ALBANY MEDICAL ANNALS. 
9 
A DISCUSSION ON THE "TREATMENT OF TYPHOID FEVER." 
Indications for Treatment, by 0. A. Ball, J\f. D. 
WE have for consideration the indications for treatment of an acute 
infectious disease of a specific form. Characterized by a gastro- 
intestinal catarrh a febril movement of continual type. Varying in 
duration from ten to twenty days or more, and in intensity from one 
to several degrees above normal temperature. Marked by great wast- 
ing and extreme prostration of the system and accompanied by certain 
nervous phenomana of greater or less urgency and recognized after 
death by constant lesions of the solatary and aguminate glands of the 
intestines together with enlargement of the mesenteric glands and of the 
spleen, a disease which attacks any period of life, though not common 
in early infancy or extreme old age. As before stated typhoid fever 
always presents uniform and constant lesions, so constant and so cer- 
At the Meeting of the Albany County Medical Society, Nov. 18, 1891. 10 
ALBANY MEDICAL ANNALS. 
tain that we can positively determine after death if not before, whether 
the disease was present in a given case or not. 
If then we have a specific disease, we must necessarily have a 
specific cause producing that disease. And our first indication for 
treatment is to destroy that cause if it can be done, or failing in that, to 
eliminate it from the system as rapidly as possible. 
Having no antidote as yet for typhoid fever, have we any 
means at our disposal to fulfill the second indication, with safety to 
the patient? This question cannot be fully discussed in a paper of 
this character at this time. Briefly we may say that no system of treat- 
ment has as yet been devised that will with certainty and in every 
case shorten the course of the disease for one hour so far as we know; 
that certain methods of treatment seem to modify the violence of an 
attack in some cases is true, but that the disease is shortened in its 
course is very problematical to say the least. There are three great 
emunctories through which we may act in aiding nature to eliminate 
disease producing elements, all of which should be called into active 
co operation in this disease. Our treatment in other respects must be 
governed by symptomatic indications, always bearing in mind and 
attempting to ward off those conditions that are likely to prove 
destructive to our patient. 
Our first care should be to instruct those having charge of the 
patient how to disinfect the dejections from the patient, not forgetting 
that the urinary secretions are just as dangerously infective as are 
those from the bowels. For disinfecting it is best to use chloride of 
liri'ie, four ounces to the gallon of water; at least a quart of this solu- 
tion should be placed in the pan in which the dejections are received, 
the same to be thoroughly mixed and allowed to stand an hour before 
emptying into closet. • The patient's buttox, thighs and genitals should 
be bathed in an aquous solution of carbolic acid after each move- 
ment of the bowels or bladder. This personal hygeia of the patient is 
just as necessary in the mild as in the more grave forms of the disease 
and should be continued for at least ten days after all manifestations 
of the disease have ceased. As a rule patients with a mild form of 
fever, say one whose temperature does not exceed 103 with a decided 
morning remission do not need nor are they apparently benefitted by 
any special course of treatment. Such cases need careful nursing, 
fresh air, clean clothing, unstimulating diet as free from starch as pos- 
sible and careful watching by the medical attendant, that no complica- 
tion may find him off his guard. They usually progress to a favor- 
able termination without much medication, or any in fact. 
We should try and ascertain from a careful study of our patient, 
and his surroundings, which of the most usually fatal forms of the dis- 
ease, he is most liable to succumb to if to either, and try to anticipate 
and prepare for the danger before it is upon us if possible. In my 
opinion the usual diarrhoea that accompanies this disease should never 
be interfered with, without there are other indications other than it 
that demands it. 
The most serious cases we meet in my experience are those at- 
tended by constipation from the first. The usually fatal forms of the 
disease in uncomplicated cases are heart failure, cerebral paralysis, ALBANY MEDICAL ANNALS. 
11 
peritonitis from perforation and intestinal hemorrhage, and infre- 
quency about in the order named. 
The diagnosis between the two conditions last named is not easy 
to be made especially when the hemorrhage is concealed, and yet it is 
very important that it should be, for our patient's life may surely de- 
pend upon our accuracy in this instance. Both are attended by sudden 
collapse and a fall of temperature below normal. To be as brief 
as possible our main diagnostic point is in careful percussion of the 
abdomen. If the collapse is due to hemorrhage there will usually be 
dullness in the right umbilical and illiac regions in as much as the 
hemorrhagic ulcer as well as the perforating one is almost invariably in 
the lower portions of the ileum. 
In perforation the escaping gase will so distend the abdomen that 
the liver dulness will be lost. This is a point that must not be for- 
gotten, for while the chances of recovery is very slight, from abdominal 
section in typhoid cases, yet the indications point too strongly to 
that proceedure to be neglected if we would give our patients all the 
chances for recovery. If then we are satisfied that perforation has 
occured, there should be no time lost in calling in a surgeon to perform 
a laparatorny. 
Danger from high temperature calls for antipyretics in some 
form whether internal medication or externally applied will be de- 
termined more by the condition of the heart and nervous system, than 
upon the theory that cold water is the only desirable means of lower- 
ing temperature. 
A frequent and feeble pulse calls for alcholic stimulants. Sleep- 
lessness and restless delirium call for active interference. 
Cerebral paralysis I apprehend is usually due to the specific poison 
of the disease and is often relieved by an energetic cathartic and 
especially one like calomel that calls the kidneys into immediate ac- 
tivity with the bowels. 
Epistaxis can usually be controlled by pressure. 
Hemorrhage from the bowels if excessive is a condition of extreme 
danger, and requires very careful management to avoid sudden collapse 
and immediate death. 
Bronchitis is present in so many cases that it may be considered 
one of the phenomana of the disease and not a complication. And 
when severe is an element of danger that should not be overlooked. 
Embolic abscess and periostitis if they occur are to be treated on 
general surgical principals. 
Hypostatic pneumonia is a resultant of a weak heart, and best con- 
trolled by attention to that organ. Thrombosis is liable to occur in 
any of the veins, and especially in the cerebral scienses. ■ Meningitis is 
so rarely present in typhoid fever that it cannot be classed as belong- 
ing to its catagory of symptoms, in fact the serous membranes pretty 
generally escape unharmed without they have been previously dis- 
eased. 
Shall we not be guided in our selection of a diet for typhoid fever 
by the same factors which lead us to select our diet in a condition of 
health, that is by our appetite and our taste. In a condition of health 
Dietetic Treatment of Typhoid Fever, by Henry Hun, M. D. 12 
ALBANY MEDICAL ANNALS. 
from time to time a keen appetite or hunger causes us to eat and no 
one needs to be told that this is essential in order that we may live. 
Furthermore, by our taste we select from the thousand things in the 
world that might be eaten, certain things which we like; thus, to take 
only one example, from the great number of saline substances we 
select salt (chloride of sodium) as a very desirable addition to our food, 
and we cannotedoubt that in the course of years, not only the individual 
but the race is gradually led to select those things which, on the whole, 
are the most healthy, and that it is better for us to eat chloride of 
sodium than chloride of ammonium or any other saline substance. It 
is true that in some cases the appetite and taste are perverted, and 
need to be restrained and guided, but in the great majority of cases 
they lead us to take those things which in a general way are best 
adapted to our needs. 
Now if it be true that disease is a process by which the system re- 
moves from itself some noxious thing which has entered it, and that 
the diseased or pathological processes are merely physiological ones so 
modified as better to preserve the integrity of the body and are in their 
nature curative, may it not be that our appetite and taste become 
changed in disease in such a way as to aid in the progress of recovery ? 
It is certainly true that in typhoid fever the normal appetite and taste 
are profoundly altered and may we not get some light on the proper 
diet in this fever by studying the altered appetite and taste? Almost 
as a universal rule in typhoid fever the appetite and taste are modi- 
fied from a condition of health in these three ways: 1st. There is a 
great thirst; 2d, there is a loss of appetite for meats and 
'vegetables (so-called hearty food), and for food containing sugar 
(sweets), and 3d, there is a persistence in a greater or lesser degree of 
appetite for liquid food of which milk may be taken as the representa- 
tive; and, for my part I believe, that we have no better indications for 
the dietetic treatment of typhoid fever than these three which are 
furnished us in the perversion of the normal appetite and taste in this 
disease, and in the short time at my disposal I shall briefly consider 
each of these indications for treatment. 
First. In typhoid fever the patients suffer the most extreme thirst 
and to refuse them water is to do what is apparently cruel, and what is, 
1 think, as a matter of fact, harmful. On account of-the high fever a 
very large amount of water passes through the skin, as both sensible 
and insensible perspiration, and the diarrhoea still further takes water 
from the system. As a consequence the skin becomes dry, the tongue 
parched and heavly coated, there is very little secretion from the 
salivary, pancreatic and intestinal glands, and all the organs and 
tissues of the body are very dry, so much so that autopsies of cases of 
typhoid fever are almost always dry autopsies, there scarcely being 
any fluid running from the tissues. 
In addition to this we have a peculiar degeneration taking place 
in the internal organs, especially the liver, kidneys and heart, to which 
great attention has been paid and to which has been attributed the 
dangerous cardiac weakness often present in this disease. This is the 
so-called parenchymatous degeneration which consists in the separation 
of little particles of solid albuminous matter from the fluid protoplasm 
of the cells, giving the cells a granular appearance, and to these degen- ALBANY MEDICAL ANNALS. 
13 
erated and weakened cells, especially in the cardiac muscle, the death 
of the patient is referred. The little granules in the cell disappear on 
the addition of acetic acid and are simply solid albuminous matter, and 
the thought must occur to us, that they are due to the fact that there 
is not sufficient water in the cell to keep them in solution. This 
parenchymatous degeneration is found in the viscera of animals which 
been exposed for a long time in a hot box to high temperatures, but have 
animals thus exposed to high temperatures who at the same time are 
given large quantities of liquid food do not show this parenchymatous 
degeneration, a further proof that the protoplasm becomes solid simply 
for want of water, and that this can be prevented by furnishing the 
system with a large quantity of water. So that from theoretical 
grounds the administration of water in typhoid fever is called for. 
Certainly in practice I am convinced that where we do give large quan- 
tities of water to our patients with typyoid fever all the symptoms of 
the disease are rendered less severe, and even the diarrhoea is not 
increased, and, I believe, that the good effects of cold baths in 
many cases is due in part at least to the absorption of water by the 
skin during the bath. Therefore, as the result of theory and practice 
we are led to follow the demands of the appetite in typhoid fever and 
to give the patient large quantities of water. This he will take 
readily enough in the early stages of the disease, and when he becomes 
dull or comatose, and in no condition to appreciate the need for water 
we should still urge him to drink it at regular intervals. 
Second. In typhoid fever there is a great aversion to hearty food, 
such as meats and vegetables, and when such food is taken nausea and 
vomiting are apt to result, and Zuezler has found that there has been a 
rise of temperature immediately following the ingestion of such food. 
This aversion to hearty food is probably due to the diminished quantity 
of water in the system and the consequent scanty secretion of the 
glands connected with the alimentary tract which is entirely insufficient 
for the digestion of such food. Furthermore, we must remember that, 
although in a condition of health by the time the food has reached the 
lower portion of the small intestines it has become so far digested as to 
be entirely fluid, yet, in the condition of disease in consequence of the 
imperfect digestion, and in consequence of the more rapid peristalsis 
which manifests itself in the diarrhoea, the food may not be perfectly 
digested and may reach the lower bowel in a more or less solid con- 
dition, and thus irritate the inflamed Peyer's patches. For the same 
reason food containing indigestible seeds or irritating insoluble 
substances, such as pepper, which might find a lodgment and cause 
irritation of the ulcerated Peyer's patches are to be avoided. 
The aversion to sugar and sweets which typhoid fever patients be- 
tray is so strong that they often will refuse to take ice-cream or 
custard, which they otherwise would very much enjoy, simply because 
they are too sweet, and they desire to have all such food made with 
little or no sugar. This aversion to sugar is, perhaps, due in part to 
the amount of water which such substances require for their solution, 
and in part to the fact that these substances are apt to produce a 
flatulent dyspepsia which is especially bad in typhoid fever where the 
tympanites is always a more or less distressing symptom. It seems to 
me, then, that besides the aversion of the patient and the difficulty 14 
ALBANY MEDICAL ANNALS. 
which we would have in administering such food that we have good and 
sufficient reasons for following the patients' taste in this matter also, 
and to exclude from the diet of typhoid fever meats, vegetables, and 
food containing much sugar. 
Third. In typhoid fever although the patients have lost all appetite 
for hearty food and for sweets yet they often show a decided appetite 
for liquid foods especially for milk and for some form of soup or 
extract made from meat. Many patients in the early stage of typhoid 
fever enjoy drinking milk very much indeed, and find a glass of cold 
milk delicious even though in health they do not like this article of 
diet, and many persons take no other food than milk during the whole 
course of their fever. In case the milk is vomited in curds it may be 
necessary to add lime water to it or to peptonize it if the addition of 
lime water is not sufficient. When even peptonized milk is rejected 
by the stomach then some preparation of infant's food, such as Mellin's 
food or Imperial Granum made with milk is often very well borne in- 
deed, or Kumyss or Matzoon may be tried; although the large amount 
of carbonic acid gas contained in these preparations of milk make them 
of doubtful value in typhoid fever on account of the tympanites. Even 
when milk is well borne it is often desirable for the sake of variety and 
to preserve the appetite of the patient to add other articles to it, the 
addition of an egg beaten up in the milk is a very nutritious, and 
where the stomach is strong enough to bear it, a very desirable thing. 
Custard of various kinds, especially rennet custard, ice cream made 
with a simple fruit flavor, and ordinary tea with much milk are often 
very grateful to these patients and very nourishing. 
Although many cases can thus be nourished throughout the entire 
fever with milk and some modification of milk, yet the addition of soups 
or meat extracts is often very desirable. The beef extracts do not 
contain, perhaps, a great deel of nourishment, but they act as stimu- 
lants and are often so eagerly desired by patients with fever that their 
use seems to be essential. These extracts of beef should be made with 
only a small amount of water and at a low temperature so as not to 
coagulate the albumen and thus impair what little nutritive value the ex- 
tract possesses. Even better than these extracts is often scraped beef, or 
the juice pressed from scraped beef, and this scraped beef can often be 
spread on thin slices of stale bread with advantage. Well boiled rice 
either alone or added to the beef extract is also of great value. The 
liquid part of oyster or clam soups made with milk, and even the soft 
part of raw oysters without pepper, and soft boiled eggs may form part 
of a diety of typhoid fever in many cases. 
Liquid or semi-liquid food composed of milk, eggs, and the juice of 
meat, must form the diet in typhoid fever, and such a diet corresponds 
to the taste of the majority of the patients with typhoid fever, and 
must be modified in each case to correspond to the taste of the indivi- 
dual patient unless the thing that he desires is manifestly injurious. 
In regard to the part that alcohol should play in the diet of 
typhoid fever I think that here too we must be guided by the taste of 
the patient. If he has been for a long time accustomed to 
the use of alcoholic stimulants, and if such drinks are pleasant to him, 
then it will we wise to continue the administration of a moderate 
amount of wine or other alcoholic drinks during the fever. But, if the ALBANY MEDICAL ANNALS. 
15 
patient has not been accustomed to their use, and has no taste for them, 
then his diet should not include them. Whether or not under certain 
conditions alcohol should be given in typhoid fever as a medicine does 
not concern us here. 
A very important branch of our subject is that of the diet of con- 
valescence from typhoid fever. But interesting and important as the 
consideration of this is I must omit it for want of time, and must 
confine myself strictly to the subject of the dietetic treatment of 
typhoid fever itself. In the consideration of this subject I have not 
mentioned a great variety of foods which have been used in typhoid 
fever, but have sought for the principles which should guide us in our 
selection of such a diet, and desire to draw attention especially to the 
importance of consulting the taste and inclination of the patient ; a 
source of knowledge and guide to treatment in all diseases of the 
greatest value, and one, which, it seems to me, has been two much 
neglected by physicians in the past very much to the detriment of their 
patients. 
Antipyretic Treatment, by J. IK Hennessy, AT. D. 
Though most of the drugs and modes of treatment that are 
used in typhoid fever, have been more or less recommended for their 
power to lower the temperature or prevent its rise, either directly or 
indirectly, still under the name Antipyretic Treatment, I believe that 
what is generally understood is the treatment of a hypernormal tem- 
perature as a symptom. 
There probably is no point in the therapeutics of this disease, upon 
which such diametrically opposed views are entertained by authors and 
general practitioners ; not only on the question " Which Antipyretic 
should be used," but also on the more important one " Should any 
such means be employed." The short time allotted renders it impos- 
sible, even if it were desirable to quote authors. 
It has been contended on the one side that the dangers of typhoid 
fever are in direct ratio to the height of the fever, and are to a great 
extent due to it ; and, therefore, that to control the temperature, is 
sure to lower the mortality. 
On the other hand it is claimed that the high temperature is not 
the cause of the nervous phenomena, the delerium, etc. ; nor of the 
accidents nor complications which may occur in the course of the 
disease, and therefore, it is useless to combat it. 
Of those who oppose antipyretic treatment, it can be said that 
their objections are chiefly theoretical ; while those who favor it, base 
their convictions upon clinical experience and on statistics drawn 
from it. 
Of the means for combating a hypernormal treatment, I will speak 
only of antipyrine, antifebrin, thallin, and the cold bath ; believing that 
quinine, salicylic acid, eucalyptus, and a number of other drugs, have 
bv common consent been dropped, either because of their faint and un- 
certain action, or on account of unpleasant effects. Antipyrine holds 
a high place as an antipyretic and is given in doses of from 10 to 30 
grs ; whenever the temperature is too high, that is when it reaches 
104 . The result is usually a fall of from two to three degrees which 
persists for a variable time (usually 24 hours). 16 
ALBANY MEDICAL ANNALS. 
The disadvantage of using antipyrine is that occasionally, distress- 
ing symptoms follow its exhibition, such as cyanosis, collapse, etc. 
Thallin is used in doses of from 2 to 5 gr. and is believed by 
many to be as good as if not superior to antipyrine. For antifebrine it 
is claimed that small doses (3 to 5 grains) repeated when neces- 
sary every 2 to 4 hours will certainly reduce the temperature, 
quiet the restlessness, relieve the severe headache, and generally con- 
tribute to the comfort of the patient; and that in these doses there is 
no danger of cardiac failure or any other unpleasant effect. That 
these drugs will reduce the temperature is a certainty, and that the 
general comfort of the patient is added to, seems to be no less true;- 
but there appears to be a fair amount of agreement among observers 
that the duration of the disease is in no way shortened, and that there 
is a greater liability to relapses than after a purely expectant plan of 
treatment. But it is the cold bath, which, during the last few years, 
has been most highly praised, and if the statistics based upon the 
treatment after the method of Brand are to be relied upon, then it is 
deserving of the closest attention. 
These statistics show a mortality ranging from 0 to 5 per cent, as 
compared with 7 to 20 per cent, under treatment hy the expectant 
method. It is true that in these figures there may be some element of 
falsity, as the good results may in part be due to better dietetic man- 
agement or to other factors of which we do not know, but we will have 
to take them as they are. 
In favor of the method, we have to admit, that those who have 
used it the most believe in it the strongest even going so far as to say 
that any case if taken early is certain to run a mild course. 
It is true that in private practice a large proportion of cases can 
not possibly be so treated; but where it is possible is it not the best 
treatment? 
According to Brand's method the baths should be given with 
regularity, beginning as soon as the patient comes under observation. 
(If the fever ends within two weeks the diagnosis of typhoid is with- 
drawn), and no matter whether .there are complications or not, such as 
intestinal hemorrhage, bronchitis or even pneumonia, they should be 
persisted in, usually with the result of having these unpleasant con- 
ditions disappear. 
The bath may be given in several ways-the full cold bath, the 
partial bath, and the warm bath gradually cooled. 
The patient is carried to the bath room or the bath tub is brought 
to the bed side, and the patient is entirely submerged except the head. 
The full cold bath, which is given in the majority of cases, should 
be of a temperature of from 64 to 68. The patient is allowed to re- 
main in this for about 15 minutes or not so long if marked shivering 
occur. The partial bath with cold affusions is to be preferred when 
there are chest complications. 
In this bath the temperature is about 82; the patient immersed in 
it and water of a temperature of 50 poured over the head and shoulders,, 
and the patient is briskly rubbed with a sponge or brush. This bath is 
said to be highly stimulating and may be continued for 5 to 10 
minutes. ALBANY MEDICAL ANNALS. 
17 
The warm bath gradually cooled is to be preferred in children, the 
aged or where there is marked cardiac weakness. 
In this bath the water at first is about the temperature of the 
patient, and is gradually cooled by the addition of ice or cold water, 
till at the conclusion it is about 68. In this the patient may remain 
from 20 to 30 minutes. In any case the bath should be discontinued 
when shivering takes place or when there is marked evidence of weak- 
ness. The patient is then put in bed; and friction, hot bottles or 
stimulants used, as may be indicated. 
The number of baths to be given in twenty-fonr hours varies from 
2 to 10 or 12 according to the temperature of the patient and the zeal 
of the attendant. 
Cold sponging as a means of lowering the temperature apparently 
takes a very low place among antipyretic remedies. 
I do not know why this should be so, nor can I say whether ex- 
tended observations have been made with it as with the cold bath, but 
it does seem that if the same time or even more were consumed, and 
water as cold 60 or 62 used that its refrigerant action would at least 
be nearly as great as when the patient is submerged, as to the applica- 
tion of cold is added the effect of evaporation. 
In it we have all the stimulating effects of the bath, without the 
unpleasant ones, not least of which is the dread (and in children this 
would amount to positive terror) and the almost unconquerable pre- 
judice of friends. Besides it may be well done without the help of a 
skilled attendant and in the most inconvenient apartments. 
Value of Alcohol in the Treatment, by S. 13. Ward. 
Typhoid fever. To discuss this subject intelligently, we must 
begin with a few words concerning the action of alcohol upon the 
human organism, from a physiological standpoint. All liquors, ales,, 
wines and beers contain alcohol in varying proportions and in varying 
combinations. The distilled liquors exert their influence almost solely 
through the alcohol which they contain, while the ales, porters and 
beers contain no inconsiderabfe quantity of solid matters, some of 
which are far from being inert. The chemical composition of alcohol, 
Cg Hg O, may properly cause it to be classed among the non-nitrogenous 
substances, which class includes also starches, sugars and fats. Physi- 
ological researches seem to have shown that alcohol is eliminated by 
the lungs, skin and kidneys combined. It appears also that it first 
circulates in the blood through all the tissues of the body, and that 
when taken in quantities sufficient to produce intoxication, a con- 
siderable percentage of it disappears by some transformation in the 
body and is not thrown off as alcohol. Taken in moderate quantities 
it produces, in some persons, a certain degree of nervous exaltation 
and sharpens the mental faculties, while in others the latter become 
blunted almost at once, and this latter condition occurs always if a 
sufficient quantity is taken. 
The phenomena attendant upon large doses, frequently repeated, are 
known to you all. Death may even follow the delirium potatorum. 
That with many persons alcohol gives temporary tone and vigor, can 
scarcelv be doubted; still, the depression following in most persons, 
more than offsets the temporary advantage. By its use in moderate quan- 18 
ALBANY MEDICAL ANNALS. 
tity, continued for a number of days, the exhalation of CO2 and also 
the discharge of urea and excrementitious matters, are notably dimin- 
ished. When the organism can be adequately supplied with food, and 
the food properly digested and assimilated, alcohol may be said to be 
always injurious; but when in almost any form of illness, food cannot 
be taken, or cannot be digested, or cannot be assimilated, then alcohol 
may temporarily replace the food and restore the powers of the body, 
but the effect of its long continued use, especially with insufficient 
nourishment, shows that it is not possible for it to long take the place 
of other and assimilable matters. 
While alcohol taken in considerable quantities produces a sensa- 
tion of warmth, yet the experience of all travelers in the Arctic 
regions shows that the men exposed to excessive cold did better with- 
out alcohol than with it. Some accidental great over-exposure may 
necessitate its temporary use, but in any other way it is positively 
injurious on account of the great depression and reaction that follow 
it. Hot coffee is found to be infinitely more valuable for the purpose 
stated. Alcohol acts as a narcotic on the sympathetic nervous system, 
while tea and coffee excite the ccrebro-spinal axis. The former stupi- 
fies, while the latter brightens the intellect ; the former inebriates, 
the latter cheers and preserves. 
When alcohol is given therapeutically, its immediate action is 
upon the sympathetic nervous system, where it exercises a sedative in- 
fluence upon the vaso-inhibitory nerves, increasing the frequency of the 
heart-beat and also its force. It necessarily follows that the capillaries 
are dilated, diffusing temporary warmth throughout the system, at the 
same time increasing the blood supply to the nerve centres ; and, if 
taken in excess, exerting its physiological influence upon the brain. 
Probably when it is decided that alcohol should be administered at all, 
there is no safer practical rule than that is doing good in any quantity, 
no matter how great, which produces no effect on the intellectual part 
of the man, and that it is given in excess just as soon as it does. 
While alcohol produces a sensation of warmth, the fact is that its 
exhibition in moderate doses produces a moderate diminution, and in 
larger doses a considerable reduction of the bodily temperature, the di- 
minution being in proportion to the amount of the alcohol ingested. 
From its chemical composition one might suppose a priori that the 
oxidation of the hydrogen which it contains would augment the tem- 
perature of the body. It is, however, an established fact that its in- 
fluence in checking tissue change and oxidation is so powerful as to 
more than offset the heat produced by its own oxidation ; and from 
this arises the fact that its administration reduces, instead of raising 
the temperature of the body. 
It is quite possible that this action is also enhanced by its capacity 
to dilate the capillaries in the skin, thereby increasing the radition of 
heat from the surface. It is also aided by the additional activity 
which it causes in the sweat glands and the subsequent rapid evapora- 
tion of perspiration. In toxic doses, the temperature has been 
known to fall from two to four degrees Fahrenheit, as a consequence 
of the influence of this drug. 
Therapeutically considered, one of the most important properties 
of alcohol is the action it has in calming bodily restlessness, in produc- ALBANY MEDICAL ANNALS. 
19 
ing sleep and in quieting delirium. Another valuable action is its 
capacity to increase the force of the heart beat. Nothnagel explains 
this by stating that it is a direct stimulant to the vagus nerve, through 
the pneumogastric centre in the brain, and that it probably also acts 
directly on the heart plexus. 
With reference to its use in typhoid fever, we may start out with 
the fundamental proposition that its administrasion should form no 
essential part of the treatment of this disease ; it should be prescribed 
only as any other drug, or remedial agent is, for well defined reasons. 
Certainly alcohol should not be administered at the outset of any case,, 
unless the patient be one of the class known as "steady drinkers," and 
show, as some of them will, within the first few days, the bad effects of 
suddenly stopping the stimulant. 
If the patient be greatly reduced in strength and especially 
anaemic, he may need alcohol earlier thun a strong, plethoric patient ; 
but it is best, under any circumstances, to reserve this powerful agent 
for possible complications that may come later, and especially for heart 
failure. 
Indications for its use are: 
First-Feeble or imperceptible radial pulse with corresponding 
weakness of the first sound of the heart on auscultation. It is possible 
that even then some other drug, such as digitalis or strophantus, may 
answer a better purpose than alcohol, or, at any rate, may prove an 
indispensable adjuvant. 
Second-The condition of the intestinal tract, principally gangrene 
and sloughing, with resulting depression. To administer alcohol 
during the first week of typhoid fever, with a view of preventing heart 
failure or depression, it is worse than useless. 
It is impossible to lay down any definite rule as to the amount of 
alcohol to be administered. The character of the heart systole and the 
symptoms on the part of the nervous system are the best guides. If 
these are improved under its administration, its use is doing good; if 
not, it is doing harm. 
It is equally impossible to lay down any exact rule as to the 
amount to be given, save that as you are giving it for some purpose, 
it is proper to endeavor to accomplish that purpose. 
As I said before, I believe that when any symptoms of intoxication 
are being produced, your stimulant is doing more harm than good. If, 
on the other hand, the pulse is increased in strength and the heart- 
sounds are improved in quality, we should not care whether half a pint 
or a pint a day is being administered. I have seen one excellent 
practitioner order a teaspoonful of whisky to be administered every 
three or four hours; and 1 have known a weak, feeble woman, who had 
never before used stimulants in her life, take a quart of brandy, a pint 
of sherry and a bottle of champagne every twenty-four hours, with the 
effect, as appeared, and as I believed, of saving her life. As as rule, 
whisky and brandy are better borne than any other form of stimulant. 
Some few patients, however, will take champagne with better effect, 
and I know of no objection to it unless the collection of gas in the 
intestines be hereby increased. Some authors recommend always 
giving the spirits diluted with water. It is my custom to give it in the 
shape of milk punch, as the mode has seemed to me to afford better 20 
ALBANY MEDICAL ANNALS. 
results. During the height of the fever, whisky and brandy have 
seemed to me to answer a better purpose than the light wines; but 
during convalescence, the latter give the best results, and especially if 
taken with meals. In no case should the amount to be administered be 
left to the discretion of friends or the family. It should be definitelv 
and specifically prescribed and the effect carefully watched. 
In conclusion, I must acknowledge my indebtedness for the 
arrangement of the physiological part of this paper to the lecture of 
my friend Professor Townsend on this subject, and for material aid in 
looking up the literature, to my friend Dr. Brennan. 
Medicinal Treatment, by T. K. Perry, M. D. 
That the medical treatment of typhoid fever has been considered 
of inestimable value is abundantly evidenced, not only by the mass of 
testimony relative to the subject, but the character and world wide 
reputation of the observers whose contributions we have regarded as 
authoritative, and for the time, convincing. When such renowned 
clinicians as Leibermeister, Zeimsson, Niemeyer, Winderlich, Trossean, 
Chomel, Murchinson, Jenner, Johnson, Parks, Flint, Loomis and Bar- 
tholow, assure their less astute brethern that certain medicinal agents 
are not only necessary, but of paramount importance in the treatment 
of this disease, it would seem extreme professional heresy, and almost 
suicidal to recede from their position. 
That a most decided revolution has been, and is, taking place con- 
cerning this very matter of medicine in typhoid fever, no one who 
reads at all carefully or comprehensively, can for a minute doubt. Nor 
is this strange when one considers that the very eminent observers 
above quoted arrived at their conclusion, and pinned their faith, in 
medicinal agents of greatly varying strength and kind. One treated 
with nitro-mur, another with sulphorous, another with acetic and yet 
another with carbolic acid. Others again extolled the use of various 
preparations of amonia, sulpho carbolates and even po. borax. Yet 
others again were of the mercurial school and believed calomel almost 
a specific. Others used iodine, or iodine alternating with either mer- 
cury or carbolic acid. Others digitatis, veratria vir, or even aconite. 
Others nitrate of silver, tartar emetic, oil of turpentine, etc., etc. Then 
came the craze for cinchona and its various preparations and finally 
alkaloids, and lastly the indiscriminate use of every so-called antipy- 
retic no matter from what source obtained. The modern practitioner, 
confronted by this mass of conflicting, confusing and almost amusing 
testimony, with his more conservative ideas, more nearly perfected 
methods of research and a much better knowledge of the natural his- 
tory and pathology of this disease, and believing it self-limited and 
tending under ordinary circumstances toward recovery, almost marvels 
that any recovered under some of the older methods, and is hjmself 
chary of all medicines, so far as their specific effect or abortive influence 
is concerned, and possibly flies to the other extreme. But, however, 
this may be, we are doubtless not all agreed on this point, and pre- 
sumably many of our ablest and best, feel a greater sense of security 
when they know that some one or more therapeutic agents are being 
given their patients at stated intervals. 
For the purpose then of fulfiling my share toward precipitating ALBANY MEDICAL ANNALS. 
21 
the subsequent discussion of this subject, permit me to direct your at- 
tention to the medicines which I belive are more generally used. First, 
we will have reference to the regular uncomplicated form and will 
group the agents according to their supposed efficacy into abortives, 
specifics, antipyretics and tonics. So noted an observer as Ziemssen 
believed it possible to abort or cut short the disease by the early and 
prompt administration of a seidlitz powder followed by full doses of 
iodide of potassium. The same author lays great stress on the early 
use of tr. iodine and calomel given alternately. Dr. Siveday of France 
believes the early use of pulv. ipec. gr. 20, with tart, emetic gr. ss., to 
be an abortive agent of great efficacy. Among our countrymen I do 
not find that abortive remedies have been given much credence. 
Under the head of specific agents may be mentioned sulphurous acid 
x to xx drops t. i. d., and continued for no longer than two weeks; 
carbolic acid gtts. i to ii, three or four times a day; tr. iodine gtts. 
iii to v in milk, t. i. d., or tr. iodine and acid carbol, given together. 
Calomel in doses of 1-20 to 1-10 gr. every three hours. 01. terebinth 
in v to xv drop doses three or four times a day. These medicines have 
the endorsement of high authority. The third group or antipyretics, 
are by far the most important as well as most numerous, they are; the 
various alkaloids of cinchona, calisaya, phenactin, salicin, naphthalin, 
antipyrine, antifebrin, iod-antipyrine and iod-antifebrin. Of this class, 
their dose, action and effect, a later speaker will inform you. As to 
tonics, particularly these applicable to an overwrought and much weak- 
ened heart muscle, may be mentioned tr. digitalis, tr. strophanthus, tr. 
adonis venalis, tr. muschus, tr. cactus grandifloria, tr. nucis vomica, or 
preparations of strychnia. The dose of any of these must be small 
and repeated not too often for fear of cumulative action. 
The complications of typhoid fever which confront us most often 
and which really do require, it seems to me some medication are 1st, 
hemorrhage from bowels; 2nd, delirium and coma vigil; 3d, excessive 
cough; 4th, peritonitis from contiguity. Hemorrhage may be treated 
with ex. ergott dr. ss. to dr. one every three or four hours, ergotin gr. 
i to iii, by mouth or hypodermatically three or four times a day. 01. 
terebinth, gtt. x to xv in milk or other vehicle every three or four 
hours. Plumbic acet., gr. ii to v. Cupric sulph gr. 1-4 to 2-3. Ar- 
gentic nit. gr. 1-10 to 1-4. Gallic or tannic acids gr. v to xv or tr. 
ferric chlor, gtts. x to xx, to be given P. R. N. I shall myself strongly 
recommend the tr. iron. Delirium may be aided by chloral, bromide 
of potassa, tr. valerian and musk, tr. hyoscyamus, tr. digitalis and 
morphia. Coma vigil by morphia, chloral or sulphonal. Cough is 
greatly helped or lessened by simple expectorants containing small 
quantities of chloroform, ether or Hoffman's anodyne, or by the use of 
the spray charged with a little morphia, belladonna or cocaine. Peri- 
tonitis from perforation seems almost hopeless from the start out, is 
best treated by opium in some form when it arises from deep ulcera- 
tion without actual perforation. Opium or morphine in large doses 
would seem to me the only therapeutic resource. 
It would seem then, from the foregoing, that while the complica- 
tions ot typhoid fever are not only amendable in great measures, but 
actually demand therapeutic interference, the disease itself is more 
satisfactorily treated, and best conducted to a safe and speedy termi- 22 
ALBANY MEDICAL ANNALS. 
nation by measures other than medicinal. At all events such is my 
individual opinion based on a very fair experience with this disease, 
both in private and hospital practice. 
Dr. Townsend: There are a few points, which I regret Dr. Hun 
did not have the time to more fully discuss, one of which is as to the 
proper diet during the first perion of convalescence. We have under- 
stood during the course of the fever that the fluid diet, as described by Dr. 
Hun is by far the best and only proper diet. Now comes the important 
question as to the beginning of the convalescence, what diet is best at 
this time ? In the early beginning of giving solid food, with the re- 
sult in all probability, or tendency at all events toward the result, of 
bringing about a condition known as relapse. Properly would this 
bring to mind a question, therefore, with reference to this subject of 
relapse, as to whether it be due to the change in diet, or whether it be 
due to a renewal of infection in certain other of the agruinate glands 
in the vicinity of those already affected. I know in some essays, 
written by Dr. A. Jacobi on the subject of typhoid fever, especially in 
regard to the dietetic treatment of its convalescence, that he seems to 
feel that the relapses are frequently occasioned by the administration 
of what Dr. Hun terms, and as we well know, " hearty food " too early 
after this period has begun. I should like to know from Dr. Hun, 
therefore, in this discussion, as to what would be the best manner of 
conducting a case during its early convalescence, with reference to the 
diet. Now, with regard to the discussion of Dr. Hennessey in connec- 
tion with the subject of antipyretic treatment. It would seem from 
my experience in numerous cases of typhoid fever that I have seen, 
that the use of antipyrine in a dose of thirty grains, would be consid- 
erable of a dose. The doctor limits it, from ten to thirty grains. An- 
tipyrine in thirty grain doses has, in my present experience, never been 
given, but in even smaller doses, fifteen grains say it has produced 
symptoms which I should think might possibly become alarming in 
some instances. With reference to the subject as to the use of anti- 
pyrine, as an antipyretic, without any question to my mind, the re- 
duction of terrtperature by the use of this drug in a number of observed 
cases, as compared with the use of of antifebrine was, that antipyrine 
was the more effective. Dr. Ward saw a case with me, where we both 
observed that antipyrine would hold the temperature down longer than 
antifebrine. It has done so m almost every case I have tried it in, 
and I have tried it on quite a number. Another fact in reference to 
antipyrine is, that I have never seen it hold the temperature down so 
long as a maximum of twenty-four hours, as suggested by Dr. Hen- 
nessey. There is another treatment in this discussion, made by Dr. 
Perry, which might be of service to some, and that is the administra- 
tion of calomel in fractional grain doses, and in which, if there be such 
a thing as the aborting of typhoid fever, which I disbelieve in, it may 
have possibly ameliorated the symptoms only. Mistaken diagnosis 
sometimes occasion such belief as cutting short this disease. Calomel 
hypodermically has been used in France considerably, and I have used 
it myself, several times with the effect of apparently ameliorating the 
symptoms. Whether this statement of mine is so or not, I don't 
General Discussion by the Members. ALBANY MEDICAL ANTALS. 
23 
know ; but as to aborting these cases effectually I am quite sure such 
is not the case. With regard to .the discussion of Dr. Ward on 
alcohol, 1 must say with him, that no case of typhoid fever can be 
judged absolutely as to the use or the indiscriminate use of alcohol. 
It is certain that what quantity will do for one may not do for another, 
and it is likewise certain also that those accustomed to drinking, at the 
time they became seriously ill are deserving of a greater portion than 
those that have not the habit of drink. The most diffusible stimulant 
mentioned has been, in my experience, brandy. This brings to my 
mind something more, where in the cases of shock from loss of blood, 
or even in cases of collapse from perforation of the bowels, that ether 
will often do more good than it (alcohol), and even better, is a solution 
of caffein with carbonate of amonia, which is a quick diffusible stimu- 
lant, and which produces definite results within the quickest space of 
time possible. These all to be used hypodermically. I have likewise 
with Dr. Ward had the experience of giving within eighteen hours a 
quart of brandy to patients who are almost in a condition known as 
articuto mortis, and have seen them revive by such quantities ; and 
another fact which has proven itself to me, is that the individual, who 
in a normal condition of affairs could not stand two ounces in the way 
of liquor, but would become intoxicated, would in a condition of 
typhoid fever be often capable of taking perhaps four times that 
amount without showing such a condition. 
Dr. Van Allen : I will reply to the question of blindness 
caused by quinine. One of the first cases I think was reported by 
Dr. Roosa in 1880 or 1881 ; he afterwards in the same number made 
an additional report in which it seemed to be a matter of doubt as to 
whether it was caused by quinine. Cases have been reported since, 
but I think it is regarded rather a result. As to the amount of the 
dose I do not remember what it was. Where aural results have been 
found to follow the use of quinine in a great many cases it has been 
with a comparatively small dose. I remember talking with Dr. 
Roosa about it and his making the remark he thought about twelve 
grains of quinine was a pretty large all around dose. 
Dr. Cook : Most authors in speaking of the use of quinine 
advocate larges doses, twenty to thirty grains once a day, but with 
me 1 have for years followed a different course, and it seems to me 
the beneficial effect is greater by giving quinine is divided doses and 
producing a depression of the temperature say on an average of one 
degree. Take a temperature that is 104 1-2 or 105, if you are able 
to hold it at 103 or 103 1-2 you are putting your patient in safety lines.* 
I was much surprised that Dr. Hennessey did not speak of quinine 
as being one of the medicines that is most frequently used for that 
purpose. I have been in the habit of using quinine in five grain 
doses, first dose ten grains and repeating every four hours in five grain 
doses, and 1 have a positive idea that I have succeeded in that way in 
controlling the temperature, that is, reducing from one and a half to 
two degress. I have tried the experiment of dropping quinine for a 
time and I found the temperature did increase and then going back 
to quinine found the temperature decreasing. I have used antipyrine 
somewhat in typhoid, but not very extensively. The first case 1 ever 24 
ALBANY MEDICAL ANNALS. 
tried it in I had the misfortune to lose my patient, and it was an un- 
pleasant occurrence. It seems to me to have a very depressing effect 
on the heart action. I think quinine sometimes lessens the pulse rate. 
I have found the pulse rate in the continued use of quinine in five 
grain doses every three to four hours to become less frequent, and I 
have had that occurence a number of times so much so that it seemed 
to me me quinine did it. 
President Hun : In regard to Dr. Townsend's question as to the 
diet in convalescence, as I said in my paper I had not time to take that 
up and have not time to take it up now. Of course the diet must be 
increased by the gradual addition of more solid food. I do not think 
there is very much danger in pushing the solid food when the patient 
has an appetite for it and seems to be able to digest it ; although it 
must be given cautiously and in small quantities at first. By the fifth 
or sixth day after the fever had ceased, the patient can begin to take 
solid food. In regard to the danger of relapse I do not think a re- 
lapse is ever caused by errors in diet. I have seen so many cases 
where through an error of diet there has been a rise in temperature 
which lasted forty-eight hours and then fell again, and seen so many 
cases of relapse occurring where diet has been absolutely fluid that I 
am inclined to think that the relapse is due to the fact that the 
typhoid germ is in the system and has not been removed, as relapses 
so frequently follow those forms of fever where antipyretic treatment 
has been used. I think there is very little danger of relapses from 
too much food. As regards the antipyrene treatment, I would like to 
say a few words in regard to the sponge bath which Dr. Hennessey 
speaks of as likely to reduce the temperature. In the City hospital in 
Boston I used sponge baths with cold water for a long time, and I 
never found the temperature diminished after such a bath more than 
half a degree in any case. In that same hospital I was ordered to give 
cold baths to two patients. We gave them systematically, we had 
the bath close to the bed and both patients died. I have also seen very 
bad results in cases in consultation in this city where antipryin has 
been used when without other apparent cause the patients have gone 
into a condition of collapse, the heart has become feeble and the 
patients have died. I may be very strongly prejudiced, but I have a 
strong feeling against the use of antipyretics except in exceptional 
cases, and then only temporarily. As regards Dr. Curtis's remarks 
about digitalis and alcohol I cannot agree with him. I think it is 
most important to stimulate the heart and I think digitalis is a very 
.valuable drug to be given in typhoid fever where the heart is weak, 
but digitalis is a very slow acting drug. In experimenting in St. Peter's 
hospital with digitalis, we could not get any effect in much less than 
thirty-six hours. It is when the collapse has come before we can get 
digitalis to act that I think brandy or whiskey or ether (sometimes sub- 
entaneously) is of the greatest importance. After you have got the 
heart toned up for twenty-four or thirty-six hours the digitalis will 
begin to act. 
Dr. Perry : It has fallen to my lot to outline a portion of this 
evening's discussion that was not the most satisfactory from the fact 
that medicinally, the treatment of typhoid fever has fallen, apparently