well to preface the suggestions to be here made, with a caution concerning a fallacy which the profession has been in the habit of adopting in the past. A most notable error is the inauguration of the treatment of typhoid with the administration of an active dose of physic, and the continuation of laxative remedies during the course of the treatment. I am confident that the profession at large makes no greater mistake than this. Let good judgment and a keen rational discrimination decide as to whether intestinal obstruction from any cause or fecal accumulation be present. If these exist, a mild laxative, accompanied with a large high enema, will be sufficient in all cases. In an observation of nearly thirty years I am convinced that large doses of calomel invariably prolong the fever, and that this foreign substance in any dose may be readily substituted by a rational organic remedy. The old practice of administering a severe emetic at the outset of the disease has become obsolete, although the stomach must be freed from any indigestible material.

The first consideration in every case must be the reduction or the restraining of the temperature. In sthenic cases, at the immediate onset of the disorder, if there be a pronounced chill, with greatly elevated temperature, of abrupt occurrence, and especially if there be, as sometimes occurs, a wild delirium, within the first few hours, it is excellent treatment to administer a full dose of jaborandi or one-twelfth of a grain of pilocarpine, hypodermically, to put the patient into a hot bath for a short time, and then wrap him in blankets and encourage profuse perspiration. I am confident I have seen cases aborted or greatly abridged by this course. The sudden early occurrence of violent delirium in the sthenic stage has no better remedy than jaborandi.

It is seldom, however, that the physician is called until the fever is well established. If there be a dark, flushed face, with full capillary circulation, a rapid, large, full pulse, veratrum should be given in small doses every hour as long as this condition is present. But this is apt to change quickly. The skin will become dry, the face flushed bright red, the mouth dry and parched, the pulse smaller and hard, yet rapid. These indications demand aconite. Of the specific remedy, five drops in four ounces of water should be administered in dram doses every hour. This agent in rather full dosage during the sthenic stage is of much benefit and I am satisfied that in very minute dosage it may be continued into the asthenic stage with only good results in its restraining influence upon high temperatures and in assisting the dissipation of heat. If there be with these later indications a great degree of nervous excitability, with contracted pupils, and muscular twitchings, gelsemium may be given with the aconite or may be substituted for it.

I am confident that belladonna is a remedy of rare value in certain cases during the first two weeks of typhoid fever. The specific indications are dulness of intellect, cool skin or cold extremities, sluggishness of the capillary circulation and dilating or dilated pupils, but I have administered the remedy when these indications were not marked, in very small doses of the tincture, combined with aconite, and obtained excellent results. It prevents local congestion and stasis in the intestinal glands and equalizes the circulation.

The coal tar derivatives have no place in the treatment of this disease. In minute doses no results are apparent, and in large doses the destructive influence of these agents upon the red blood-corpuscles and in forming methemog-lobin overbalances any beneficial effect their depressing influence may have upon the temperature.

Bryonia has an important place in the treatment of all stages of typhoid. Whenever there is deep tenderness on pressure, sharp, quick cutting pains, or evidences that the peritoneum is involved, this remedy will control the temperature and will exercise a beneficial influence upon the inflammatory processes. Homeopathists use this remedy in the treatment of the fever during the period of prostration—the asthenic stage—and obtain excellent results. I think if the dosage be small enough it may be given in alternation with aconite, but the dynamic rather than the physiologic action of both agents must be sought for. During this stage rhus toxicodendron is a remedy of value. The sharp, burning heat in the skin, with circumscribed bright red spots upon the cheeks, with sordes upon the teeth, the tongue and mucous membranes dry and red, the eyes bright and restless, with the presence of tympanites, all demand this agent. If the tongue be bright red with a pointed tip upon which the papillae are elongated and pointed, this agent will be of direct benefit.

Arnica is indicated in those cases where the nervous system is greatly at fault—is greatly depressed. It increases the nerve force, adds strength to the heart, slows the pulse and reduces the temperature. It is especially indicated where, from extreme depression, there are frequent involuntary discharges. Where there is low, muttering delirium, the tongue dry and parched, and the throat apparently clogged with foul, stringy mucus, it is demanded. It stimulates the respiration and promotes the oxygen carrying power of the blood. It increases nerve sensibility, overcoming paresis. It acts upon the secretory function of the skin and kidneys in a satisfactory manner. The dose is small—from five to fifteen drops in a four-ounce mixture is given in dram doses frequently.

Much is said concerning the desirable influence of digitalis in typhoid fever. When this agent is studied in comparison with cactus grandiflorus and the latter remedy is understood in all its bearings, it will be found that cactus is superior to the better known drug. Cactus increases the musculo-motor energy of the heart, increasing its action, and seems to supply nutrition to the central nervous system. It stimulates the heart from actually increased nerve tone, through improved nutrition of the entire nervous and muscular structure of the heart. It does not whip up the heart only, as digitalis and strychnin do, but adds tone. It produces no gastric irritation, and being non-toxic, is harmless in any dose. Its influence, therefore, in the extreme prostration of typhoid is most salutary. It also prevents heart complications and relieves the strain which the persistent high temperature and increased activity of the circulation throw upon this organ. Through this influence it certainly restrains the temperature. When typhoid or other protracted fever has produced dilatation of the heart we have no better remedy than cactus.

I have administered the phosphate of iron in trituration at the period of the highest temperature each day in these fevers, with good results. I have dissolved ten grains of the third decimal trituration of ferrum phos. in a teacupful of boiling water, and administered this in teaspoonful doses every ten minutes during a period of two or three hours in each twenty-four hours of the first week or ten days, when the temperature was the highest, discontinuing all other remedies while this was given, and have seen most desirable results.

Hemorrhage is almost an unknown complication with those who have used echinacea in typhoid. If it occurs it is treated with astringents according to its indications. A full dose of ergot will sometimes exercise a wide influence of much value over the entire circulation, or if hemorrhage is anticipated this agent may be given in from five to ten minim doses every three hours with great advantage. Its influence upon the central nervous system is most salutary if there be a tendency to dulness or coma. Hamamelis, thuja, collinsonia, erigeron, capsella or aromatic sulphuric acid or nitric acid are often most serviceable remedies selected according to their specific indication. In extreme passive hemorrhage gallic acid is important, especially if hematuria be present.

The delirium must be treated directly. I have observed that but little benefit from any other treatment will occur while delirium exists. For this condition hyoscyamus is of much value in the excitable or wild form. It may be given with confidence. It may be given alternately with ergot or gelsemium if determination of blood to the brain be plainly apparent.

Ergotin granules are a form most convenient of administration. In extreme stupor with subsultus tendinum I have obtained the best of results from hydrobromic acid fifteen minims and ergot ten minims every two or three hours persisted in until the condition was overcome.

The bromides and chloral in consistent doses will be found of service in the insomnia and restlessness of typhoid. Hyoscyamus, passiflora and cannabis indica are also of much value.

Diarrhea will not prove a serious complication if no active physics have been used and if the bowels be freely flushed after each large movement a few times, with an antiseptic flush. Geranium, epilobium or erigeron in sufficient doses will usually control excessive action. Thorough irrigation of the colon with the physiological salt solution to which are added a few drops of carbolic acid, will control the diarrhea, remove existing tympanites effectually and restore to a degree the strength of the patient, increasing the force and volume of the pulse.

Quinin has no place in typhoid as a specific antipyretic, but in those cases where malarial manifestations are present as a complication it may be given in the early stage of convalescence only at that period of each twenty-four hours when the temperature drops below 101° F. And it must be discontinued when any apparent nervous irritation appears from its use. The bisulphate should be given in preference to the sulphate because of its ready solubility and absorption. This agent may be continued with the tincture of iron as a tonic throughout the twenty-four hours when the temperature is normal and the secretions are restored. Other restorative agents are nux vomica, strychnin—preferably the strychnin arsenate, hydrastis, phosphorus, or the glycero phosphates, bovinine, the hypophosphites and cod liver oil. I have combined the tincture of iron and dilute phosphoric acid and given full doses of this with small doses of quinin with good results. Other tonics will suggest themselves to the experienced physician as directly indicated.

Antiseptic Measures:—While typhoid is an infectious disease and while we believe the bacteria act in the intestinal canal upon Peyer's patches, we do not get the pronounced direct results from intestinal antiseptics we would anticipate, because the bacilli and the resulting toxines are not active upon the surface of the mucous membranes, and after the bacilli penetrate the structure of these membranes, they have passed beyond our reach, and this before the fever appears. Much good is accomplished by this class of agents in preserving an antiseptic condition of the gastro-intestinal tract.

I have mentioned the persistent use of hydrogen peroxide. I would further advise its use in all enemas and especially when diarrhea is present. Systematic and thorough lavage of the intestinal tract is an important feature of the treatment of typhoid. Two tablespoonfuls of hydrogen peroxide in each quart of water after each bowel movement cleanses the lower intestinal canal and assists in controlling further bowel movements. This is especially true in tympanites also. If this condition be severe, a half dram of the spirit of turpentine should be mixed with the water and injected once each day.

Echinacea has been extensively used in the past ten years, and while it has not aborted the fever, it is the best of our agents in antagonizing the influence of the toxines within the system. It may be given in conjunction with all other indicated remedies in from five to ten drop doses every two hours. All observers unite in the opinion that it greatly modifies the severity of every case. It lessens the fever and materially shortens its course. But few cases continue beyond three weeks when this agent is used. It preserves the integrity of the blood, sustains the action of the heart, stimulates the stomach, encourages nutrition and positively wards off complications and sequelae.

Baptisia is indicated when the tongue is dry and coated with a brownish coat; when the mucous membranes are dark colored, purplish or dark red and when the breath and fecal discharges are fetid and there is sordes on the teeth. It is a great favorite with those who have had experience with it. It should be given as soon as these indications appear.

The sulpho-carbolates have an important influence when there are evidences of sepsis and decomposition of undigested food substances, especially if the mucous membranes are pale, the tongue broad and thick and coated white. The sodium sulphite is administered at this time with good results also, especially if the coating on the tongue be dirty or yellowish white. The indications for acids in typhoid are plainly marked in most cases, but hydrochloric acid is of benefit in its influence upon the stomach and digestion when the usual indications of a deficiency of acids in the system are not plainly apparent. When the mucous membranes are deep red, and the tongue has a slight brown coat, or a dry brown stripe down the center, this agent is indicated. But it may be given diluted after the food when there is extreme prostration at any time if the body of the tongue be of a deep red or even if there is a whitish fur on the tongue, or if the papillae are greatly elongated and tipped with white. It is especially serviceable in the early stages of convalescence.

Turpentine is a remedy of importance when there is marked deficiency of the secretions of the mucous and glandular organs of the intestinal tract, with tympanites. If the tongue be very dry and pointed and dark colored it may be given in an emulsion every two or three hours in doses of from two to five minims. It may also be applied in the form of a stupe, externally. From half a dram to two drams stirred thoroughly into an enema of very warm water and introduced through a high rectal tube will remove the accumulated flatus in tympanites and give immediate relief.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.