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. 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.

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. Wilson' has recently used with great success in the treatment of typhoid fever the following prescription, which was originally suggested by Roberts Bartholow: B. Tinct. Iodinii f3ij.; Acid. Carbolici liq. f3j.-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 Costa2 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. Rothe3 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.

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.

1

Transactions of the College of Physicians of Philadelphia, 3d Series, vol. vi., Philade phia, 1883, p. 221. 'Deutsche Med. Wochenschr., 1880.

'Ibid., p. 234.

VOL. I.-22

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 petechia. 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 rupos, which literally means smoke, and which is employed in the treatise on internal affections attributed to Hippocrates for a similar purpose. According to Murchison,' 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.

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

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

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 Corradi1 it may be said to have been practically undescribed before the year 1546, when Fracastorius 2 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 opportuity 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.

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 Langrish 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, J. Carmichael Smyth," and others.

3

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

1764.

Quoted by Murchison.

The Modern Theory and Practice of Physics, by Browne Langrish, p. 354, London, Observations in Diseases of the Army, London. Quoted by Murchison,

5