Part 55

Other post-mortem appearances which are met with less frequently than those above detailed are inflammation, and even ulceration, of the mucous membrane, of the bladder, inflammation of the salivary gland, peritonitis, and congestion of the pancreas and of the stomach.

The muscular tissue of the heart is generally softened and easily torn. It is not, however, as stated by some authors, invariably so, for in several cases in which it was examined by Da Costa it had undergone this change in one case only, in which there was no reason to suspect previous disease of the heart. The alteration is similar in kind to that which takes place in the voluntary muscles. An effusion of serum, which may be of a deep-red color from the transudation of the coloring matter of the blood, is {358} sometimes found in the pericardial sac, as are ecchymotic patches upon the surface of the heart. The endocardium may be stained from the imbibition of blood. On the other hand, endo- and peri-carditis are excessively rare.

Notwithstanding the severity of the cerebral symptoms in typhus fever, there are few or no important changes found in the brain or its membranes after death. The sinuses are occasionally filled with dark fluid blood, and the appearances of congestion of the brain are sometimes present. In other cases there may be an increased amount of serum beneath the arachnoid and into the lateral ventricles, but not more than is often seen after death from other causes. Very rarely a slight film of hemorrhage has been found in the cavity of the arachnoid, and sometimes also the evidences of non-inflammatory softening of the brain. Actual inflammation of the meninges has only been detected in a very few cases. There may also be congestion of the spinal membranes, increase of the spinal fluid, and softening of the cord itself. The ganglia of the sympathetic system appear to undergo a form of granular degeneration.

DIAGNOSIS.--The diseases which most closely resemble typhus fever are typhoid fever, measles, meningitis, and typhoid pneumonia.

The circumstances under which typhoid and typhus fever occur are different. Typhoid is never generated by overcrowding, and if contagious at all is much less so than typhus. Prostration occurs much earlier and is usually much more marked in the latter. The eruption in the former does not appear until the eighth day, and comes out in successive crops, and usually disappears under pressure as long as it lasts, and therefore may be easily distinguished from that of the latter. The duration of typhus is from ten to twenty days; that of typhoid is rarely less than twenty-one. Nevertheless, cases are occasionally met with in which it is impossible to arrive at a correct conclusion as to their nature unless some light is thrown upon it by the existence of other and more characteristic cases in the same house or neighborhood. I have recently had under my care a case which eventually proved to be typhoid fever, but which I and many others who saw it at first believed to be typhus in consequence of the presence of an abundant eruption, which did not disappear under pressure, and was finally converted into petechiæ.

The eruption of typhus is sometimes found upon the face, especially in children, and then presents a considerable similarity to that of measles, which, however, usually appears a little earlier. There is, moreover, rarely the same amount of prostration or stupor in the latter disease, which is also attended by coryza and more bronchial catarrh than is often present in the former. The eruptions in the two diseases differ. In measles it is crescentic in shape, and is more elevated than in typhus. It is also brighter in color, disappears under pressure, except in malignant cases, as long as it lasts, and is followed by free desquamation of the cuticle, which is not often observed in typhus. The temperature may be high in the former, but it usually falls upon the sixth day.

In meningitis the headache is much more severe, and does not disappear upon the occurrence of delirium. It may be so severe as to cause the patient to cry out. The senses are painfully acute. There are intolerance of light and sound, and some hypersensitiveness of the surface, {359} strabismus, inequality of the pupils or some other local paralysis, and retraction of the head. Nausea and vomiting are more common than in typhus, while the utter prostration of the latter disease is wholly wanting, and so is of course the characteristic eruption. The tâche meningitique is wanting in the latter, but too much reliance should not be placed upon either the presence or absence of this sign. The diagnosis is only likely to be difficult in those cases of typhus in which the delirium is active. In that form of typhus in which the symptoms simulate those of delirium tremens some difficulty may also be experienced in making a diagnosis, especially if the patient be a drunkard. In delirium tremens it will be remembered, however, that there is little or no elevation of temperature, that the skin is bathed in perspiration, the tongue moist, and the characteristic eruption absent. Typhoid pneumonia can be distinguished from pneumonia complicating typhus fever by the presence of the eruption in the latter.

Other diseases which have occasionally been mistaken for typhus fever are remittent fever, Bright's disease, giving rise to uræmia and purpura. It does not seem likely that even the severest forms of malarial fever should ever present such a resemblance to typhus fever as to make the differential diagnosis a matter of difficulty; but it would appear from the history of the latter disease given by Murchison that such a mistake has occurred in some of the Spanish American countries. The enlargement of the spleen and liver is much less marked than in remittent fever, and the remissions of temperature are much less decided. Uræmia may at times present a good deal of resemblance to the condition often seen in typhus fever after the supervention of coma or stupor, but the history of the case, the absence of fever and of eruption in the former, will generally enable us to distinguish between the two conditions. It should be remembered, however, that Bright's disease may occur in the course of typhus fever. Purpura may generally be recognized by the absence of fever and by the occurrence of hemorrhages from the nose, gums, and bowels.

PROGNOSIS.--The age, habits of life, and previous condition of health, as well as the character of the prevailing epidemic, must all be fully considered before making a prognosis in any special case. The disease usually runs a much milder course in children and young people than in adults past thirty years of age. After this age the mortality progressively increases, and in advanced life it becomes very high, being often as much as 50 per cent. or over. Sex does not of itself exercise much influence upon the course of typhus fever, for, although a few more men than women die of it, this appears to be attributable to the greater prevalence of drinking among the former. Previous intemperance acts unfavorably by producing a degeneration of the tissues of the body, thus rendering the patient less able to withstand the effects of the disease. Drunkards have therefore always furnished a large proportion of the fatal cases. The mortality among patients who are unfortunate enough to take typhus fever as they are convalescing from other diseases is usually also very great. This has often been observed in general hospitals in which cases of fever as well as those of other forms of disease are admitted. Fat, lymphatic, or muscular people more frequently die of it than those of a different conformation. Gerhard found it especially {360} fatal among negroes in the epidemic of 1836, and Buchanan seems to have had a similar experience at the London Fever Hospital. It is a fact noticed by English writers that people of the better class, although seldom attacked by typhus, often suffer severely from it. The mortality is always high among those patients who previously to contracting the disease have been for some time deprived of sufficient food, or have been overworked, or who have been the subjects of mental anxiety, worry, or any other depressing emotion. It is high also among those who in the beginning of the disease have exhausted their strength in the vain effort to resist the disposition to go to bed. The chances of recovery are, on the other hand, very much improved by the removal of patients from crowded, ill-ventilated houses to the wards of a spacious, airy hospital.

Unfavorable symptoms are a profuse dark-colored eruption associated with purpura spots and vibices, general lividity of the surface, great injection of the pupils, and a dusky hue of the countenance; extreme prostration; an excessively frequent and feeble pulse, especially if it is at the same time irregular or intermittent; absence of the cardiac impulse and of the systolic sound; hurried and spasmodic or abnormally slow respiration; great dryness and retraction of the tongue; excessive prominence of the nervous symptoms, such as headache, delirium, whether active or muttering; unequal or pin-hole contraction of the pupils; strabismus or other local paralysis; sleeplessness; muscular tremblings; subsultus tendinum; carphology; protracted hiccough; retention of the urine; relaxation of the sphincters of the bladder and rectum; coma and especially coma vigil, and convulsions; continued high temperature, rising instead of falling after the tenth day, especially if it is associated with coldness of the extremities and of the breath; a profuse perspiration without a general improvement in the symptoms; diminution in the quantity of the urine, or the presence in it of albumen, blood, or casts; vomiting; and diarrhoea. Hope, however, should never be abandoned even in the most unfavorable cases, as recovery has sometimes occurred when the patient seemed almost in articulo mortis. Convulsions are said to be invariably followed by death, and Graves regarded the presence of the pin-hole contraction of the pupils as of very grave import.

Favorable symptoms are--reduction of the frequency of the pulse, a fall of temperature, a diminution of the stupor or a resumption of consciousness, and a return of appetite and of moisture to the tongue. When the patient begins to improve he will often without assistance turn upon his side after having lain for a long time upon his back, and this change of position is sometimes the first indication of the approach of convalescence.

The mortality varies of course in different epidemics. The cases which have come under my own care being too few in number to draw deductions from on this point, I must rely upon the experience of those whose field of observation has been more extended than my own. According to Murchison, out of 18,268 cases of typhus fever admitted into the London Fever Hospital during twenty-three years, 3457 proved fatal, making a mortality of 18.92 per cent., or 1 in 5.28. Deducting 686 cases fatal within forty-eight hours, the mortality falls to 15.76 per cent., or 1 in 6.34. Included among the fatal cases is a large number in which {361} the disease had run its course to a favorable termination, and in which death was really due to sequelæ, such as pneumonia, erysipelas, etc. Moreover, the death-rate in the hospital is greater than in the community, because children, who rarely die of typhus fever, are seldom brought to it; while, on the other hand, it receives a large number of the infirm and aged inmates of the metropolitan workhouses. Making allowance for these sources of fallacy, Murchison believes that the actual mortality of typhus is not more than 10 per cent. In Gerhard's cases the proportion of deaths amongst the black was much greater than amongst the white men; thus, of the whites 1 died in 4-2/3, of the blacks 1 in 2-19/28. Amongst the women the reverse was true; thus, 1 white woman died in 4-3/5, but only 1 colored woman in 6-1/2, nearly. Da Costa lost 6 out of 39 cases. In one of the fatal cases the diagnosis was doubtful; in another there was a great deal of previous disease; in two others death was due to complications--so that there were but two in which the fatal result could fairly be attributed to the disease itself.

TREATMENT.--Typhus fever is an eminently preventible disease. It is therefore proper that the description of its curative treatment should be preceded by a few words in regard to its prophylaxis.

It is still an unsettled question whether or not typhus fever ever occurs de novo, and although the recent discovery by Klebs and others of bacillus peculiar to typhoid fever (the bacillus typhosus), and of special bacilli in other analogous diseases, renders it highly probable that typhus fever has also its own bacillus, and that therefore it is not likely to arise except as the result of infection, it must be admitted that it has often prevailed in localities into which it has not been possible to trace its importation. Under these circumstances it will be well to refer to those conditions which are asserted by some authors to favor its spontaneous generation, especially as these same conditions are certainly known to favor its propagation. It will not be necessary to do this at any great length, as they have all been fully described in discussing the etiology of the disease. The most important of them is the overcrowding of human beings, especially when combined with deficient ventilation, destitution, and want of personal cleanliness. The knowledge of the laws of hygiene is now so universally diffused that this combination of conditions never occurs at the present time to anything like the degree it often existed in the eighteenth century, and consequently epidemics of this disease are not only less frequent, but are also much milder in character, than formerly. Much work, however, still remains for sanitarians in the improvement of the homes of the poor, which even in this country are too often overcrowded and ill-ventilated.

The extension of the disease in a community will almost always be prevented by the prompt isolation of the first few cases. This can often be thoroughly done, if the patient is in easy circumstances, by placing him in an upper room, which should be stripped of its carpets, curtains, and other unnecessary furniture; by cutting off all communication between him and his attendants and the rest of the household; and by the free use of disinfectants. The room should be airy, and to ensure good ventilation a window should be left partly open. This may be done during the febrile stage, even in winter, without the risk of any injury to the patient. Among the poorer classes, however, {362} isolation can rarely be effectually carried out, and it is therefore much better to remove the patient to a hospital. Upon the admission of such a patient to an institution of this character his clothes should be at once disinfected. This may be done by washing the underclothing in a disinfecting fluid, and then exposing them to a free current of air, and by subjecting the outer clothing to a very high temperature in an oven or to the fumes of burning sulphur. Murchison believes that a neglect of this precaution has often been the cause of the extension of the disease to other inmates of the hospital, especially when the patient resumes during his convalescence the same clothing he wore upon admission. If the hospital is a general one, he should be placed, whenever practicable, in a well-ventilated ward by himself or with other patients suffering from the same disease. As this is not always possible, the number of the other occupants of the ward should be reduced and their beds placed as far away as possible from his. As the infectiousness of typhus fever is very much lessened by free ventilation, this precaution is often alone sufficient to prevent its extension to them. It is also well, however, to supplement it by the use of disinfectants. The diffusion of a solution of carbolic acid in the atmosphere of the ward by means of the steam atomizer has not only rendered the odor emanating from the patient less perceptible, but has also appeared to diminish decidedly the risk of infection. As a still further precaution the patient may be sponged with a weak solution of carbolic acid or some other disinfectant. His nurses should be selected, whenever practicable, from among those who have had the disease themselves. They should never sleep in the sick room, lounge about the patient's bed, or inhale his breath. They should be allowed a certain amount of time every day for rest and recreation in the fresh air, and should have a full supply of nourishing food. On the other hand, they should be warned against the danger of over-stimulation, which is often resorted to in the hope of warding off the disease, and should be relieved as far as possible from attendance upon other patients. It may be well here to say that the nursing of a case of typhus fever should never be undertaken by the relatives or friends of the patient, except as a matter of necessity. Not only do the anxiety and distress they naturally feel unnerve them and render them unfit to carry out the directions of the physician, but they can rarely execute the many offices required in the sick room with half the skill of a trained nurse or with so little annoyance to the patient.

Before the patient is allowed to leave his ward he should have a warm bath. If the disease has occurred in a private house, the room which he has occupied should be thoroughly disinfected. This is best done by replastering, repapering, and repainting it. In many cases, however, it will be sufficient to fumigate it with burning sulphur, and then to air it for several days. The bed and bedding should also be disinfected, and, where this cannot be thoroughly done, the latter had better be destroyed.

Of primary importance in the treatment of typhus fever is the regulation of the diet. Although there are no ulcers in the bowels in this as in typhoid fever, and although, consequently, there is not the same imperative necessity in this as in the latter disease to restrict the patient to liquid articles of food, experience has shown that such articles are much more readily digested and assimilated than solids. The diet {363} should consist, therefore, of milk, beef-tea, and chicken or mutton broth. Of all of these, milk is incomparably the best, and it should form, unless the patient manifest an unconquerable repugnance to its use, a large part of the nourishment in every case. Farinaceous articles of food are generally not well borne in this fever, because the diminution in the secretion of the salivary glands which almost always exists prevents their proper digestion. After the third or fourth day nourishment should be given in small quantities at short intervals, as every two hours, every hour, or even every half hour when the prostration is extreme. It should be the aim of the physician to give an adult at least two quarts of milk or their equivalent daily.

It is sometimes necessary to put a delirious patient under some restraint to prevent him from leaving his bed or doing some other act of violence. Frequently a judicious nurse will be able to accomplish this without the use of an undue amount of force, but at other times it will be necessary to have recourse to mechanical means of restraint. Usually, all that is necessary is to pass a folded sheet across the patient's chest, the ends of which are fastened to the sides of his bed.

It is now a universally accepted axiom among physicians that typhus fever is a self-limited disease, and that any attempts to cut it short is worse than useless. Not only do remedies which are employed for this purpose often produce alarming prostration, but there can be no doubt that they have in some cases been the cause of a fatal termination, which under another plan of treatment would have been averted. During the last century it was not uncommon to bleed, and to bleed largely, in the beginning of an attack of typhus fever, but even then there were physicians--as, for instance, O'Connell, Rogers, Pringle, and Rutty--who raised a warning voice against the practice. Sir John Pringle goes so far as to say that "many have recovered without bleeding, but few who have lost much blood." A very similar opinion was also expressed by Baron Larrey in the early part of this century. Indeed, it is very evident that the same difference of opinion existed as to the employment of venesection in the treatment of acute affections when these authors wrote as prevailed in England and this country until within the last thirty years, and that the disastrous results which occasionally follow the abstraction of large amounts of blood from patients affected with fevers and inflammations were as fully recognized then as now by many physicians. This would seem effectually to dispose of the change-of-type-in-disease theory which was generally accepted in the first half of this century as sufficient to explain the fact which could no longer be overlooked that this class of patients did much better under a supporting than a depleting plan of treatment. Purgatives were also at one time freely given for the purpose of arresting the disease, but the results obtained from their use were scarcely less unfavorable, and they are now never employed with this view. The use of quinia in large doses has also been advocated for the same purpose, but experience, while it has shown that it is a valuable remedy, has demonstrated also that it does not possess {364} this power. Exactly the same thing may be said of the cold-water treatment of typhus fever. There is no evidence that it has ever shortened the duration of the disease.

If the physician is called to a case of typhus fever during the chill, before reaction has taken place, he will of course have recourse to diffusible stimulants and external warmth to aid in the establishment of this process. More frequently he is not sent for until after the chill has been succeeded by fever. His treatment will then, of course, vary with the condition of the patient. If his stomach is loaded with food, an emetic should be administered to him. If the bowels are constipated, a mild cathartic will often be of service, but after the bowels have been once well moved it is generally unnecessary to disturb them further. During the first day or two, while the fever is still moderate in degree, and during the uncertainty which then usually exists as to the diagnosis, it will be sufficient to prescribe the neutral mixture or the spirit of Mindererus in tablespoonful doses every two or three hours. Upon the third day more active remedies will generally be required to reduce the temperature. This is best done by the cold-water treatment in some form or other, or by the internal administration of antipyretic doses of quinia. The manner in which the cold water is to be used and the cases to which it is applicable must be left in a great measure to the judgment of the physician. In the form of the cold affusion it is now rarely resorted to, although Currie obtained most excellent results with it. It is calculated, however, to alarm a timid patient, and it is probably owing largely to this fact that it has fallen into disuse. The cold bath, packing in a cold wet sheet, and sponging with cold water are the more usual means of employing cold in the treatment of typhus fever at the present day. The cold bath is much used in Germany in the treatment of different forms of fever, and even of inflammation. It is also resorted to in this country, but it has never attained the same popularity here as abroad. The best way of using it is as follows: The patient as soon as his temperature rises above 103° F. should be placed in a bath having a temperature between 80° and 90°, and which, whenever practicable, should be brought to his bedside, as when he has to be carried to the bathroom he is sometimes not only alarmed and rendered very nervous by the operation, but may exhaust himself in his struggles to free himself from his attendants. After his immersion cold water should be gradually added until the temperature of the bath is between 60° and 70° F. The length of time he should be allowed to remain in the bath will of course depend upon circumstances. If shivering is produced by it, he should be at once removed from it and thoroughly dried and put back to bed. If no such symptoms are observed, he may be allowed to remain in it longer. As a general rule, a half hour is as long as will be necessary or safe for him to continue immersed at any one time. His temperature will usually continue to fall for some time after his removal from the bath, but in the course of a few hours it will be found to have risen again to 103° or over, when he should have another bath. In this way it may be necessary to repeat the baths from eight to twelve times a day. Some authors recommend that the patient should be placed at once in a bath having a temperature of 50° F., {365} but this method of applying cold possesses no advantage over that above described, and is, like the cold affusion, very apt to excite alarm in the patient. The cold bath is not, however, well borne by all persons, and alarming symptoms, and even fatal collapse, have followed its use in the old and feeble. It is also contraindicated when the skin is covered with a profuse sweat or when the disease is complicated by an internal inflammation. When the means of giving a cold bath are not at hand, the cold pack will often be found a very efficient substitute for it. Sponging with cold water, although not so efficacious in reducing the temperature, has advantages over either of these methods of applying cold. In the first place, it is more agreeable to most patients and less calculated to excite alarm in those who are timid. Again, it may be more frequently repeated, and may be used in cases in which the cold bath is contraindicated. Occasionally alcohol or vinegar may be added with advantage to the water, with the view of increasing its refrigerant effects.

When quinia is given for the purpose of reducing the temperature in the treatment of typhus fever, it must be used in large doses, as much as ten or fifteen grains repeated once or twice in the course of twenty-four hours being required for this purpose. When given in these quantities it has the disadvantage of producing deafness and occasionally of increasing the headache. I have therefore contented myself in the cases which have fallen under my own care with giving it in more moderate quantities, in combination with one of the mineral acids, as, for instance, a couple of grains of quinia in solution with from eight to ten drops of dilute muriatic acid, repeated from four to six times a day. The mineral acids were originally recommended in the treatment of typhus fever in the belief that they neutralized the poison which caused the fever, and which was supposed to be ammonia or some of its compounds. Although this theory is now no longer entertained, there can be no doubt that the tendency in this disease to the accumulation of ammonia in the blood is prevented by their administration. Digitalis, aconite, or veratrum viride may also be given in appropriate doses if with a high temperature there coexists great frequency of the pulse. The first-named remedy is especially indicated if there is at the same time diminution of the secretion of urine.

As the disease progresses other symptoms present themselves for treatment. One of the most urgent of these is the prostration. This not only appears early, but is often extreme, and if not met by appropriate remedies will often of itself be sufficient to cause the death of the patient. As soon as it makes itself manifest stimulants must be prescribed. These are, however, not to be resorted to simply because the patient has typhus fever. Many cases do perfectly well without them. In the young and robust it is often unnecessary to have recourse to them. On the other hand, in the old, the feeble, and the intemperate they should be employed early. The rule laid down by Stokes, that they should be administered as soon as the first sound of the heart becomes indistinct and inaudible, may be adopted for our guidance in this respect. At first they should be given tentatively. If the delirium, headache, and other nervous symptoms are increased after their administration, it is best to withhold them. They should be continued, on the other hand, when under their use the delirium ceases or grows milder, the other nervous {366} symptoms subside, and the patient falls into a refreshing sleep. The amount required to prevent fatal prostration will of course vary in each case. I have rarely myself found it necessary to prescribe more than half an ounce of whiskey or brandy every two hours, and frequently a very much smaller quantity has been found sufficient. Cases are, however, reported in which from twenty to twenty-four ounces daily have been given with asserted advantage.

Another symptom which often demands prompt relief is the headache. When not severe, it may be relieved by the application of cold to the head, either in the form of the ice-cap or by means of cloths frequently wrung out of cold water, and by the administration of moderate doses of potassium bromide; but when intense it requires more active treatment for its removal, such as the application of cups to the back of the neck or of leeches to the temples. General bleeding will accomplish the same result, but the good which is done by it is often more than counterbalanced by the prostration it induces. Sleeplessness is also sometimes the cause of a good deal of distress to the patient. When it occurs early in the disease and is caused by the headache, it will generally subside under the use of the remedies which are employed for the relief of the latter symptom; but when it comes on at a later period, it will often require special treatment. There is some doubt as to the propriety of giving opium under these circumstances, but Murchison, Gerhard, and others assert that it may be given not only without injury, but with positive advantage to the patient. Graves was in the habit of combining it with a small quantity of tartar emetic in the condition in which the sleeplessness is associated with active delirium. If, on the other hand, the delirium is of a low muttering character, it should be given with a diffusible stimulant.

In this condition I have often found a pill containing a small quantity each of opium and camphor, frequently repeated, to answer an admirable purpose, not only in procuring for the patient the needed repose, but also in diminishing the restlessness, jactitation, and subsultus tendinum. Opium should, however, not be used at all or used very carefully in cases in which there is congestion of the lungs or disease of the kidneys. The existence of the pin-hole pupil is also a contraindication to its employment. In young and robust patients, if the insomnia is attended by active delirium, chloral in twenty-grain doses, repeated if necessary, may often be given with advantage, but it should never be prescribed in cases in which the action of the heart is feeble. Other remedies which have been recommended in the treatment of this condition are belladonna, hyoscyamus, musk, chloroform, and cannabis indica. Potassium bromide appears to have no power to relieve it. No special modification of the above treatment is needed when delirium occurs independently of sleeplessness and headache. When the stupor is profound, efforts should be made to rouse the patient by the use of counter-irritants to the shaven scalp or to the nape of the neck. Murchison speaks well of the administration of strong coffee under these circumstances. If there is at the same time suppression or diminution of urine, diuretics should be administered in the hope of stimulating the kidneys to increased secretion. Retention of the urine is not an infrequent occurrence in this condition, and the physician ought never, therefore, to accept the assertions of the {367} nurse or friends of the patient that the latter has passed water, but should satisfy himself by an examination in regard to the condition of the bladder at every visit. He will often find that the apparent passage of urine is nothing more than the dribbling due to an over-distension of this organ. Neglect of this precaution has occasionally been the cause of much subsequent distress to the patient, as cystitis is sometimes set up as a consequence of it. In one case which came under my observation, and in which this precaution had been neglected, the patient suffered from incontinence of urine for some time after his recovery from the fever. Thirst is a symptom which is always present and complained of at the beginning of the fever, and usually bears some proportion to the severity of this process. Weak tea, an infusion of cascarilla-bark, and camphor-water have all been recommended by different authors for its relief, but it is probable that no one of them possesses any superiority over water. If the stomach is irritable and water is not retained, small pieces of ice should be allowed to dissolve in the patient's mouth. Later, when the stage of stupor supervenes, it is very important to see that the patient obtains a full supply of water. In this condition he will not call for it, although it is even more urgently required than before.

Vomiting may occur at any time in the course of typhus fever. If it is observed at the very beginning of an attack, an emetic will often arrest it, but when it supervenes at a later period, it is generally of cerebral origin, and will usually subside under the use of the remedies already referred to which are prescribed for the relief of the nervous symptoms. In addition to these, sinapisms may be applied to the epigastrium, and champagne, when the circumstances of the patient will permit it, should be given in the place of whiskey or brandy. When everything is rejected by the stomach, recourse must be had to nutritious enemata. Constipation is to be overcome by gentle purgatives, as the use of powerful cathartics is very apt to be followed by troublesome diarrhoea. If this should come on, it is best treated by small doses of opium in combination with a mineral or vegetable astringent. When these fail, it may sometimes be relieved by a prescription containing sulphuric acid and morphia, and at others by enemata of from twenty to thirty drops of laudanum in warm water. When glandular swelling occurs in the parotid region or in other parts of the body, an effort should be made to promote resolution by painting them with tincture of iodine. Blisters have also been recommended for the same purpose, but they should be used carefully, as in low conditions of the system they are sometimes followed by sloughing of the integuments. If these remedies fail, poultices should be applied. As soon as pus has formed it should be evacuated by one or more free incisions.

Very few attacks of typhus fever run their course without the occurrence of some pulmonary complication. When this is slight it demands no special modification of the previous treatment, and it is sufficient to apply mustard poultices or stimulating liniments to the chest. But in cases of greater gravity, it matters not whether the complication is bronchitis, congestion of the lungs, or pneumonia, a more active treatment is required. Under these circumstances the ammonium carbonate in five-grain doses, given in mucilage of acacia, frequently repeated, or from thirty minims to a teaspoonful of the aromatic spirit of ammonia every {368} two hours, sufficiently diluted, may be prescribed with great advantage. When gangrene supervenes the prognosis is almost hopeless, but an effort should be made to save the patient's life by the administration of potassium chlorate and of an increased amount of stimulus. Murchison also speaks well of the inhalation of tar vapor and of carbolic acid.

As the other complications of typhus are at least of as common occurrence in typhoid fever, it will avoid a good deal of useless repetition to refer the reader to the article on the latter disease for a description of the treatment which they render necessary.

The patient should be kept in bed for some time after the subsidence of fever. Although relapses are rare in this disease, recrudescences of fever not infrequently occur as a consequence of undue exertion in the early part of convalescence. Syncope is also not infrequently produced by the patient's sitting up too soon. The diet should be carefully regulated until the recovery is complete. It should at first consist wholly of liquid or semi-liquid articles of food, but later meat in some digestible form may be allowed. Stimulants are often as urgently demanded at this time as during the fever itself. They should be given as the strength returns in gradually diminishing quantities. The length of time during which it is necessary to continue them will depend in great measure upon the previous habits of the patient. As a general rule, their use should not be abandoned until he is able to leave his bed, and they may often be continued after this with benefit to him. As convalescence progresses it will be well to substitute ale or porter for the brandy or whiskey the patient had previously taken. A return to health will also be promoted by the judicious use of tonics, such as iron, quinia, Huxham's tincture, tincture of nux vomica, the mineral acids, and even cod-liver oil in some cases.