159 Art. VIII.-Annual Address dellvcwu before the Medical Society of the State ofJYew York, Fcb'y 7, 1843. By William Taylor, M. D., Presi- dent of the Society. Gentlemen : The publication of the transactions of your society has placed in the hands of the profession an annual of medical in- formation, which has thus far equalled the anticipations of its most ardent friends. Embracing the transactions of your an- nual meetings, the proceedings of the county societies, prize essays, and contributions of gentlemen devoted to medical science, it constitutes a periodical of value to the professson, and has contributed much to give the society that elevated character for usefulness, which it has hitherto sustained. That it may continue to be the vehicle of useful matter, dif- fusing the benefits of your organization, it is incumbent upon the members of the society, and especially those whose posi- tion gives a claim to their services, to contribute whatever the lights of experience, observation, and reflection, may sug- gest as best calculated to promote, the objects for which you are associated. With an acknowledgement of this obligation, the duty devolved upon your presiding officer at the close of his official term would be discharged on this occasion with no ordinary pleasure, could I confidently anticipate offering that, which would be interesting to the profession, and useful to the public. In selecting for my remarks at this time the subject of fe- ver, I am sensible that I do but step in "a well worn pathway of medical literature," which has been occupied by men of learning, experience, and skill, in almost every age, and by none with more of intelligence, and I may add success, than those of a recent period. But, notwithstanding the improve- ments, real or imaginary, of modern times, and all the advan- tages derived from the investigations of pathological anatomy, a diversity of opinion still exists, in many respects, relative VOL. V. 160 Dr. Taylor on Typhoid Fever. to fever, and particularly as to the primary or essential morbid condition. This has ever been a fruitful source of specula- tion, and has given rise to various and often fanciful theories, and consequently to an unsettled and unsatisfactory practice. The hope may have been entertained, that the day of vi- sionary and speculative theories had passed by, and that, a sys- tem, based upon the foundations of pathological anatomy, and reared upon the principles of inductive philosophy, was about to be established, which would be settled, uniform, and per- manent. This hope however has not yet been realized, and the time is probably far distant when it will be, although it must be acknowledged that much which is valuable and im- portant has been accomplished. The delicate and complicated machinery of life, the mysterious laws which govern the func- tions of health and control the numerous and complex sympa- thies of the nervous system, the changes which all these may undergo in passing from health to disease-the uncertainty as to the manner in which the morbific agent, whether mala- ria or contagion, exerts its influence upon the human sys- tem in the developement of fever, whether its force is first ex- pended upon the nervous system, depressing its energies and producing new chains of morbid sympathies, or, upon the blood, introducing into the circulation a poisonous principle which changes its properties, or, whether it more directly effects some of the organs or tissues, producing functional de- rangement and altered structure, present difficulties which may never be satisfactorily surmounted. But little is or can be known of the primary cause, that un- seen influence, which at times affects whole regions of country producing epidemic fever. It presents no sensible qualities by which it can be detected and examined, and we can form, no definite idea of its properties, or of any thing in relation to it, further than as exhibited in its effects. This subject was pro- bably as well understood in the days of Sydenham, and as clearly defined by that sagacious physician as it has been at any time since. He says-" the matter seems to stand thus : there are various general constitutions of years that owe their origin neither to heat, cold, dryness, nor moisture; but rather Dr. Taylor mi Typhoid Fever. 161 depend upon a certain secret and inexplicable alteration in the bowels of the earth, whence the air becomes impregnated with such kinds of effluvia as subject the human body to par- ticular distempers, so long as that kind of constitution prevails, which, after a certain course of years, declines, and gives way to another. Each of these general constitutions is attended with its own proper and peculiar kind of fever, which never appears in any other." This concisely expressed opinion, al- though it sheds but little light upon the subject, is quite as satisfactory as much that has been written upon it since his time ; and our want of more definite knowledge of the proper- ties or nature of this morbific agent is the less to be regretted, because, were it better understood, we should not probably be any better prepared to guard against its influence, or better qualified to meet its effects upon the human constitution. But the remark that, " each of these general constitutions is attended with its own proper and peculiar kind of fever, which never appears in any other," is, perhaps, worthy of more con- siderate attention; for, if the existence and character of epi- demic fever depends upon effluvia diffused through the atmo- sphere; peculiar or specific in their effects, might we not ex- pect, that the morbid condition of fever in different epidemics would vary, in some respects, according to the peculiar atmo- spheric constitution prevailing at the time ? It is well known that, endemic intermittents and remittents are produced by malaria generated in newly cultivated low lands, marshes, stagnant water, &c., and although these may sometimes ap- pear almost continued, and even assume in their progress a typhoid type, still, their distinctive character is usually suffi- ciently marked to indicate the treatment adapted to that form of fever. So, also, in the prevalence of epidemic or endemic continued fever, there is usually that similarity in some of the more prominent or peculiar symptoms and sometimes in the development of particular local affections, as to suggest the idea that there must be something specific in the cause which acts with so great uniformity upon the human body. Not even in the eruptive fevers, known to depend upon a specific contagion, do we find much more uni- 162 Dr. Taylor on Typhoid Fever. formity of symptoms than we often find in epidemic con- tinued fever. That form of fever recently distinguished by the term typhoid, (to which it will be my chief object presently to invite attention.) exhibits with great uniform- ity those symptoms which indicate local inflammation as apparently an essential pathological condition; and, when it prevails as an epidemic, we may early anticipate, with almost unerring certainty, the development of some degree of in- flammation of the mucous membrane or follicles of the intes- tines, and by suitable means obviate, to some extent at least, the danger. It was probably the prevalence of fever of this character in Paris and other parts of France, that led some of the distin- guished pathologists of that country to regard gastro-enteritis as the essential morbid condition of fever generally ; and con- sequently particular regard was always to be had to this con- dition in the treatment. Hence a peculiar practice was in- culcated, which, although important and well directed for the object in view, could not, in its indiscriminate adoption and the extreme to which it was carried, be otherwise than some- times injurious. This opinion however was not generally re- ceived either in this country or England, and, it is believed, is regarded at present with much less favor in France. Al- though gastro-enteritis is often found to exist in typhus, and other forms of fever, yet the occurrence of this condition is far from being uniform, and cannot be viewed essential to the character of fever generally. It may ordinarily, perhaps, be regarded as depending upon some peculiar predisposition, or upon causes originating in the progress of the disease, rather than upon any common cause acting with specific influence upon the system. Still, it is well known that a peculiar at- mospheric condition giving rise to an epidemic disease may, and often does, have a modifying influence upon the character of febrile diseases generally. This is sometimes so strikingly manifest as to exhibit the power of the predominating influ- ence in apparently preventing, for the time being, the usual effects of other morbific agents. During the spread of the Asiatic cholera through this country it was observed, that Dr. Taylor on Typhoid Fever. 163 when the disease reached those places where the inhabitants were subject annually to endemic fever the cholera prevailed more extensively and with greater severity than in other loca- tions ; but the endemic fever did not as usual make its appear- ance. Here was an existing predisposition to fever from local malaria: but the predominating influence controlled the cha- racter of the disease. A fever originating from local causes, or spreading by con- tagion, may be essentially modified in its character by the more common atmospheric constitution prevailing at the time; and this may, perhaps, best explain much of that difference observed in fever of the same type in different epidemics. A distinguished American author (Dunglison) in a recent work on the Practice of Medicine, says : " There are no morbid ap- pearances which invariably pi esent themselves in fatal cases of typhus. Were we to judge from one epidemic we might be disposed to infer, that the disease is characterized by a certain set of morbid results ; but, by taking a more general view we are less disposed to adhere to this opinion, and are led to give them a wider range. It has been maintained that in true contagious typhus there is no dothinenteritis or folli- cular gastro-enteritis, and such appears to have been the case in the epidemic which prevailed at Philadelphia in the spring and summer of 1836 ;" and after describing the appearances on dissection, he adds : " these were the appearances of one epidemic, but, as the lesions in question must be regarded as secondary, they may vary according to the character of the prevailing disease. Thus in contagious typhus, which pre- vailed in Glasgow, dothinenteritis or enlargement of the mu- cous follicles of the smaller intestines and enlargement and ulceration of the aggregate glands of the lower third of the ilium, occurred in combination, and were found in about one in six of those who died of typhus." " It would appear, (says the same author,) that the typhoid fever or follicular enteritis is one of the most frequent and the most severe acute affec- tions observed at Paris; the various forms of the common continued fever occurring there being essential varieties of the same malady. It is likewise not uncommon in the United 164 Dr. Taylor on Typhoid Fever. States, where it presents the same anatomical character as in France." But, if this disease has existed or prevailed to any considerable extent in England, it appears not to have made the same impression upon the minds of physicians there as in some other places, for, it is said, " the British practitioners generally do not admit this new division of typhoid fever or follicular enteritis and typhus," regarding the intestinal affec- tion as an accidental complication occurring in ordinary typhus. Can this difference in the morbid results exhibited in fever in different epidemics be regarded as merely accidental ? When the development of local lesion in any one epidemic is neither uniform nor of frequent occurrence, it may doubtless be so regarded ; but, when a particular set of morbid results are found to exist much more frequently than otherwise, al- though they may not constitute an essential pathological con- dition, they may still he considered as depending upon some- thing peculiar in the common cause influencing the character of the fever, and determining the particular local affection ; and, still further, this local affection may be so uniform and common as to authorize the opinion that it constitutes an es- sential condition of the disease. " Fever [says a modern writer] expresses a state in which are observed variations in animal heat, acceleration of the pulse, and general disorder of the functions with or without local lesion." A variety of causes may induce this state, yet, when fever prevails epidemically we may infer some general cause, some atmospheric influence, giving it a distinctive cha- racter. This atmospheric condition may continue for a long- er or shorter period of time, undergo changes, become ex- hausted, and in its turn give place to some new combination of causes forming a different atmospheric constitution, and impressing a modified character upon continued fever. It may hence be inferred, that any general conclusion as to the pathological condition essential to fever, drawn from the examination of any particular class of cases, or such as may occur in any one epidemic, or even such as may occur in the same location for a series of years, would be very liable Dr. Taylor on Typhoid Fever. 165 to error. And besides, while it is admitted that the investi- gations of pathological anatomy have contributed largely to the advancement of knowledge upon this, as well as other branches of medical science, opinions put forth as based upon even this source of information, may be received with some degree of caution when it is considered that the most severe functional derangement may exist without apparent organic lesion, and that it is often extremely difficult if not impossible to discriminate between those appearances essential to the disease, and such as have arisen in its progress and may be regarded as accidental. But, it may be remarked, that upon a question subject to so much speculation as that of the essen- tial morbid condition of fever, even wrong opinions, promul- gated with zeal and ability, and under the sanction of distin- guished authority, may result in more general good than evil. And such, it is believed, is peculiarly the case with regard to the plausible doctrine before alluded to, that fever is primarily seated in the lining membrane of the stomach and bowels, inasmuch as it arrested and fixed the attention of the profes- sion on a point of great practical importance, directed inquiry as to the condition of this membrane in febrile diseases gene- rally, with more care and minuteness of investigation, and led to the adoption of a more cautious, safe, and judicious practice. I will here take occasion to express the opinion that there is an increased tendency or predisposition to disease of the mucous membrane of the alimentary canal, not only in fever but in other diseases, and that affections of this membrane are of much more frequent occurrence than formerly. This opinion has been formed from some personal observation, and from conversation with gentlemen of intelligence and experi- ence ; and the fact that these lesions were comparatively but little noticed by medical writers of former periods, would seem to corroborate the opinion, unless it be supposed that they over- looked that which is now so apparent as to attract general at- tention. If this opinion is well founded it would be a subject of much interest to inquire as to the cause, whether it can be attributed to some atmospheric influence, or to some common 166 Dr. Taylor on Typhoid Fever. error of living. Experience has demonstrated the important truth, that upon the influence of the latter over the powers of life will depend to a great extent the effects of the former, and that a well regulated mode of living may go far to render in- noxious those atmospheric influences which otherwise subject the human body to the ravages of disease. Errors of diet are a fruitful source of human suffering, and a departure from that simplicity which nature requires, in the preparation and quality of nutriment may often induce that morbid condition of this membrane which so frequently exists as a primary chronic affection, or that predisposition which is excited to ac- tive disease, constituting a troublesome complication in febrile complaints. But it would be particularly worthy of inquiry as to the influence in this respect of the very common and habitual use of stimulating and intoxicating drinks, which has so extensively prevailed for many years past. From the ap- pearances noticed in post mortem examinations of the in- temperate, and particularly the appearances exhibited in the living subject after indulgence in the use of ardent spirits, as described by Dr. Beaumont in the celebrated case of Alexis St. Martin, it is evident that the vessels of the lining mem- brane of the stomach, and probably some portion of the intes- tines, must be kept more or less in a state of irritation and hypercemia ; and when its delicate structure is considered, it may well excite surprise that serious and fatal consequences do not more frequently result from this cause. But, subject as it is to constant exposure, and designed to perform impor- tant functions in the animal economy, it seems endowed with wonderful powers of endurance, and capable of recovering a healthy state even after oft repeated and long continued inju- ries. A morbid condition, thus induced and continued for a long period of time, may not be confined in its consequences to the individual, but may possibly be extended to his poste- rity in an hereditary predisposition to disease, and particular- ly of this membrane. It is not, however, my design to pursue this subject, and I have offered these remarks chiefly with the view of inviting attention to it, and with the hope that it may receive such further investigation as its importance may seem to merit. Dr. Taylor on Typhoid Fever. 167 'Contagion. Whether continued fever in any of its forms is communicated by contagion is a question which has given rise to different opinions and much discussion. It is, how- ever, now generally admitted that genuine typhus is conta- gious. This opinion, many have been slow to adopt, and some may yet be found opposed to it; but recorded testimony, and facts derived from personal observation, are to my mind conclusive in its favor; and I entertain but little doubt, that in other forms of continued fever there is often emitted from the body of the sick an effluvia, which, superadded to the at- mospheric cause, render those in attendance much more lia- ble to the disease, and which sometimes give to it, apparent- ly, a contagious character. But, I have alluded to this sub- ject only for the purpose of adding to the mass of accumulated testimony the facts contained in the following extract from a communication received from my friend, Doct. Stearns, of Pompey. " The first case of typhus fever which prevailed in this town (Pompey) in 1829 and 1830, occurred in the month of October. A young man who had resided for some time in the state of Ohio, returned sick with the usual symp- toms of typhus fever. The family in which he had resided had permitted water and vegetables, which had been frozen to remain in the cellar until late in the spring, and which had become very offensive. Soon after the stagnant water and filth were removed, five of the family fell sick of a malignant fever, some of whom died. From these the disease spread, and from eighty to an hundred cases occurred. The young man alluded to, feeling the premonitory symptoms, left Ohio and was enabled to reach his friends in this town, where he died in five days after his arrival. Two young men who had attended him were soon after taken sick with the same kind of fever, one of whom died, the other, after a long and se- vere sickness, recovered. These cases I did not see. The first that occurred under my immediate observation and care, was a young lady who had nursed a friend sick with the fe- ver, and soon after her return home was attacked with the usual symptoms. In ten or twelve days four or five other members of the family were taken sick, the symptoms vary- VOL. V. 168 Dr. Taylor on Typhoid Fever. ing only in degree. Two young ladies who were visiting this family, one of whom resided in the town of Onondaga, and the other in the town of Nelson, after remaining a short time returned to their respective houses, and in ten or twelve days, the usual time after exposure for the effect to he pro- duced, both were taken sick with the typhus fever. Thus I might trace every case that occurred to its source, which in all amounted to seventy or eighty, and not an individual to my knowledge had the fever who had not been exposed to the contagion, and almost every person who was among the sick became more or less affected." Typhoid fever. With these somewhat desultory remarks, I come now to consider that form of fever which has recently been distinguished by the term typhoid, to which, I have said, it was my chief object to invite attention. This term has usually been applied to designate a stage or condition of fever approximating in its general character to that of typhus ; and as a convenient and appropriate term, will doubtless continue to be thus applied. But, it has recently been used to distin- guish a particular kind of fever, which in many of its aspects resembles typhus, but which has its peculiar characteristics, being usually attended with inflammation of the mucous mem- brane, or more particularly the mucous follicles of the intes- tines-the glands of Peyer and Brunner; and so commonly has this been found to exist, as to be supposed an essential pathological condition. Hence it has also been denominated dothinenteritis, follicular enteritis, gastro-enteritis, with nerv- ous affection of the brain, &c. A fever, answering in many respects to the character which has been given of this disease, prevailed in the village of Manlius and its vicinity, in the summer and autumn of 1S41, and has exhibited itself in several well marked cases during the past season. I shall confine myself chiefly to a descrip- tion of this fever, as it presented itself to my own observa- tion, and to the treatment which was usually adopted. Nothing very peculiar was noticed in the first stage of the disease ; it was accompanied by the usual symptoms of febrile attack. The period between the first indications of disease Dr. Taylor on Typhoid Fever. 169 and its more full or perfect development, I think was general- ly more protracted than in simple continued and inflammatory fever, and less so than is often observed in typhus. The tongue, as is common in fever, exbihted a variety of appear- ance, but there was usually some peculiarity which attracted attention. In the first stage its upper surface was usually covered with a white or brownish coat; in some, it appeared as if covered with a paste of indian meal, in others, the white coat was irregularly spread over parts of the tongue leaving patches, commonly on the sides, resembling a raw surface ; and in almost all the tip and edges were red from the com- mencement of the disease. Commonly within a week or ten days this coat disappeared, often coming off in patches, leav- ing a smooth, dry, red surface; and in the advanced stage of severe cases the tongue became chapped, the teeth and gums covered with a brown sordes, and sometimes the whole mouth exhibited something of a dark reddish, or perhaps better de- scribed by the term fuliginous appearance. In a few in- stances this organ appeared enlarged, was moist, and very red from the first to the last stage of the fever; and one case of this description terminated fatally from intestinal hemorrhage. One of the peculiarities which attracted attention consisted in the almost uniformly red appearance of any portion of the sur- face of the tongue not covered with a coat, and any change in this respect was apparently accompanied with a corresponding change in the local affection. Hence, it was regarded as af- fording an indication, of perhaps not less certainty than any other one symptom, of the extent or degree of the local irrita- tion ; and a favorable opinion entertained from witnessing a return to a more natural color, or a change from a red to a coated surface was seldom mistaken. However just may be the remark of Stokes, as applied to other forms of fever, that we " should study the appearance of the tongue in fever more as indicative of the general condition of the patient than of the state of the gastro-intestinal membrane," I am convinced, that in this epidemic at least, the reverse of this would be more correct, and that the appearance of the tongue should be re- garded more with reference to the local affection than to the 170 Dr. Taylor on Typhoid Fever. general condition of the patient. And, I may add, notwith- standing the fact stated by the same author, that " you will often see in the advanced stage of fever a red, dry, and chap- ped tongue become pale, moist, and smooth, under the use of wine, carbonate of ammonia, and other stimulants," I have not yet learned to look upon a red tongue in any stage of fever, especially if it exist to any considerable degree, or length of time, without a strong suspicion of some grade of inflammation, or at least an hyperasmic state of some portion of the mucous surface of the stomach or the intestine ; for, it may frequently happen, that during the existence of local inflamation in fever, the prostrate energies of the system and consequent condition of the local affection may require stimulants as the only means of sustaining the patient, and restoring the local disease to a healthy condition ; and indeed this opinion is most emphatical- ly expressed by the distinguished author above referred to, who says, " that at certain periods of all inflammatory affec- tions stimulants become antiphlogistics ! In a few cases the stomach was irritable, with considerable nausea, vomiting, and tenderness of the epigastrium ; but usu- ally there were no clear indications of lesion in this organ, especially to any considerable extent. Diarrhea was a com- mon and sometimes troublesome symptom, which often ap- peared at the commencement of the disease; and in almost every case a tendency or disposition to this affection was ob- vious in some stage of the fever, and usually through its en- tire course, which, however, it was generally not difficult to control. Meteorism also was of not much less frequent occur- rence, and in the few cases in which the tympanitic state of the bowels was not prominent there was more or less unnatu- ral fullness, and some degree of resonence from percussion was perceptible. More or less tenderness upon pressure was experienced in a large proportion of the cases, but this was not always observed even in those which in other respects clearly indicated local inflammation. In a few instances the disease was complicated with bronchitis, and in one severe protracted case, as the intestinal affection subsided, bronchitis was kindled up, appearing like a translation of the inflamma- Dr. Taylor on Typhoid Fever. 171 tion from one mucous surface to another, The state of the circulation, heat of the surface, thirst, &c., were not material- ly different from what is usually observed in genuine typhus; perhaps a higher degree of arterial action, and more intense thirst, especially in the early stage of the disease, might con- stitute a difference. The character of the delirium also re- sembled typhus, but was of less frequent occurence than in the latter disease. If sudamina, or an eruption of small ves- icles, appeared in more than one case it was not noticed, and in this the eruption was every extensive about the neck and chest. The " rose spots," or small red or rose colored spots about the size of a pin's head which have been noticed as of frequent occurrence, and regarded by some as a symptom of the typhoid fever, were not observed in but few cases ; in two or three they were scattered over the chest, abdomen, and. on the arms. They may have been present in others and over- looked, for their size, and sometimes being few in number would render them liable to pass unobserved by one not an- ticipating or looking for them; and I may add, that in the first case I was called to visit, after my attention had been directed to this eruption as a symptom, the spots were disco- vered in considerable numbers, although they had not been noticed by either the friends of the patient or the attending physician. Hemorrhage from the nose attended a few cases, and one case of intestinal hemorrhage occurred which I have before noticed. The subjects of the disease were mostly young people ; three or four cases fell under my care under ten years of age, and I believe none over thirty. The contin- uance of the fever varied from two to four weeks, perhaps its most frequent duration was about three weeks. Causes.-As the disease made it appearance in a section of the country usually healthy, and no local causes were known to exist which could satisfactorily be assigned as the origin of the fever, it is proper to presume some common atmospheric origin. The fevers which formerly prevailed to some extent in this location, were usually of a remittent and intermittent character. But from changes in the face of the country, these have chiefly disappeared, and for the last ten or twelve 172 Dr. Taylor on Typhoid Fever. years fevers have assumed more of a continued form, varying from an inflammatory to a typhus type, perhaps commonly more nearly resembling the synochus of Cullen, and with a manifest increasing tendency to lesions of the mucous mem- brane of the intestinal tube. The scarlatina also made its appearance for the first time about the period when fever of the former character began to disappear, and has continued to prevail more or less up to this time. Although this latter fever is doubtless contagious, and at times highly so, yet it has now and then made its appearance in different places un- der circumstances that seemed to exclude the idea of a con- tagious origin. Hence its existence, in these cases at least, may be supposed to depend upon a common atmospheric con- stitution favorable to its production. The epidemic, under consideration prevailed to the greatest extent in a neighborhood in the village situated in the vicini- ty of a factory dyke, the mud from the bottom of which had been some months before thrown upon its banks. But as the first cases which occurred were some distance from this, and several cases happened some miles from the village, which could not possibly be attributed to this origin, it is believed that this can be considered only as a superadded cause pre- disposing to fever, while the more general atmospheric con- stitution controlled and gave character to the disease. Pathological Condition.-I have no additional facts to strengthen the opinion that the disease in question is seated in the mucous membrane or mucous follicles of the intestines. Those who are accustomed to a country practice will appre- ciate the difficulty of frequent post mortem examinations, and none were had during the prevalence of this epidemic under my own observation. Although most of the forms of contin- ued fever may be regarded as an affection of the whole sys- tem, and local lesions not so much an essential condition as an accidental or secondary occurrence ; yet, the symptoms which usually attended this fever, and the results of the exa- minations of distinguished pathologists in a disease similar in many or most of its characteristics, appear to me sufficient to give it a place as a separate and distinct affection from typhus Dr. Taylor on Typhoid Fever. 173 fever, and to authorize the conclusion that the condition above mentioned is the true pathological state. Perhaps no one symptom could be regarded as a certain indication of the lo- cal inflammation, but, taken in the aggregate there could be, to an experienced mind, no question as to the presence of some grade of an inflammatory condition of some portion of the surface of the intestines, and the investigations above re- ferred to, render it quite probable at least, that the mucous follicles are most commonly, if not uniformly, the seat of the affection. Treatment.-I am not aware that any efforts to cut short the disease, or to break it up in the commencement, were suc- cessful, It may be remarked, that the treatment adapted to inflammation of a mucous surface is, in some respects, quite different from that which is required in inflammation of a se- rous membrane. This however will depend somewhat upon the seat of the local affection, as well as general condition of the patient. Usually general bleeding is less frequently re- quired in the former than in the latter, and especially to the same extent; and, as in this fever the indications of the ne- cessity of active depletion were seldom urgent, and those of an opposite condition were usually manifest in the course of the disease, general blood-letting was not had recourse to, except in cases where the arterial action was high in the first stage, and when once practised it was seldom found necessary to repeat it. The administration of cathartic medicine in the commence- ment of fever is usually judicious and proper ; indeed, it is re- garded in most cases as indispensable. But, in the disease in question, cathartics should be given even in the commence- ment with great caution, and none but the mildest in their operation should be administered. Moderate doses of castor oil, senna and salts, or salts and cal. magnesia, were found sufficient for all needful purposes; and, where no strong ob- jection exists, I believe no better laxative can be employed than the ol. ric. From the peculiar character of this fever it must be apparent that the too common practice in febrile diseases of often repeating active cathartic medicine would be 174 Dr. Taylor on Typhoid Fever. highly injurious. The excellent remarks of Stokes, in his lec- ture on typhus fever, are so directly in point, and in my judg- ment so vastly important, that I trust I shall be excused in quot- ing him. He says: "A common practice has prevailed in these countries, and, indeed, still exists to a very great extent, of making the patient take purgative medicine every day ; and this, I regret to say, is too often done, even in cases where the surface of the small intestine presents extensive patches of ulceration. Now, I will ask you, can any thing be so bar- barous as this, or can it be exceeded in folly or mischief by the grossest acts of quackery ? Here we have an organ in a state of high irritation, and exhibiting a remarkable excite- ment of its circulation; and yet we proceed to apply stimu- lants to that organ, and to increase the existing irritation. Would it not be absurd in a case of inflammation of the knee or elbow joint to direct the patient to use constant exercise and motion ? Would it not be very strange practice to apply irritants to a raw and excoriated surface ? Yet something equally absurd, and equally mischievous, is done by those who employ violent purgatives in a case of inflammation of the digestive tube in fever. This has been the great blot in the history of British practice. Calomel and black bottle, and even jalap, and aloes, and scammony, have been prescribed for patients laboring under severe and extensive dothinente- ritis. Morbid stools are discharged ; the more morbid they are, the more calomel and purgatives does the physician give to change their character, and to bring them back to the standard of health. I want words to express the horrible consequences. Too often have I seen fever patients brought into the hospital with diarrhea, hypercatharsis, and inflamma- tion of the mucous membrane, from the use of purgatives ad- ministered before their admission. Practitioners will not open their eyes. They give purgatives day after day-a very easy practice, and one for which there are plenty of prece- dents-but it is fraught with the most dangerous conse- quences." These remarks are worthy the high authority from which they have emanated, merit the deliberate atten- tion of every physician, and are perhaps but little less appli- cable to this country than to Great Britain. Dr. Taylor on Typhoid Fever. 175 The great point to be aimed at in the treatment is to pre- serve the intestines in a quiet state, avoid whatever may irri- tate them, and by counter irritation and general remedies, to alleviate and subdue the local affection and control the fever. I have seen patients with a red tongue, meteorism and diar- rhea, carried through the fever successfully, without the ad- ministration of a dose of cathartic medicine, except a mild laxative in the commencement; and I believe it is often bet- ter, in this condition, to depend entirely upon enemata, so far as may be necessary to procure evacuations, than to adminis- ter even laxatives. After what has been said upon this point it is hardly necessary to add, that but little benefit can be ex- pected from emetics, except for the purpose of unloading the stomach of offensive matter in the commencement of the dis- ease ; and serious injury may result from their use, especially when prompt emesis is not produced. Antimonials should be avoided, as calculated to aggravate the disease; even the milder preparation, the James' powder, in cases where the ge- neral febrile excitement seemed to render its use expedient, and when indications of the local affection were but slight, could not be freely used or long continued without increased manifestation of intestinal irritation. Such, however, was not observed to be the effect of the use of ipecac ; but, on the con- trary, given in small doses, and especially combined with opiates, it appeared to exert a salutary influence. Pul. dov. ii. to iv. grs. at intervals of four or six hours, with or without an additional quantity of ipecac, or a powder composed of sulph. morph, and ipecac, in corresponding doses, was much relied upon ; to which was usually added pul. gum acacite or pulv. rad. glycyrrh, and the creta ppt. when the disposition to diarrhea was urgent. A powder of this description, varying the quantity of the different articles and the frequency of the dose according to circumstances, was usually found sufficient to preserve a quiet state of the bowels, and appeared to exert otherwise a favorable influence upon the disease. Acidulated drinks operated less favorably than alkaline-the former seemed to aggravate the local affection, the latter to have an agreeable effect in allaying thirst and correcting the condition VOL. V. 176 Dr. Taylor on Typhoid Fever. of the stomach. The sup. carb, soda was preferred, a weak solution of which was given as a common drink. Cold water was allowed according to the inclination of the patient, a free use of mucilages enjoined, and preparations of arrow root, pearl barley, &c., chiefly relied upon as nourishment. The spirit of nitric ether was found an agreeable remedy. Given in gum water it appeared to have a general quieting effect, acting favorably upon the kidneys and upon the surface. In the more advanced stage of the disease, when symptoms of an adynamic state existed, small doses of pulverized camphor were advantageously added to the prescription. Mercury, in any of its preparations, was not freely used or relied upon as a common remedy. In some cases in which the tongue continued obstinately red, and the symptoms gene- rally unrelieved by the usual treatment, small doses of calomel effected a decidedly favorable change. When this remedy is employed, it is a point of the first importance that the dose be •well regulated ; and it is only in small and unirritating doses (1 to i' gr- or even a less quantity, which may be added to the powders before mentioned) not with the view of getting up a mercurial action, which should be carefully avoided, but chiefly for the purpose of the change in the condition of the local affection, which, perhaps, its direct action upon the dis- eased surface of the intestines may effect, that the benefit of its use is mainly to be relied upon. In fever usually deno- minated bilious, calomel has been considered the most im- portant remedy, and its use almost or quite indispensable. The impression that a disease was bilious-a term not always conveying a very definite idea, or some vague notion of the deobstruent powers of mercury, or the idea that a mercurial action would supersede an existing morbid condition, has af- forded a sufficient reason for the free employment of this re- medy in fever generally. That much good may have been accomplished there is no doubt, and the extent of the evil which has resulted it is impossible to ascertain. That the impres- sion that it has been used too freely, or that a change in the character of fever has rendered its employment less judicious, is becoming somewhat common, is evident from the fact that Dr. Taylor on Typhoid Fever. 177 it is much less depended upon, and used with more caution at the present day than formerly; and with reference to the section of the state in which I reside, this impression in both respects is, in my judgment, well founded. The tympanitic affection was appearently best relieved, es- pecially in the advanced stage of the disease by the use of ol. Terebinth, in repeated doses of four to six drops. The good effect of this remedy was sometimes witnessed in not only relieving this symptom, but in changing a red and dry tongue to a moist, and more natural appearance. The Bals, copaiba, in similar doses and for the like object was admin- istered, and frequently with marked benefit; but this remedy was most relied upon in those protracted cases where ulcera- tion was apprehended. These remedies, however, are not regarded as judicious and entirely safe in the early stage of the disease, but should be reserved for that more advanced stage, when the local inflammation may be supposed to have changed from an active to a more passive state, or alow grade of action, in which, a local stimulant of this character may be not only safe, but highly important. Particular attention was paid to external applications throughout the course of the fever. Sponging or bathing the body with water was directed according to the temperature of the surface, and applications to the abdomen were usually di- rected from the commencement. In mild cases the constant application of wilted burdock leaves or flannel moistened with warm vinegar was deemed sufficient, and relied upon with apparently good effect. Cupping and leeching, and especial- ly the latter when leeches can be obtained, should be had re- course to in all cases where the symptoms indicate much ac- tive local inflammation; and the absence of tenderness upon pressure should not always deter us, for it is well known that this condition of the mucous membrane may exist to a consid- erable extent when it cannot be detected in this manner. The application of sinapisms was most commonly relied upon as a counter irritant, and these were evidently of most essential service. They were applied over the abdomen in such a man- ner and of such varied strength, as to keep up pretty constant- 178 Dr. Taylor on Typhoid Fever. ly some degree of redness and irritation. Epispastics were not so much used, and when applied it was deemed of some im- portance to suffer them to remain no longer than the com- mencement of vesication, and to follow their application with a poultice or fomentation. Tonic and stimulant remedies were seldom much required. In some protracted cases attended with a good deal of prostra- tion of the powers of life, either the serp. virg ; sulph. quinine or wine was had recourse to, but administered sparingly and with caution. It is often a nice point and somewhat difficult to determine, as to the precise time and condition of the pa- tient in fever, when remedies of this class are required ; and I entertain the opinion, that error more often lies on the side of too early stimulation, than in the opposite course. In this epidemic, either from the original character of the disease, or other causes, these remedies were seldom urgently demand- ed. Light nutritious diet was chiefly relied upon to sustain the patient and when this course could be safely followed, convalescence progressed with more steadiness and certainty, than when urged by tonies and stimulants. I have thus detailed with perhaps unnecessary minuteness the treatment usually adopted, and which in the proportion of about nineteen out of twenty cases was successful. How far the disease in question may have been modified by local causes it is impossible to ascertain, but, I am induced to believe something similar has prevailed more or less in differ- ent places throughout the country, and if the manner in which I have invited attention to its peculiar characteristics, and the suggestions as to treatment, shall be useful to any one in his endeavors to arrive at just conclusions and to adopt a safe and successful practice, I shall indeed be gratified, although deep- ly sensible I have made a very inadequate return for the con- fidence you have been pleased to repose in me.