Compliments of Dr. f. f. Levick. 
T Y P 11 O I 1) F E V E R. 
By JAMES J. LEV1CK, M.D. 
[/>'EEKIXTED EROM THE THI1.ADEL1T11A MEDICAL TIMES, Al'RIL 22, 1882.]' TYPHOID FEVER. 
A DISTINGUISHED English physi- 
cian, in one of his most valuable 
papers, has recently said that " the sum of 
his own experiments constitutes each man's 
experience, to which, in proof of the cor- 
rectness of his practice, he appeals as to a 
judge whose decision is final and infalli- 
ble." "And yet," he adds, " how differ- 
ent are the conclusions, all based on ex- 
perience, drawn by different observers, in 
regard to the effects, on any given disease 
or symptom, of any given remedy 1" 
Notwithstanding all the various sources 
of error, he intimates that it is the duty of 
those who have had opportunities for the 
observation and study of disease to give to 
others the results of that observation and 
study. This, then, must be my apology 
for venturing to offer these remarks on a 
subject so well known to the profession as 
typhoid fever is. The adoption of the 
word "typhoid," and its retention for an 
independent fever, curiously illustrate the 
earnestness with which the theory of the 
distinct character of this fever was resisted. 
It was indeed a compromise with those who 
still claimed that, if it were not the true 
typhus fever, it was very closely allied to 
it. The nomenclature of disease is, how- 
ever, not an exact science ; and I have 
taken much comfort in a fact I have re- 
cently discovered, that, primarily at least, 
the Greek word means not stupor, 
as has been taught from the days of Hippo- 
crates, but smoke, mist, cloud, and, dismiss- 
ing from the mind all thoughts of typhus 
fever, have been glad to find in typhoid- 
smoke-like-a word which aptly describes 
the obscured, misty, clouded mental at- 
mosphere which belongs to this disease. 
It is unnecessary here to dwell on the 
causes of typhoid fever ; but I cannot avoid 
expressing my conviction that there has 
not been that value attached to a peculiar 
susceptibility to this disease, oftentimes 
inherited, which I believe is a very potent 
factor in its development. This tendency 
or susceptibility has not entirely escaped 
the notice of writers on typhoid fever, but 
it has never had that general recognition 
which it deserves. I have myself no more 
doubt of such a susceptibility, in some 
families, than I have of a tendency in 
others to phthisis. Indeed, it often hap- 
pens that this susceptibility is found in 
families in which this tendency to phthisis 
exists. I have known a family in which 
three of its members have died of con- 
sumption and two others, escaping con- 
sumption, have been very ill with typhoid 
fever. Again, it has happened to the 
writer to attend three generations of a 
family in which the liability to typhoid 
fever is a very marked one,-viz., the 
mother, her three sons, and her grand- 
son. That this was not referable to any 
one local cause was shown by the fact that, 
with a single exception, these cases oc- 
curred in long intervals of years, in differ- 
ent houses, and in different parts of the 
city. In this family the liability to typhoid 
fever is a very marked one. Of the broth- 
ers and sisters of the mother here referred 
to, and their descendants, I have a record 
of twenty-three who have had typhoid fe- 
ver, and this has occurred to them in dif- 
ferent cities, in different States, in town 
and in country, and under the most favora- 
ble social and hygienic conditions. 
My attention has been especially drawn 
to these cases from the fact that the parents 
were personal friends of my parents, and 
that they and their descendants had the 
same social and hygienic surroundings as 
my own parents and their descendants 
had; and yet in the one family there have 
been twenty-three instances of typhoid fe- 
ver, and in the other but one. 
It is impossible for me to believe that 
of the one family twenty-three have been 
especially exposed to the specific poison of 
typhoid fever, while in the other there has 
been but one such exposure. I am irresist- 
ibly led to one of two conclusions,-either 
that all are exposed to this poison, which 
some are always able to resist, or that there 
exists in some individuals and in certain 
families an especial susceptibility-I had 
almost said, a predisposition-to this dis- 
ease. Be the state of things what it may, this 
liability to typhoid fever should always be 
inquired into as an aid in the early diag- 
nosis of typhoid fever. 
It is not the purpose of this paper to 
consider in detail the various phenomena 
of typhoid fever ; this has been done by 2 
TYPHOID FEVER. 
the writer elsewhere; * but so deeply im- 
pressed is he with the importance of the 
early recognition of the red spot-the 
characteristic eruption-that he desires 
strongly to urge the necessity of a very 
thorough search for it. The physician 
should not be content with merely looking 
at the abdomen, where the books tell us it 
is to be seen, but should examine the back, 
the arms, the legs, and the chest. The 
truth is, there is scarcely a part of the 
body where it may not occasionally be 
found. In my own observations I think I 
have most frequently first seen it on the 
right hypochondrium, over the articulation 
of the cartilage of the eighth rib. 
It is indeed of vital importance that the 
physician should make himself familiar 
with the nature and appearance of this pa- 
thognomonic eruption, should understand 
that it is entirely unlike the rubeoloid 
eruption of typhus and the petechiae which 
are so often mixed up with this, that it is 
not an extravasation, but a local hyper- 
semia, that it therefore disappears on press- 
ure, promptly to return when that press- 
ure is removed. All these facts must be 
carefully considered, and, thus thoroughly 
acquainted with it, a single spot determines 
at once the diagnosis, and may save the 
patient from a course of medication un- 
suited to him, or in very mild cases may 
prevent the sick man from incurring such 
exposure as might suddenly prove fatal to 
him. 
During the war of the Rebellion a mem- 
ber of the medical staff of the Satterlee 
Hospital, very zealous and faithful in the 
discharge of his duties, had for a week 
suffered from debility and general malaise, 
with the merest trace of fever. Prompt to 
detect disease in others, he was less care- 
ful with himself, and, supposing that he 
merely needed rest and change of air and 
scene, had his trunk packed and his ar- 
rangements made for a visit to New York. 
A medical friend calling to see him the 
night before his proposed journey, not sat- 
isfied with the history of his symptoms, 
made a careful examination, and found a 
single but an unmistakable "red spot." 
The journey was stopped, the patient put 
to bed; a mild but positive attack of fever 
ensued, from which recovery happily fol- 
lowed. The recognition of this single spot, 
it is quite probable, saved to the profession 
a life which has since been of much value 
to it. 
It is generally stated in the books that 
there is no relation subsisting between the 
abundance of the eruption and the gravity 
of the disease. This may be true, but I 
always regard the occurrence of a copi- 
ous eruption as a favorable symptom. I 
am not prepared to announce it as a law, 
but, so far as my observation goes, I have 
never known serious disease of the bowels 
to exist in this fever when there was a 
copious skin eruption. The converse of 
this proposition does not hold, as a single 
spot may also be associated with a very 
slight disturbance of the bowels. 
A marked example of a very copious 
eruption has, within a few weeks, come 
under my notice. It occurred to a physi- 
cian of a neighboring county, who, while 
having under his care a large number of 
typhoid-fever patients, became himself the 
subject of the disease. I saw him, in con- 
sultation with three of his medical friends, 
in what seemed to be the close of the sec- 
ond week of the fever. The eruption was 
an abundant one, and for the most part 
eminently characteristic ; but with the or- 
dinary isolated lenticular spots were several 
unusual eruptions. These last were circu- 
lar patches about half an inch in diam- 
eter, and of a pale-pink color. A close 
examination of them showed that these 
circles were formed by the aggregation of 
individual lenticular spots, and that in this 
aggregated form they lay side by side, 
radiating as it were from a common cen- 
tre,-that, in other words, they were not 
distinct but confluent. I had never seen 
such a grouping, and should have been 
puzzled as to its significance had there not 
been so many spots of the usual character 
elsewhere. 
A careful watch for, and study of, the 
red spot, may prevent an error of diagnosis 
which has more than once occurred. Ref- 
erence is now made to the occurrence in 
the summer-time, during, perhaps, an epi- 
demic of diarrhoea or dysentery, of a mild 
case of typhoid fever, whose only obvious 
symptom is looseness of the bowels. Such 
a case might readily be regarded as one of 
the prevailing epidemic. The habit of 
examining the abdomen for the spot of 
typhoid fever in every case of diarrhoea 
would prevent such an error of diagnosis. 
It is well to bear in mind also that diar- 
rhoea is not always present in the early 
* Medical and Surgical Reporter, June, 1862. American 
Journal of the Medical Sciences, April, 1864. TYPHOID FEVER. 
3 
stage of typhoid fever; while, on the 
other hand, the fact that the bowels in a 
case of fever are not constipated, should 
always excite suspicion as to its nature. 
Recent apparatus and observations have 
given much greater accuracy than formerly 
to the study of the temperature in this dis- 
ease, and the thermometer is now as much 
employed in this as the stethoscope is in 
the study of cardiac disease. No one who 
has learned its value will be likely to lay 
it aside ; and yet there are occasions in 
which the thermometer is not available. 
Sometimes it is forgotten and left at home, 
sometimes the index becomes immovably 
fixed in the tube, sometimes the thermom- 
eter is accidentally broken ; there are some 
patients who are alarmed, and others who 
are nauseated, by its use. In the high 
delirium and fierce jactitation which are 
sometimes present, the use of the instru- 
ment is almost impossible. Hence it is a 
matter of importance that the graduate in 
medicine should early learn to notice the 
relative temperature of the body, should 
be able to recognize, when he takes his 
patient's hand in his own, by the feel of 
the skin, by the heat, dryness, or moisture 
of the surface, what the febrile state then 
is. The tactus eruditus is, indeed, as neces- 
sary for the practitioner of medicine as it 
is for the obstetrician or the gynaecologist. 
I pass by the ordinary symptoms of this 
disease, all of which are so well described 
in the books, pausing merely to say that 
early, persistent headache, even though it 
be but moderate, with an elevation of 
temperature and a tongue lightly coated, 
should always be regarded with suspicion, 
especially so if with these the patient re- 
ports that his bowels are loose, or that they 
are "regular." 
Perhaps I may here say that, next to 
remittent fever, the two diseases which 
have given me most trouble in the early 
differential diagnosis of typhoid fever have 
been tuberculous meningitis in children, 
and influenza, or, as it should be called, 
epidemic catarrhal fever, in adults. Of 
course this difficulty can occur only in the 
very early stage of the disease, before there 
has been time for the eruption to appear. 
When called to a case of typhoid fever, 
my own practice is always to explain to 
those having the care of the sick that the 
great dangers in this disease are from hem- 
orrhage and from perforation of the bowel. 
I generally take a cambric handkerchief 
and show to the nurse what such a perfo- 
ration is, and how, from improper food, 
it may occur. Such an illustration doubt- 
less adds to the anxiety of the nurse, but it 
also adds to the safety of the patient; and 
it is better to be temporarily anxious than 
to be permanently bereaved. 
Without doubt, the safest and best diet 
for the typhoid-fever patient is milk ; but 
milk is not altogether without its dangers. 
Much attention has of late been called, 
in the English journals, to the importance 
of giving milk in small quantities at a 
time, and it is referred to as though it 
were a new observation or discovery of 
these writers. Those who sat under the 
teachings of the late Professor Wood well 
know that the caution against large draughts 
of milk was always given in his lecture on 
typhoid fever. In his work on the Prac- 
tice of Medicine, printed in 1847, he says 
that milk should be given only "in small 
quantities, and frequently repeated." The 
discomforts from milk are not imaginary ; 
I have more than once seen a hard, tough 
coagulum vomited after a copious draught 
of milk, and have known much'pain follow 
accumulations in the bowels after its pro- 
longed use ; but I still think that, rightly 
administered, it is altogether the safest and 
best diet for the fever-patient. Sometimes 
it is well to boil it, and in many instances 
the addition of lime-water is useful. 
For beef-essence I have a kindly regard, 
for the good I once thought it did, as one 
has for a friend of his early life, even though 
that friend may have failed him in later 
years. But I am thoroughly convinced 
that a sick man cannot live on beef-essence 
alone. It may be, and, when given hot 
and strong, it doubtless is, a grateful stim- 
ulant, and, as an adjuvant, comes in nicely; 
but, if the patient is not to be starved, it 
must be supplemented by milk. When it 
is used, I prefer that it should be made at 
home. Of the prepared articles substi- 
tuted for this I decidedly prefer John- 
ston's Fluid Beef. 
I cannot too strongly commend~to those 
of the profession who may not have seen 
it an admirable little essay, by Dr. John 
F. Meigs, " On the Internal Use of Water 
for the Sick, and on Thirst." Its author 
justly says that it is absolutely necessary 
that the fever-patient should take freely of 
water, to reduce the temperature and to 
compensate for the unusual combustion of 
tissue which is going on ; that his attendant 4 
TYPHOID FEVER. 
should not wait for him to ask for the water, 
but should frequently and systematically 
give it to him. I believe that if this were 
done we should see fewer cases than we 
now do of a dry tongue and a hot, burning 
skin. In this connection I may here say 
that I think we have rather lost, than 
otherwise, by giving up the use of wine- 
whey, which, it seems to me, is much less 
used now than it formerly was. I do not 
attach much value to the nutritive qualities 
of the whey, nor is there much stimulation 
in the small quantity of alcohol,-though 
there is some,-but its regular, prolonged 
use supplied a liquid which easily and 
promptly passed, by a dialytic action, into 
the blood, and thus helped to compensate 
for the loss of fluid from the blood and the 
tissues. 
It must, of course, be left to the judg- 
ment of the physician to decide when, and 
in what form, alcohol becomes necessary. 
I confess to a preference for brandy for 
punch, rather than whiskey. 
And here it may be well to call attention 
to the importance, in treating this disease, 
of strict attention to the particulars of that 
treatment. The care-taker of the sick 
should be told that when milk-punch is 
ordered it should be made in certain pro- 
portions. These, it is true, vary with dif- 
ferent physicians. For my own patients 
I generally direct that one large table- 
spoonful of brandy should be added to 
four tablespoonfuls of milk which have 
previously been poured out and sweetened. 
To this a tablespoonful of lime-water may 
sometimes be advantageously added. 
Champagne, so useful in many diseases, is 
often inadmissible in this, from its ten- 
dency to act on the bowels, causing or 
keeping up diarrhoea. 
It is sometimes necessary, especially in 
the country, to tell the nurse that wine- 
whey should be made from sherry or ma- 
deira, and not from claret or port, or from 
currant or other home-made wine ; that ice 
should be pounded in a towel, and placed 
in a funnel lined with flannel, which is set 
in a pitcher deeper than the funnel, and the 
ice given to the patient from a spoon, and 
not in his fingers; that a poultice, to be of 
use, on the abdomen or elsewhere, should 
be a light one, covered with silk oil-cloth 
or gum-cloth, and not removed for many 
hours; and that in case of sudden and 
alarming fall of temperature, or of sudden 
failure of heart-power, much help may be 
had from short stockings filled with hot 
salt, one of which should be placed in 
each hand of the patient. 
These are little matters, which it will be 
said should be known by every one; but, 
unfortunately, in practice we find that 
such is not the case. 
When called to see a patient with a fever 
which is at all a suspicious one, I direct 
for him, if it can be had, a warm bath (not 
a hot one) ; and I do so because of its 
soothing effect and because I wish the skin 
to be in a condition readily to perform the 
unusual duties which must soon devolve 
upon it. The bath should be given, if the 
weather be cold, in a warmed bath-room, 
and the patient not be permitted to make 
any exertion, and every precaution be used 
against taking cold. 
It rarely happens that cathartic medi- 
cines are needed, but, should they be, by 
far the safest of them will be found in syrup 
of rhubarb or castor oil, a dessert-spoonful 
of which will be sufficiently active. All 
hydragogue cathartics, such as podophyllin 
or the compound cathartic pill, must, of 
course, be studiously avoided. A tea- 
spoonful of sweet spirit of nitre in a large 
wineglassful of water will often, in this 
early stage, give the patient a quiet night, 
and the next morning will find him with 
little or no fever. 
He should now have, in divided doses, 
fifteen grains of sulphate of quinine. Each 
physician has his favorite way of exhibiting 
this medicine, and I am no exception to 
the rule. I order twelve pills of three 
grains each to be made of quinine in which 
I have confidence, Rosengarten's or Powers 
& Weightman's, and the excipient I prefer 
is glycerin. A three-grain pill thus prop- 
erly made is not a large one, and, served 
from a box in which powdered arrow-root 
is used, instead of the disgusting liquorice 
powder, is altogether acceptable to the 
patient. Old quinine pills or sugar-coated 
ones I carefully avoid. One pill at ten 
o'clock, two at eleven, and two at twelve 
are sufficient for the first day; indeed, in 
many cases the fifth pill may be omitted. 
Repeating the dose of nitre at bedtime, 
the following morning four pills (twelve 
grains) in divided doses may be given, and 
the next day three, which last number 
should be continued during the ensuing 
fortnight unless some contra-indication 
show itself. 
As the disease advances in its regular TYPHOID FEVER. 
5 
course, certain special phenomena show 
themselves, prominent among which is 
sleeplessness, with or without delirium. If 
the patient be a vigorous adult, I not un- 
frequently direct that at bedtime a little 
pill should be given him containing one- 
sixth of a grain of acetate of morphia and 
one-half a grain of the alcoholic extract 
of hyoscyamus. This is generally suffi- 
cient to give a good night's rest, or, if it 
be repeated during the night, it should not 
be done in a shorter interval than that of 
four hours. It is true that it has rather a 
tendency to give a dryish tongue next morn- 
ing, though the combination with hyoscya- 
mus lessens the probability of this. When 
chloral was first introduced, I thought we 
had found just the right hypnotic for ty- 
phoid fever,-a good night's rest and a 
moist tongue,-and I used it freely; but 
one or two idiosyncrasies coming under my 
notice, in one of which ten grains were 
followed by stertorous respiration and flap- 
ping cheek, and in the other by injected 
eyes and an aggravation of headache, made 
me more cautious in its use and led me to 
prefer the combination I have mentioned. 
Bromide of potassium in moderate doses is 
at best but an uncertain remedy, while in 
large doses, sufficient to produce sleep, it 
is very apt, in typhoid fever, to irritate the 
bowels and increase the diarrhoea. 
Not unfrequently, in the course of the 
disease, there comes on a condition in 
which the remedy proposed by the late Dr. 
Wood-the oil of turpentine-comes in so 
usefully. I am well aware that there are 
physicians who look upon this medicine as 
of doubtful efficacy, while there are others 
who, like myself, regard it as of much 
value in the treatment of typhoid fever. 
It was not in every case of this fever that 
Dr. Wood gave turpentine : it is not in 
every case that it is needed. In his " Prac- 
tice" he says, " It may be employed in all 
cases in the advanced stages of this dis- 
ease, when the tongue is dry; . . . but 
there is a particular condition ... in 
which I have seldom known it to fail; this 
is when the tongue, having begun to clean 
off, suddenly becomes quite dry again, and 
the process of cleaning is suspended, when 
there is an increase of tympanites, and an 
aggravation, or certainly no abatement, of 
the other symptoms." Doubtless, in such 
a condition it is pre-eminently useful; but 
I think it is best to anticipate this, and 
thus prevent the full development of the 
lesions of which this dry tongue is the ex- 
pression. In a case now under the writer's 
care, although the tongue remained moist, 
yet the lips had become dry and tense; 
and the turpentine was given with the hope 
of averting the dryness of the tongue, and 
with the most satisfactory results. And 
here occurred an illustration of the impor- 
tance, in treating this fever, of attention 
to particulars. The emulsion was put up in 
a rural district, and the little patient com- 
plained greatly of the harsh, disagreeable 
taste. On examining it, I found it to be 
of strong resinous odor and a sharp, irri- 
tating taste. Dismissing this, and substi- 
tuting for it the same prescription put up 
by one of the best pharmacists in the city, 
the whole character of the medicine was 
changed, and there was no further com- 
plaint of it by the patient. 
The physician, therefore, especially in 
the country, should see to it that the tur- 
pentine used by him has not been exposed 
to the air, has not become resinous, and is 
exhibited in such a form as will not be dis- 
agreeable to the patient. It should always 
be given in emulsion, and not merely 
dropped on a lump of sugar, as is some- 
times done. I have never agreed with Dr. 
Wood that the turpentine in this disease 
acted directly on the intestinal ulcers; I 
believe its action to be a systemic, not a 
merely local one ; but I do not yield to 
him in my estimate of its great value in 
the treatment of typhoid fever. Dr. Wood 
used to say of its dose, that, for an adult, 
less than ten drops every two hours did 
not profit much; that more than this, given 
night and day, was unnecessary. 
So many medical men in whose judg- 
ment I have confidence attach great im- 
portance to the use of the mineral acids, 
and especially the hydrochloric, in the 
treatment of this fever that I cannot doubt 
their value. I have, however, had but little 
personal experience in the use of them; 
and that little has not been of a very en- 
couraging character. 
A grave complication which comes on 
in the course of typhoid fever is the very 
feeble condition of the muscle of the heart, 
-a condition which, so far as drugs are 
concerned, is best remedied by the exhi- 
bition of brandy and ammonia. I should 
be very loath indeed to rely upon or to re- 
sort to digitalis as a heart-strengthener in 
the advanced stages of this or any other 
exhausting fever, but should prefer to use 6 
TYPHOID FEVER. 
what I have named and tonic doses of qui- 
nine. Above all things else, it is here of 
importance that the patient keep the re- 
cumbent position, and avoid even a slight 
strain on the enfeebled cardiac muscles. 
Hence he should not rise from his bed even 
to a commode, but should use the bed-pan. 
I am well aware that this last charge is at- 
tended with many practical difficulties, and 
I have never yet seen a china bed-pan of 
which the patient did not complain. In- 
deed, I have sometimes feared that much 
harm was done by the unnatural position 
and straining required to use it. I there- 
fore much prefer the hard-rubber article. 
Where this is not at hand, an excellent 
substitute may be found in the ordinary 
household dust-pan. This should be cov- 
ered with an old towel, and may readily 
be slipped under the patient, the urinal 
having first been used. 
Were this a treatise on typhoid fever, it 
would be proper to consider in detail the 
many suggestions which have lately been 
made with reference to its treatment. To 
one or two of these I shall briefly refer. 
The use of those measures which will 
directly reduce the temperature in high 
fever has of late, and very properly, claimed 
much attention. Strictly speaking, it is 
the correction of the disturbed nervous ac- 
tion which permits, determines, or devel- 
ops this elevation of temperature that is 
needed. The expression of that disturb- 
ance, as seen in the unnatural heat of the 
patient, is one of the obvious symptoms 
which may well claim attention. Hence 
the external application of cold is often a 
very valuable part of treatment, directly, 
by reducing the temperature, and, indi- 
rectly, by preventing the lighting up of 
local inflammations which this great heat 
may develop. It is true that these effects are 
not always permanent, and that the treat- 
ment itself is not always without danger. 
In that terrible form of heat-elevation 
formerly described as calor mordax, a tem- 
perature of 104° F. and upwards, which 
is often found in typhus, and sometimes, 
though more rarely, in typhoid fever, very 
decided antipyretic measures are demanded. 
More than twenty years ago I called at- 
tention to the analogy which existed in the 
condition of the typhus-fever patient when 
in this calor mordax state, and that which 
rapidly shows itself in cases of sunstroke.* 
As I have long held that in this form of 
sunstroke there is no treatment so efficient 
as the rubbing of the patient with large 
pieces of ice, or, if this cannot be done, by 
using copious affusions of cold water, so I 
believe that this high, biting skin temper- 
ature of typhus may be most efficiently 
treated by similar ice-friction. In typhus 
there is comparatively little danger of or- 
ganic inflammations ; even the pneumonia 
which sometimes attends it is more hypo- 
static than acutely congestive. The dura- 
tion of typhus is comparatively a short one, 
and so imminent is the danger to life that 
whatever is done must be done quickly. In 
typhoid fever, if the patient be treated from 
the start, the temperature rarely reaches 
this calor mordax state. Should it do so, 
the wet sheet or the cold-water sponging 
might well be used; and I can imagine very 
high temperatures in which the ice-friction 
might be permissible; but, as a rule, this 
last is uncalled for, and would be some- 
times dangerous. There is in typhoid fe- 
ver a strong tendency to the development 
of local inflammations, as of the bronchi, 
the lungs, the abdominal viscera, and the 
great veins of the lower extremities. Ty- 
phoid fever does not rapidly tend to death, 
as typhus does, and neither demands nor 
justifies the extreme measures which are 
called for in typhus. 
This little paper is written not for the 
sick in hospitals or for their care-takers, 
who have about them all the appliances 
which science can suggest and the experi- 
ence which a great hospital alone can give. 
Nor is it intended chiefly for the rich in 
great cities, who in sickness, as in health, 
have conveniences and luxuries which 
wealth can always command. Rather is 
it written with the hope that in its'details, 
which are given with much simplicity, a 
suggestion may here and there be found 
which will be of practical value to those 
medical men whose lot it is to practise 
their profession in remote country places, 
where they have no one to look to for 
counsel or for aid, and where they are 
compelled to care for the sick under many 
privations, and sometimes amid the most 
unfavorable circumstances. 
It is indeed one thing to prescribe for 
disease, among one's books in the luxury 
of the study, and quite another thing to 
treat the sick man in his own home, face 
to face with him and his surroundings. 
Hence it is little short of mockery to tell 
* American Journal of the Medical Sciences, January, 1859. TYPHOID FEVER. 
7 
the practitioner in the country, where, rela- 
tively, typhoid fever is most prevalent, that 
it is best treated by daily or oftener placing 
the patient in the bathing-tub, when in 
not half of his patients' houses is a bath- 
room to be found. Indeed, under the most 
favorable conditions, I very much doubt 
if more harm than good is not done to the 
sick man by the perturbation it occasions 
him to have his clothing pulled over his 
head and shoulders, himself lifted bodily 
by two often awkward and careless men 
into and out of the bathing-tub, rubbed, 
and his shirts then pulled on again, all of 
which, inelegant as it seems even to write 
it, has to be done, and, if Liebermeister's 
advice be followed, six or eight times daily. 
As has already been said, a good, thorough 
ablution in the early stage and frequent 
careful spongings are both useful and neces- 
sary ; and there are cases of very high 
temperature in which the wet sheet may 
be used with advantage; but more than this 
is rarely practicable or desirable. There 
is probably more to be hoped for in the 
so-called antipyretic doses of quinine than 
in an active hydropathy, though this, too, 
may be carried to an undue extent. 
For the diarrhoea which is often a trouble- 
some and exhausting complication, reme- 
dies administered by the rectum rather than 
by the mouth will always be found most 
efficient. Of these a suppository of one 
grain or of two grains of opium, or an ene- 
ma of thirty or forty drops of laudanum 
in a tablespoonful of warm water, will gen- 
erally be sufficient. Warm water is better 
than starch-water, and half an ounce will 
be retained when the quantity mentioned 
in the books-two ounces-would be re- 
jected. Should additional medication be 
needed, we have in paregoric (tinct. opii 
camphorata, U. S. P.) a good, honest, old- 
fashioned medicine which has stood the 
test of time and comforted many a one,- 
I had almost said, from his cradle to his 
grave. This is really one of the very best 
preparations for internal exhibition in the 
diarrhoea of typhoid fever. Especially 
adapted to children, it is also admirably 
suited to adults, is safe, grateful to the 
stomach, mildly astringent, and, indeed, 
fulfils many indications, one of the most 
valuable of which is found in its soporific 
effect.* 
I have said that paregoric is a safe rem- 
edy, and this is a great recommendation, 
for, valuable as opium is, it is sometimes a 
very dangerous medicine in this or any 
other disease of great debility. I have 
often thought that much harm has been 
done by the popular-professional teaching 
that ''opium is a stimulant." 
In one sense of the word perhaps it is 
so. In small doses, given in health or in 
slight deviations from it, it may quicken 
mental action, brighten the intellect, and 
the heart's movements for a time may even 
seem stronger; but the temporary stimu- 
lation thus developed is a very different 
thing from that which is produced by alco- 
hol, by ammonia, or by tonic medicines. 
In most cases it is rapidly followed by a 
grave exhaustion. Especially is this true 
of morphia, which, calming the brain and 
benumbing the great centres of respiration 
and circulation, may easily lull a feeble 
patient into a sleep which, this side the 
grave, knows no waking. 
There are derangements of health, oc- 
curring to persons ordinarily strong and 
vigorous, which not only bear but re- 
quire active treatment, and in which the 
healthy condition can be restored only by 
the exhibition of decided doses of medi- 
cine. These come to be regarded, and 
perhaps justly, as the typical doses of the 
medicines used, and, as such, are taught to 
the student in the lecture-room, and ac- 
cepted by him. There are, on the other 
hand, times in the course of disease when 
the forces of death and of life are so evenly 
April, x88o. He was near the end of the second week of his 
illness, and had, up to that time, been under the care of a 
homoeopathist, who, I was assured, had confined his diet to 
gum-water, with the occasional eating of white grapes. The 
symptoms had become so alarming that the homoeopathist 
was dismissed, and, with great reluctance, 1 consented to 
take charge of the case. It would indeed be difficult to un- 
dertake a more unsatisfactory charge. The lad was greatly 
emaciated, his pulse a mere thread, his blood so impover- 
ished that his knees, where they touched each other, and the 
elbows, from pressure on the bed, had become ecchymosed. 
For five nights there had been persistent insomnia. There 
was no unmistakable tache rouge, but there were diarrhoea 
and decided delirium. I never felt more deeply the responsi- 
bility which rested on me, not only towards the lad and his 
family, but also towards the profession, which this change of 
treatment in the middle of his illness imposed. 
I first saw him at 8 p.M. What real treatment, if any, he 
had heretofore had could not be learned ; but it was impera- 
tive that something should be done for the night; and so, 
after giving the little fellow some brandy-and-milk, I could 
see my way clear to give him nothing more than thirty drops 
of paregoric with twenty of sweet spirit of nitre, to be repeated 
in two hours' time if he did not sleep. It was an immense 
relief to learn next morning that the second dose had been 
followed by a quiet and refreshing slumber, and that the little 
patient's condition had greatly improved. The case proved 
to be yet a very serious one, and required some weeks of close 
watching before entire recovery took place, in which I had 
the judicious counsel of Dr. J. F. Meigs ; but to this day' the 
family of my little patient have a grateful regard for paregoric 
and nitre. 
* There may perhaps, without impropriety, be here men- 
tioned a case in which the good effects of paregoric were very 
marked. A little boy 6 years old came under my care in 8 
TYPHOID FEVER. 
balanced that, as it were, the weight of a 
feather may fatally depress the beam. At 
such a time, he who watches the balance 
must see to it that by no act on his part 
shall that fatal feather's-weight be placed 
there. 
In the course of an exhausting fever, in 
the case of an emphysematous or greatly 
diseased lung, in a dilated and feeble heart, 
such a fatal weight may be found in one- 
half, or even in one-fourth, a grain of mor- 
phia, in twenty grains of chloral, in a two- 
grain extract-of-opium suppository, and 
in half a grain or less of morphia given 
hypodermically. The physician who pre- 
scribes from a thoughtful recognition of 
his patient's condition, and not merely 
from the books, will adapt his dose to that 
patient's condition, and will not, by par- 
alyzing the medulla, further cripple a heart 
and lungs whose nerve-supply is already 
nearly lost. I trust I shall not be deemed 
querulous when I add that I have some- 
times been amazed at the doses of opium, 
morphia, chloral, and salicylic acid which 
I have known prescribed not only for the 
young and vigorous but also for the old 
and feeble patient. It is so much better 
to give a small and safe dose, which may 
be repeated if necessary, than to give what, 
though regarded as the ordinary dose, may 
be a fatal one to a patient greatly enfeebled 
by age or disease. 
Perhaps such caution will be deemed 
excessive and be regarded as a timidity of 
practice which is characteristic of age. I 
well know that increasing years bring with 
them an increased consciousness of the 
value to a family of the life of each mem- 
ber of it, and a deepened sense of our re- 
sponsibility to those who intrust their lives 
to our keeping; but I cannot regard any 
watching as too great, or any caution as 
excessive, which may save children from 
the dreary uncertainties of orphanage or 
parents from that loneliness of hearth and 
of heart which belongs to a childless old 
age. 
Hemorrhage from the bowel is regarded, 
next to perforation, as the great danger 
of typhoid fever; and when it does occur 
it is certainly a grave symptom. I cannot 
but think that, in this country at least, it 
is not of such frequent occurrence as has 
been supposed. It has happened to the 
writer, in public and in private practice, 
to see a good deal of typhoid fever, but, ex- 
cepting in the Chickahominy cases, he has 
never had a hemorrhage occurring in the 
course of this disease. He does not claim 
this exemption as anything else than his 
good fortune, though he has a hope that 
the early exhibition of turpentine has had 
its value in preventing this accident. 
He cannot, therefore, speak from experi- 
ence, but, a priori, he would expect benefit 
from the exhibition of Monsel's solution 
of iron, fifteen drops in a large wineglassful 
of sweetened water, every hour or two, or, 
if this be not tolerated, a pill of acetate of 
lead gr. ii, opium gr. every two hours. 
This may be supplemented in some cases 
by turpentine stupes to the abdomen ; in 
other cases by ice to the abdomen and by 
astringents in the rectum. 
When convalescence has been estab- 
lished, there comes a time when'there is 
no longer a loathing of food, even though 
the appetite may not be fully developed. 
One is sometimes almost at his wits' end 
to suggest a dietary suited to the capricious 
appetite of his patient. Not knowing where 
to find such a dietary, I venture to put on 
record here what I have found to be safe 
and palatable. 
The diet having consisted chiefly of 
milk, a wineglassful of cream be 
substituted, and, as an approach to solid 
food, there may be dipped into this and 
eaten the little flat sponge-cake known as 
the "lady-finger," but which, from its 
shape, might be better called "lady's san- 
dal," and which must not be confounded 
with the unwholesome cake known as the 
croquant. Next in the ascending scale we 
may allow vanilla ice-cream, taking care 
that it be fresh and sweet. For those who 
like it, chocolate cream may, after a time, 
take the place of vanilla, and a cup of 
cocoa may be taken at breakfast. A little 
later the yolk of a soft-boiled egg may be 
eaten, or that of one boiled for a long time 
and broken up with the bowl of a spoon 
into powder. A potato, roasted with the 
skin on, may perhaps be nowallowed, with 
a little butter and salt. Nutritious soups 
may also be given, but, even at this stage, 
it is best to strain them. A thin piece of 
roast beef, or the tenderloin of steak, may 
next be chewed, but not swallowed. A 
little later the white meat of poultry finely 
cut up may be eaten; but small birds, 
especially reed-birds or rice-birds, should 
be avoided, on account of the danger from 
the little bones, fragments of which have 
sometimes been fatally swallowed. Oysters TYPHOID FEVER. 
9 
by it. But I confidently assert that, so far 
from his safety being endangered by it, in 
the large majority of cases the patient's 
chance of recovery will be increased by 
the removal and its consequences. 
It is a very different thing to travel in 
an English railway carriage and to make a 
journey on one of our railroads, with its 
drawing-room and sleeping-cars, where one 
may be almost as comfortable as in his own 
bed. We need but recall how our soldiers 
with this fever so well bore even the rude 
transportation of the war to know that such 
journeys may be safely made. One of my 
own patients, a few years since, though at 
the beginning of the third week of this 
fever, came safely through in a sleeping- 
car from Cincinnati to Philadelphia,-a 
journey of more than seven hundred miles, 
-and certainly without any aggravation of 
the disease, from which she happily recov- 
ered. I would therefore strongly urge that, 
if he be at all near the line of a railway, 
or if there be no very rough road to travel 
over, the typhoid-fever patient should be 
brought to his home at the very earliest 
suspicion of the disease. But his ticket of 
travel should be a through one: there 
should be no stopping by the way. 
I read in the text-books and in the 
journals of various special remedies for 
typhoid fever, among which are carbolic 
acid, tincture of iodine, nitrate of silver, 
and salicylic acid. Some of these are rec- 
ommended by men whose experience is a 
large one, and in whose judgment I have 
entire confidence. Edo not doubt the 
correctness of their statements, although 
I have no personal experience with these 
medicines. But for myself, I am bound 
to say that whatever of success I may have 
had in the treatment of typhoid fever has 
been in direct proportion to the simplicity 
of that treatment. Attention to minute- 
ness of detail, both in what I do myself 
and in what I order to be done by others, 
frequent visits to the sick, constant vigi- 
lance with respect to diet, the avoidance 
of all harsh and dangerous drugs, and the 
use of such simple medication as has here 
been indicated, have, in their results, been 
sufficient to satisfy me in the past and to 
make me hopeful for the future. 
roasted in the shell are very appetizing, and, 
when convalescence is fully established, 
may be safely taken. Various dishes usu- 
ally taken at dessert-floats, cup-custards, 
jellies, Spanish cream, and the like-may 
safely vary the menu. 
Later in the convalescence there comes 
a fierce appetite, which needs curbing rather 
than urging. 
In the London Lancet (November 15, 
1879) there isan admirable paper by Sir Wil- 
liam Jenner on the treatment of typhoid 
fever. It is marked by such modesty and 
by such real merit that it is with extreme 
reluctance I venture in any way to object 
to it. But I cannot, in justice to my-own 
convictions, refrain from expressing my 
dissent from that portion of it which for- 
bids the removal to his home of the typhoid- 
fever patient who has been taken ill while 
away from that home. I am the more 
compelled to refer to this because the ad- 
vice has been adopted and repeated by 
the author of the best American treatise on 
typhoid fever which has for many years 
appeared among us. 
Whoever has known, in himself or in 
one of his family, what it is to be ill away 
from home, at the sea-side or at a distant 
mountain-resort, knows what, even under 
the most favorable circumstances, such an 
absence implies. There is to the sick man 
himself the dreary, depressing conscious- 
ness of being away from his home, which 
he may never again see, the absence of his 
home comforts, the difficulty of obtaining 
the needed medicines, the greater difficulty 
in promptly getting his own physician, ex- 
cept at great cost or at great personal sac- 
rifice on the physician's part; while with 
the family there is the very serious incon 
venience of being with the sick man, or 
the distress of separation, heightened by 
the daily and often unsatisfactory telegram. 
And when, after weeks of such anxiety and 
discomfort, there comes the dreaded mes- 
sage that the end is at hand, there is the 
hurried journey to be made to the dying, 
and the sadder homeward journey with the 
dead. Surely, one who has known all or 
aught of this will admit that it is far better 
to bring the sick man to his home, even 
though his safety might be somewhat risked 
Philadelphia, 1200 Arch Street, March 20, 1882.