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 THE 
 
 TREATMENT 
 
 OF 
 
 TYPHOID FEYER, 
 
 AND REPORTS OF FIFTY-FIVE CONSECUTIVE CASES, 
 WITH ONLY ONE DEATH. 
 
 BY 
 
 JAMES BARR, M.D., 
 
 PHYSICIAN TO THE NORTHERN HOSPITAL, LIVERPOOL ; 
 MEDICAL OFFICER OF HER MAJESTY'S PRISON, KIRKDALE, ETC. 
 
 INTRODUCTION 
 
 BY 
 
 W. T. GAIRDNER, M.D., LL.D., 
 
 PROFESSOR OF MEDICINE IN THE UNIVERSITY OF GLASGOW ; LECTURER ON 
 
 CLINICAL MEDICINE, AND PHYSICIAN TO THE WESTERN INFIRMARY, 
 
 GLASGOW ; PHYSICIAN TO THE QUEEN IN SCOTLAND. 
 
 LONDON : 
 H. K. LEWIS, 136, GOVVER STREET, W.C 
 
 1892. 
 
m 
 
 LIVERPOOL : 
 PKINTKD BY S. HILL AND CO., COLLEGE LANK, 
 
TO 
 
 WILLIAM TENNANT GAIRDNER, M.D., LL.D., 
 
 IN SINCERE ADMIRATION OF HIS QUALITIES AS A PHYSICIAN, A CLINICAL 
 
 TEACHER, AND A PIONEER IN ADVANCING THE TREATMENT 
 
 OF FEVERS, THIS WORK IS 
 
 WITH EVERY SENTIMENT OF AFFECTION AND ESTEEM BY HIS PUPIL 
 AND DEVOTED FRIEND 
 
 THE AUTHOR 
 
INTRODUCTIO^' 
 
 BY 
 
 W. T. GAIRDNER, M.D, LL.D. 
 
 I TRUST it will not be supposed that in acceding to the 
 earnest request of Dr. Barr that I should write a few remarks 
 as an introduction for his book, I am at all under the impression 
 that I can do so with authority, cr, indeed, with any other 
 object in view than to give a perfectly sincere expression torn}'' 
 regard for an old pupil, who has, in the course of years, and 
 even according to the internal evidence in this work, arrived at 
 a position so independent and so entirely his own, as no longer 
 to require a recommendation. There was, indeed, one occasion 
 since his studentship, on which it was possible for an old 
 teacher to say an effectual word on behalf of Dr. Barr. A 
 member of the House of Commons, forgetful of the restraints 
 which, in an assembly of gentlemen, are usually considered 
 essential in commenting on personal character, had allowed 
 himself the privilege of making a violent and unfair attack on 
 Dr. Barr in respect of a public duty thoroughly well performed, 
 but which happened to be disagreeable to some of the honour- 
 able member's friends. The words might have been actionable, 
 had they been spoken elsewhere than in the House. No one 
 who knew Dr. Barr believed them to be true. But being thus 
 spoken, the effect on the minds of his medical brethren in 
 Liverpool was such, that a document, signed by 187 of them, 
 was at once forwarded to the Secretary of State, as a perfectly 
 spontaneous expression of the indignation felt by the 
 signatories as regards this unprovoked and most reprehensible 
 attack, and of their high appreciation of the character which 
 had been thus injuriously assailed. One who is held in so 
 much esteem where he is best known, is in no need of further 
 testimonials : but I had the opportunity then, as I have now, 
 of declaring that Dr. Barr was, in his day, a most distinguished 
 
vi IXTRODUCTIOX BY PROFESSOR GAIRDXER. 
 
 student of Glasgow University ; and that his career since he 
 left us has been such as to inspire confidence, not only in his 
 rectitude of purpose, but in his accuracy of statement in detail, 
 and in his highly-cultivated practical sagacity. As regards the 
 present work, I venture to think that these qualities are 
 sufficiently apparent, and will commend themselves to all well- 
 informed readers. 
 
 These general statements will not, I suppose, be held as com- 
 mitting me on all points, or even on any one point, to an entire 
 acceptance of Dr. Barr's views, either theoretical or practical. 
 But, in consideration of the cautious and even (as some have 
 thought) unduly sceptical attitude I some years ago* adopted 
 as regards the so-called antipyretic treatment of the specific 
 fevers, it is not at all displeasing to me to have to confess that 
 Dr. Barr's researches, and also certain modifications of detail 
 and even (I think) of principle, which are apparent in the more 
 recent work of Liebermeister, on "Antipyretic Methods of 
 Treatment,"! have done much to remove my difficulties, and to 
 present these methods under forms which justify them, to my 
 mind, as very probably deserving of adoption. It seems now 
 to be conceded that the cumulative proceedings formerly 
 regarded as absolutely indispensable for safety, whenever the 
 axillary temperature reaches 39'^ C, are no longer in favour, 
 and are, indeed, both distressing and dangerous. Yeratrum and 
 even digitalis are all but discarded, and even the very large and 
 frequent doses of quinine are (to judge from the tables) 
 comparatively little employed. Baths are used chiefly at night, 
 so as to come in aid of the normal remissions, and only so as 
 to secure a considerable remission once in the twenty-four 
 hours, not a continuous lowering of the temperature. More than 
 a half of the cases are now treated either without any very 
 active measures, or with baths alone ; and nearly a quarter of 
 them " entirely without the stronger antipyretic methods," i.e., 
 
 * Glasgow Medical Journal, vol. x., N.S. 1878, pp. 416, .503 ; also 
 British Medical Journal, 1884, vol. ii., p. 112.5. 
 
 t In Von Ziems.sen's " Handbook of General Therapeutics," vol. ii., 
 translated by Matthew Hay, M.D., 1885. 
 
INTRODUCTION BY PROFESSOR GAIRDNER. Vll 
 
 even without baths.* It is impossible to avoid observing here, 
 either that Professor Liebermeister's views have unders^one a 
 change amounting to a revolution,, or that the expressions 
 employed in his earlier monograph were very misleading. In 
 either case, I see no reason to regret having issued my 
 " Cautions " in 1878. The evils that I apprehended are now, 
 at least, admitted, and are practically reduced to a minimum. 
 
 But now Dr. Barr comes to the front with a new proposal 
 which, whatever its ultimate fate, may be accepted in the 
 meantime as one well deserving of attention, and more logical, 
 I think, than the newer German position. If the reduction of 
 temperature by the abstraction of heat is an object of so great 
 importance, why not do it continuously, but in such a way as 
 shall cause no distress at the time, shall avoid violent transi- 
 tions, and allow of natural rest, and, as far as possible, a 
 normal periodicity of all the functions, undisturbed by the 
 perpetual interference at all hours of the day and night, which 
 characterised the earlier antipyretic methoils '{ The objection 
 to these, with many of us, lay in the points summed up as 
 follows, in my reply to Liebermeister, viz : — That the rules set 
 forth in his earlier article required the constantly repeated 
 bathings to be " carried to the verge of collapse-temperatures, 
 so as in many cases to make stimulants needful for checking 
 further descent ; that even sleep at night is to be disturbed in 
 order to give these baths " (and this without the day-interval 
 for repose which he now not only permits, but enjoins) ; "and 
 that, besides this systematic interference by night as well as 
 by day, the failing appetite and powers of nutrition of the 
 patient are to be taxed by giving enormous cumulative doses 
 of the strongest, and, in some cases, actively poisonous, drugs ; 
 which, again, are to be pushed even to the point of vomiting, 
 .so as to require the use of stimulants for restorative purposes."! 
 These objections may seem to have been, more or less 
 
 * Compaie Op. cit. p. 125, et seq., and the Tabular Statements in pp. 
 143-4, with the previous Monograph of Liebermeister, on Tyjihoid 
 Fever, referred to by me in 1878. 
 
 t Glasffow Med. Journal, uhi supra., p. 504. 
 
Vlll INTRODUCTION BY PROFESSOR GAIRDNER. 
 
 effectually, obviated in the more recent practice of Lieber^ 
 meister himself ; but they are more logically and completely 
 met, as it seems to me, by the proposal now set forth by 
 Dr. Barr. Indeed, I have held all along, and have taught, 
 that if heat-abstraction is permanently to be adopted as an 
 essential part of the treatment of pyrexia, it ought to be in 
 the form which Stokes advocated in small-pox, and Hebra in 
 pemphigus. To Dr. Barr will accrue all the credit of a first 
 experiment in this direction ; an experiment at once bold and 
 cautious, on a sufficient scale to command attention, and with 
 results which cannot easily be explained away. More than 
 this, it would, perhaps, be inexpedient at present to affirm ; 
 but in the working out of this valuable experiment, I have no 
 hesitation in saying that the reader will find in the details 
 many side-lights upon the progress and course of enteric fever, 
 which will tend to confirm, or to create, confidence in Dr. Barr's 
 methods, and in his narrative of events. 
 
 I have now discharged to the best of my ability, the duty 
 that has been laid upon me ; and I have only, in conclusion, to 
 deprecate the extremely complimentary terms in which Dr. Barr 
 has alluded to my own labours, for which I have never claimed 
 any higher rank than that they were directed to the re-instating 
 of principles of treatment that had been at one time lost sight 
 of ; and to the correction of abuses which, according to the 
 most enlightened medical opinion, had extensively prevailed, 
 and were perhaps tending even to increase in 1864. My sole 
 ambition was, in the interests of humanity, to state the grounds 
 for maintaining these principles and staying these abuses, not 
 as matters of controversy, but rather so as to make controversy 
 difficult, or impossible. And in this respect, at least, my efibrts 
 may be said to have succeeded. But I have never claimed any 
 originality, or any special credit, in these papers; which it seemed 
 to me to be only the duty of a teacher of medicine to write, not 
 as subserving his own reputation, but simply as vindicating his 
 oral instructions, which Dr. Barr, no doubt, as an attached pupil, 
 remembers with more appreciation than they have deserved. 
 Glasgow, December, 1891. 
 
PREFACE. 
 
 In introducinsj the taak, or continuous bath, in the treatment 
 of severe cases of Typhoid Fever, I am fully cognisant of the 
 difficulties which would attend its general adoption ; but these 
 difficulties are not insuperable, either in public or private 
 practice, and, where human life is concerned, I am of opinion 
 that no obstacles should be allowed to impede our path. A 
 good many cases of Typhoid Fever are permitted to die from 
 want of taking sufficient trouble to keep them alive. This may 
 seem a bold statement, for one who has fully recognised the 
 value of expectant treatment, to make, but I am convinced of 
 its accuracy. Expectancy, when rationally carried out, answers 
 admirably in a large number of cases, but it should never be 
 allowed to degenerate into laissez faire. 
 
 Since this work was completed, I have had another death 
 from Typhoid Fever, complicated with double pneumonia; but 
 I have also hai I sixteen more cases — the majority of which have 
 been of marked severity — so my mortality now stands at two 
 deaths in seventy-one cases. 
 
 Owing to the low vitality of many patients, the neglect of 
 early treatment, and the complications which frequently arise 
 in Typhoid Fever, there must always be a certain mortality 
 under any system of treatment ; but our duty is plainly to 
 reduce the death-rate as nearly as possible to the vanishing 
 point. I feel firmly convinced that a lessened mortality may be 
 expected to follow the adoption of the recommendations which 
 I have sketched out in this work ; but I should much dread 
 the adoption of the tank treatment by any one who is not 
 prepared to take the trouble to see it intelligently carried out. 
 
X PEEFACE. 
 
 To our public-spirited Committee of the Northern Hospital 
 I am under many obligations, for affording me every facility 
 for carrying out this treatment. To my friend and senior 
 colleague, Dr. E. H. Dickinson, and to many other medical 
 men, I am much indebted, for kindly placing patients under 
 my care. To Drs. Milligan, Macadam Wallace, Cuming Askin, 
 and Brooks, who have, in succession, held the office of House 
 Physician at the Northern Hospital, my best thanks are due, 
 as without their able and hearty co-operation it would have 
 been impossible for me to have carried out the numerous 
 observations on which this work is based. My reports of the 
 cases are to a large extent abstracts from their copious notes. 
 And to our excellent staff of nurses, who would reflect credit 
 on any Institution, my gratitude must be warmly expressed for 
 their untiring zeal and the lively interest which they have 
 taken in all the patients. Without drawing any invidious 
 distinctions, I must specially mention our head nurses. Miss 
 Duckett, Miss Eardley, Miss Fletcher, and Miss Lloyd, as the 
 intelligent and trustworthy manner in which they have had all 
 my instructions carried out has been worthy of the highest 
 praise. In the treatment of Typhoid Fever, good nursing is 
 one of the most important factors, and those who read this 
 work will find that, in my opinion, good nursing involves the 
 carrying out of a great many details. 
 
 Liverpool, December, 1891. 
 
CONTENTS. 
 
 PAGE 
 
 Dedication ... *. ... iii 
 
 Introduction, by Professor Gairdner v 
 
 Preface .. ix 
 
 Introduction 1 
 
 A History of the Treatment of the Continued 
 
 Fevers from the time of Sydenham ... ... 7 
 
 Diagnosis ... ... ... ... ... ... ... 38 
 
 The Treatment of Typhoid Fever 43 
 
 The Treatment of Complications ... ... .., 77 
 
 Tabular Statement of Fifty-five Successive Cases 
 
 OF Typhoid Fever with only One Death ... 84 
 
 Cases Treated in the Tank ... ... 86 
 
 Temperature Charts 169, 170 
 
 Cases Treated with the Wet-pack, etc 171 
 
 Cases Symptomatic ally Treated 195 
 
INTRODUCTION. 
 
 In the treatment of any disease it should always be recollected 
 that it is the patient rather than the disease that the medical 
 attendant is called upon to treat, and when I entitle this work, 
 "■ The Treatment of Typhoid Fever," it is not to be supposed 
 that I in any way depart from this principle. The character 
 and severity of all acute diseases vary very much in different 
 cases, so that there will always be free scope for individualism in 
 medical practice, not merely so far as the individual physician 
 is concerned, but also in respect of every individual patient. 
 I am strongly averse to any routine system of treatment, and, 
 therefore, if in the following pages I seem to advocate such a 
 system, it is because common factors are present in a large 
 number of cases of the disease of which I am about to treat. 
 
 In dealing with any disease it is most important to have a good 
 knowledge of its pathology, and with respect to the pathology 
 of typhoid fever there is a fair unanimity of opinion; it will 
 therefore be quite unnecessary for me to divert the attention 
 of my readers from the subject matter of this work to one on 
 which we are all agreed. The diagnosis of typhoid fever is 
 often a matter" of some difficulty, and frequently it is only by a 
 process of elimination that we can arrive at any certainty in 
 the matter. 1 shall refer to this question later on. Mild cases 
 of typhoid fever require very little treatment and should all do 
 well, but the new method of treatment which I have been 
 carrying out is chiefly applicable to the more severe cases, and, 
 therefore, its merits can be readily tested. It is from the 
 latter class that the mortality of the disease is chiefly derived, 
 and any treatment which lessens the death rate has much to 
 commend it. 
 
 Typhoid fever is a disease from which no class of the 
 community is exempt, and therefore any suggested improve- 
 
2 THE TREATMENT OF TYPHOID FEVER. 
 
 ment in its treatment must interest all those who are 
 actively engaged in general practice, and especially attract the 
 attention of those who have largely got to deal with this 
 disease. In England and Wales during the past ten years the 
 average annual number of deaths from this disease has been 
 5922. In The Liverpool Medico-Chirurgical Journal, July, 
 ] 889, Dr. Hope informs us that in Liverpool alone the number 
 of deaths "during the last ten years average 129, fluctuating 
 within comparatively narrow limits." These figures show, to my 
 mind, that there is great room for improvement, not merely 
 in preventive but also in curative medicine, and therefore I 
 need offer no apology for troubling the medical profession 
 with a mode of treatment which, in my opinion, offfers fair 
 prospects for at least lessening the mortality of typhoid fever. 
 No doubt, as " prevention is better than cure," ifc would be 
 much better if sanitarians could wipe out the cause of the 
 disease, but as there is every reason to believe that it will be a 
 very long time before sanitation has arrived at such a state of 
 perfection, those of us who are actively engaged in the treatment 
 of disease must exercise our best judgment not only in lessening 
 mortality but also in restoring our patients to perfect health 
 
 I have not the slightest intention of attempting any complete 
 historical sketch of the various evolutionary phases in the 
 treatment of fevers — and it would be quite impi-acticable to 
 separate typhoid from the other continued fevers, as it is only 
 within a generation that a specific distinction has been drawn — 
 but a work of this kind would be very defective, which did not 
 take into account what has been done by our predecessors. 
 The progress has not been uniformly in the right direction, and 
 even in the present day we seem to be oscillating between 
 expectancy and active medication. 
 
 In this country much of the improvement has been 
 attained by what has been termed " armed expectancy," a 
 good deal of which armament consists in a fair amount of 
 common sense, but in the present day there is such a temptation 
 to experiment with a whole host of new antipyretic, and 
 antiseptic remedies, that I am afraid patients sometimes stand 
 
INTRODUCTION. ' 3 
 
 ija greater danger from the treatment than the disease. 
 Certainly, it would have been well if some of the antipyretic 
 drugs had never been manufactured. In 1886, when writing 
 about one of the best of these drugs, antipyrin, I spoke against 
 its regular use in the continued fevers, "as it in no way 
 modifies the progress of the disease, and as it is questionable 
 how far a mere reduction of temperature is beneficial, it should 
 be held in reserve as an agent at hand to combat hyperpyrexia." 
 I have since seen no reason to alter the view then expressed, 
 and regarding many of the other new antipyretics I would be 
 sorry to speak so favourably. Those who look upon all the 
 evils of fevers as chiefly due to the pyrexia, must find in these 
 remedies very efficient weapons, but the handling of which has 
 not, unfortunately, produced very satisfactory results. 
 
 Formerly the cause of fevers was looked upon as a materies 
 morbi, an entity, which required to be eliminated by blood- 
 letting, emetics, diaphoretics, and purgatives. Now our 
 energies are expended in a dififerent direction; we attempt 
 to kill the bacilli, which may seem an excellent method, and 
 from a sanitary point of view almost command universal 
 adoption, but where we have got to cure our patients as well 
 as to kill the bacilli, we find that the latter task is not so easily 
 accomplished. Though the bacilli are short lived, and evoke 
 changes which tend to their own extinction, yet during the 
 short period of their existence they are very tenacious of life, 
 . and it is usually more difiicult to kill them than their host. 
 Dr. Cash showed how anthrax might be prevented by the use 
 of the perchloride of mercury, but when this and most other 
 infectious diseases are established our efibrts to kill the bacilli 
 are futile, and the most we can do is to enable the patients to 
 survive the attack of these microscopic myrmidons. 
 
 Pasteur has admittedly been very successful in preventing 
 the development of hydrophobia by his inoculations with 
 attenuated virus ; as a means of rendering the body immune 
 against that dreadful disease, the treatment is somewhat com- 
 parable to that of vaccination. More recently Koch has 
 advanced another principle of treatment, with immediate 
 
4 THE TREATMENT OF TYPHOID FEVER. 
 
 reference to tuberculosis, but which, no doubt, he hopes to 
 extend to other infectious diseases. He proposes a very 
 powerful product, tuberculin, of the tubercle bacilli, as a specific 
 for tubercular tissue, if not for tubercular disease. The principle 
 of treatment has so little to commend itself to my mind that I 
 have not used it, but contented myself with reading the litera- 
 ture of the subject, and observing a few cases under the care 
 of medical friends. It appears to me that severe cases of 
 phthisis have within themselves good laboratories for the 
 manufacture of tuberculin, and they get the " febrile reaction " 
 (which has recently produced a form of wild delirium in the 
 medical profession), every afternoon, without, in the majority 
 of cases, effecting any self cures. Koch's treatment seems only 
 suited for mild cases in a very early stage, but even then the 
 remedy in many instances is more fatal than the disease. Such 
 cases are frequently cured with improved nutrition, but what 
 I wish to see is a specific for acute tuberculosis ; so with 
 typhoid fever, we do not want a cure for mild cases, but a 
 specific for the most severe types. If we cannot eradicate or 
 destroy the typhoid bacilli, we want an agent to antagonise 
 the poisonous leucomaines, which they generate, just as atropine 
 ■ antagonises the action of muscarine. Some good work in this 
 direction has been done by Hankin, Behring, Eatasato, Roux, 
 Yersin, and others. 
 
 In an interesting article on " Cures for Infectious Disease? " 
 in the British Medical Journal, February 28th, 1891, Mr. 
 Hankin says, " Our knowledge of the nature of the conflict 
 between the organism and the microbe has now so far advanced 
 that, of the numerous cures that have been attempted, a 
 partial explanation of the modus operandi of the curative agents 
 can in many cases be brought forward. Such " cures " can be 
 roughly divided into two classes ; (a) those in which a " febrile 
 reaction " is probably produced, and (6) those in which a 
 bactericidal substance is introduced into the living animal 
 body." He then refers to Buchner's method of curing anthrax 
 by injections of sterilised cultures of bacillus pneumonia; to 
 Emmerich's inoculations with the erysipelas microbe; and to 
 
INTRODUCTION. 5, 
 
 his own cures of anthrax by injections of minute quantities of 
 pepsin and trypsin. All these substances produce a " febrile 
 reaction," and he has " found that when the animal's power of 
 resisting the onset of the disease has been increased by injecting 
 a "protective proteid," a febrile reaction occurs, and on the 
 death of the animal the bacilli showed various signs of degen- 
 eration." 
 
 It has been assumed that the high temperature is inimical 
 to the life of the bacilli, but Bouchard has shown that this 
 explanation does not hold good, and Hankin has found that 
 during the " febrile reaction," " protective proteids " are formed, 
 which antagonise the action of the bacilli, therefore, it would 
 seem that what we want is the introduction of " protective 
 proteids " from without, and thus obviate the necessity of the 
 body generating its own antidote, and so save it from the evil 
 effects consequent on the high temperature. Mr. Hankin 
 refers to the work of Behring and Kitasato on tetanus and 
 diphtheria. " These investigators have succeeded in curing 
 the above mentioned diseases by the injections of serum from 
 animals that had previously been made immune against the 
 tetanus and diphtheria bacilli. In this case, however, the serum 
 appears to owe its curative power t j a substance that destroys 
 the poison produced by the microbes rather than the microbes 
 themselves." " Behring has made mice immune against 
 anthrax by injection of rat's serum. Ogata and Jasuhwara 
 have succeeded in curing mice -from attenuated anthrax by 
 injections of blood from dogs, rats, and frogs." Mr. Hankin 
 has attained similar results from the injection of rat's serum. 
 The defensive proteids, or alexins, present in the normal animal, 
 he terms Sozins ; and those present in the artificially immune 
 animal, Phylaxins. From such experiments as these we may 
 hope in the future to obtain great results in the treatment of 
 all infectious diseases. 
 
 It has appeared to me that the chief incidence of typhoid 
 fever under thirty years of age may be due to the greater 
 alkalinity of the blood serum and intestinal secretions in early 
 life. Over thirty years of age I have found it principally in 
 
6 THE TREATMENT OF TYPHOID FEVER, 
 
 those who were in a depraved vital condition, or in those who 
 had an insufficient supply of animal food. The acquired 
 immunity against the disease I believe to be associated with 
 the increased formation of acid in the system. In the treat- 
 ment of the disease I am always anxious to render the alvine 
 excretions acid. Rather opposed to these views is the known 
 fact that the typhoid bacillus grows on slices of potato with an 
 acid reaction. Recently, Professor Uffelmann has found that it 
 will grow on nutrient gelatine rendered acid with citric and 
 acetic acids, and that it bears a high degree of acidification. 
 However, it is not entirely a question under what unfavour- 
 able circumstances the typhoid bacilli may grow, but they 
 certainly seem to flourish most luxuriantly in the alkaline 
 contents of the small intestines — where also there is no oxygen. 
 I shall now give a brief review of the treatment of continued 
 fever from the time of Sydenham, with more special reference 
 to the antipyretic treatment. 
 
A HISTORY OF THE TREATMENT OF 
 THE CONTINUED FEVERS, FROM THE 
 TIME OF SYDENHAM. 
 
 Sydenham was the genius of his age, and since his time 
 
 there have been few such close observers of natural phenomena. 
 
 Of him the poet Sewel wrote : — 
 
 " Syd'nham, a great and mighty genius came, 
 Who founded Medicine on the noblest frame : 
 He study'd Nature thro', and Nature's laws, 
 Nor blindly puzzled for the peccant cause. 
 
 Father of'physick He — Immortal Name ! 
 Who leaves the Grecian but a second fame. 
 Sing forth, ye Muses, in sublimer strains, 
 A new Hippocrates in Britain reigns : 
 With ev'ry healing plant his grave adorn, 
 Saviour of many millions yet unborn." 
 
 Sydenham's great success in practice largely depended on 
 his close observance of natural laws. He aided and assisted 
 the natural processes of cure, and did not thwart nature like 
 many of his predecessors and successors. By nature he always 
 meant " a certain assemblage of natural causes, which, tho' 
 destitute of reason and contrivance are directed in the wisest 
 manner, whilst they perform their operations, and produce 
 their effects ; or, in other words, that supreme being, by whose 
 power all things are created and preserved, disposes them all 
 in such manner, by his infinite wisdom, that they proceed to 
 their appointed functions with a certain regalarity and order, 
 performing nothing in vain, but only what is best and fittest 
 for the whole frame of the universe, and their own peculiar 
 nature ; and so are moved like machines, not by any skill of 
 their own, but by that of the artist." In his opinion, "a 
 disease, how prejudicial soever its causes may be to the body, 
 is no more than a vigorous effort of nature to throw off" the 
 morbific matter and thus recover the patient." 
 
8 A HISTORY OF THE TREATMENT 
 
 In treating of the continued fever of the years 1661, 1662, 
 1663, and 1664, he only used blood-letting "in young persons 
 of a strong and sanguine habit. After the bleeding he ordered 
 an emetic in cases where there had been any retching, as he 
 thought that by thus expelling the " humour," he obviated the 
 occurence of diarrhoea towards the termination of the fever. 
 He ordered the antimoniaJ emetic to be followed by three 
 quarts or a gallon of posset drink, " because this kind of 
 emetic is dangerous unless plentifully diluted ; and therefore 
 as often as the patient vomited, or purged, he was directly to 
 take a draught of the posset drink, by which means griping 
 was prevented and the vomiting rendered more easy." " As 
 soon as the operation was over, the severe symptoms, viz. : — 
 the nausea, anxiety, restlessness, deep sighing, blackness of 
 the tongue, &c., usually abated, and went off, so as to leave 
 the remainder of the disease tolerable." 
 
 In the present day emetics are not employed frequently 
 enough (a few tumblerfuls of hot water are usually sufficient 
 without any medicinal substance), but those who have 
 witnessed the beneficial effects which often follow such a 
 mechanical procedure, are not likely to neglect its use. The 
 bleeding and emetics were only used at the beginning of the 
 fever, and both were omitted in the case of children under 
 fourteen years of age. He prescribed a clyster occasionally 
 during the progress of the fever, but towards the decline, " the 
 more costive he is kept, the more secure I judge him ; the 
 febrile matter then proceeding more kindly and quietly to 
 concoction." " Cordials, as I have experienced when given too 
 soon, do mischief, and unless bleeding has preceded, may drive 
 the crude matter of the distemper upon the membranes of the 
 brain, the pleura, &c., and therefore I never give them when 
 either no blood, or very little has been taken away ; or when 
 no other considerable evacuation has been made ; or the 
 patient has not passed the meridian of life." " The fever 
 itself is no other than the instrument of nature, by means 
 whereof she separates the vitiated parts of the blood from 
 the sound ; though she does this in a manner perfectly ira- 
 
OF THE CONTINUED FEVERS. 9 
 
 perceptible at the beginning, and even at the state of the dis- 
 temper, but more manifestly in the decline thereof, as appears 
 from the sediment in the urine. The concoction of the febrile 
 matter here means no more than a separation of the morbific 
 particles from the sound, whence the way to hasten this con- 
 coction is not by moderating the fever, but the effervescence 
 must be kept up so long as the safety of the patient will 
 give leave ; but when the disease is in the decline, and the 
 separation becomes manifest, warmer medicines should be 
 immediately given, in order to finish the operation with greater 
 certainty and expedition." 
 
 We thus see that he did not believe in antipyresis, though 
 much of his treatment had a cooling tendency. He gives 
 several prescriptions for cordials, from which we cull the 
 following ingredients, borage, citron, black cherries, barley 
 cinnamon water, prepared pearl, sugar, strawberries, oriental 
 and occidental begoar, a leaf of gold, syrup of the juice of citron 
 and cloves. However, he does not seem to have prescribed 
 without a definite object in view. " When the fermentation 
 neither rises too high, nor sinks too low, I leave it in that state, 
 without prescribing any medicines, unless forced to it by the 
 importunity of the patient, or his friends ; and then I direct 
 such only as may please without prejudicing." 
 
 His treatment of the humbler classes was more simple, but I 
 have no doubt not less effectual. " I should not omit, that fre- 
 quently when I was called to persons of low circumstances, I 
 ordered them to do nothing else, after bleeding, and vomiting 
 when required, but to keep in bed during the whole course of 
 the distemper, and to sip only water gruel, barley gruel and 
 the like ; to drink moderately of warm small beer to quench 
 their thirst, and to take a clyster of milk and sugar every day, 
 or every other day till the tenth or eleventh day of the dis- 
 temper ; but towards the end of the fever, when the separation 
 has begun, and proceeded slowly, to promote it, I allowed them 
 now and then a little stronger malt liquor, instead of cordials. 
 And thus without anything further except a gentle purge at 
 the end of the distemper, they generally did well." 
 
10 A HISTORY OF THE TREATMENT 
 
 In the treatment of the plague of 1865 and 1866, Nature 
 seems to have failed him, and he resorted to rather profuse 
 bleeding and sweating. He placed a high estimate on the use 
 of blood-letting in this disease, " but tho' I greatly approve of 
 this method, and have formerly experienced its usefulness in 
 many instances ; yet, for several reasons, I prefer the dissipa- 
 tion of the pestilential ferment by sweat to its evacuation by 
 bleeding ; because sweating does not weaken the patient so 
 much, nor hazard the reputation of the physician." 
 
 The continued fever of the years ]667, 1668, and 1669, 
 seemed largely to assume the characteristics of typhoid as we 
 now see it ; the disease was long drawn out, did not end by a 
 crisis, the bowels were loose, and the petechise were few. In 
 this disease we find him using cooling remedies, and recom- 
 mending the patients to sit up a good part of each day so as to 
 avoid being over-heated in bed. 
 
 The continued fever of the years 1673, 1674, and 1675, seems 
 to have been a mixture of typhus and typhoid. He found 
 that free blood-letting did not answer, he used large blisters 
 between the shoulders to arouse the patients up from their 
 stupor, insisted on them getting out of bed each day, and when 
 too weak to sit up he directed that they should be dressed, and 
 lie on the bed with the head well raised. 
 
 The following observations are as applicable to-day as when 
 they were written. " Nor do I think it below me to acknow- 
 ledge, with respect to the cure of fevers, that when no manifest 
 indication pointed out to me what was to be done, I have con- 
 sulted the safety of my patient, and my own reputation, most 
 effectually, by doing nothing at all ; for whilst I carefully 
 attended to the disease, in order to cure it in the best and 
 safest manner, the fever either went off gradually of itself, or 
 came to such a state as showed that medicines were to be used 
 to remove it. But it is much to be lamented that abundance of 
 sick persons are so ignorant, as not to know that it is some- 
 times as much the part of a skilful physician to do nothing at 
 all, as, at others, to exhibit the most effectual remedies ; whence 
 they not only deprive themselves of the advantages of a fair 
 
OF THE CONTINUED FEVERS. 11 
 
 and honourable procedure, but impute it either to negligence 
 or ignorance, whereas the most illiterate empiric knows how to 
 heap medicine on medicine as well as the most prudent physi- 
 cian, and usually does it in a much greater degree." 
 
 He gives a good account of the use of Peruvian bark, or 
 Jesuit's powder, in the treatment of intermittents, and tells us 
 that it was introduced into London about the year 1650. In 
 an essay, on the rise of a new fever in 1685, we find him 
 speaking of " a change of the constitution of the fever," which 
 reminds us that our immediate predecessors spoke of " a 
 change of type," to account for their change of practice. 
 Sydenham, however, continued his practice of moderate blood- 
 letting and purging. He laid it down as an axiom in the 
 treatment of all fevers that emetics and purgatives should 
 never be administered before the bleeding. The basis of his 
 treatment consisted of bleeding and purging, while sweating 
 took a subsidiary place. With Sydenham, everything was 
 brought to the test of experience, and he seemed to hold in 
 low esteem " those physicians who regulate their practice 
 more by idle speculation than experience founded on the 
 solid testimony of the senses." 
 
 I might give many more extracts from the writings of this 
 truly great man, but these must suffice. His work for a long 
 time remained the standard authority in Britain, and to a 
 great extent regulated the practice on the Continent. The 
 celebrated Boerhaave said of Thomas Sydenham that he was' 
 "the ornament of England, and the Apollo of the art, whom I 
 never consider but my mind presents me with the genuine 
 picture of an Hippocratic physician, and to whom physic is so 
 much indebted, that all that I can say will fall far short of 
 his merit." 
 
 Among those who trod the paths laid down by Sydenham 
 may be mentioned — Hermann Boerhaave, Hoffman, Baglivij 
 Ramazzini, Heister, Van Sweiten, Mead, Huxham, Shaw, 
 Nicholls, Hoadley, Cheyne, Hillary, Turner, Fuller, Arbuth- 
 nott, Wintringhara, Clifton, Langrish, Barker, Swan, Stone- 
 house. 
 
12 A HISTORY OF THE TREATMENT 
 
 Hoffman used warm bathing in maniacal disorders ; and in 
 the treatment of the plague (which seems to have been a 
 species of anthrax)., he avoided blood-letting, and was very- 
 sparing in the use of remedies, observing " that few are best." 
 He studiously watched natural processes, and he used the 
 term Nature, as " a word to signify the structure, mechanism, 
 and contrivance of the body, acting with certain powers, 
 according to certain necessary and mechanical laws, assigned 
 it by its maker." 
 
 Huxham described a low putrid fever which was epidemic 
 at Plymouth in the autumn of 1729. " It remitted towards 
 the end, and at length intermitted. It chiefly affected the 
 head, stomach, and loins, as if the small-pox was coming on, 
 and was attended with an oppression of the breast, sighing, 
 and great faintness. It chiefly attacked children, women, 
 young or weak persons. The blood taken away was seldom 
 viscid ; the urine mostly crude, thin, and frequently let fall a 
 cineritious, slimy, and imperfect sediment, resembling flour, 
 called by Hippocrates a. branny sediment; the more perfect 
 the sediment was, the more hopes there were of recovery. 
 The tongue was not very dry, but appeared to be covered with 
 a kind of viscous brownish mucus. Towards the declension of 
 the distemper a looseness or sometimes a dysentry, especially 
 if a vomit had been omitted in the beginning, became very 
 immoderate, and even proved fatal to some." He found that 
 " bleeding, unless in the beginning, seldom did service ; vomits 
 were highly necessary, and afterwards frequent blisters." He 
 gave plenty of liquids, avoided strong purgatives, and admin- 
 istered' bark towards the declension of the fever. He used 
 ipecacuanha as an emetic, occasionally strengthened with two 
 or three grains of tartar emetic. 
 
 Dr, Langrish, speaking of intermittent fevers, in his "Theory 
 and Practice of Physic," says—" The cold bath, where age or 
 no inward weakness forbid it, is exceedingly proper, especially 
 in the summer season, to recover the lost tone of the fibres, 
 and to grind and comminute the viscid ill-conditioned juices, 
 and to prevent catching cold," There is one sentence which 
 
OF THE CONTINUED FEVERS. 13 
 
 might have emanated from a clergyman rather than a physi- 
 cian. Speaking of the virtues of nitre, he says — " It is highly 
 esteemed, and constantly used in all distempers where the 
 blood boils with fervent heat." 
 
 In 1753, Dr. Swan published his third edition of the works 
 of Sydenham, whom he held in the highest reverence, and to 
 whose precepts he closely yet intelligently adhered. 
 
 In 1752, Sir John Pringle recommended in malignant fevers, 
 an abundant supply of fresh air. He bled and gave emetics 
 in the early stages, afterwards used diaphoretics, especially 
 spiritus mindereri, and laxatives. Towards the close of the 
 disease, when there was great prostration, he gave bark and 
 serpentary roots, and cordials. " But, for a grateful cordial in 
 this state, there was nothing comparable to wine, whereof the 
 common men had an allowance to half-a-pint a day, of a 
 strong kind, made into whey or added to the panado, which 
 was their only food. But to others out of the hospital, I 
 commonly prescribed Bhenish or French wine, of which several 
 have consumed a quart a day, and some part of that undiluted." 
 He made some valuable experiments with septics and anti- 
 septics ; showed that alkalescence did not necessarily lead to 
 putrescence, and was about the first to point out the antiseptic 
 property of ammonia. 
 
 In 1757, 1762, and 1779, the first, second and third editions 
 of Dr. Lind's admirable work on the "Health of Seamen, Fevers, 
 and Infection," etc., appeared. It was he who discovered "the 
 method of freshening sea-water by distillation," he laid down 
 excellent rules for preventing and limiting the spread of 
 infectious diseases, and ascribed great importance to a free 
 supply of fresh air, not only in the treatment but also in the 
 prevention of the disease. 
 
 The views of Cullen for a long time regulated the practice in 
 Edinburgh, and owing to his world-wide reputation had a very 
 extended influence. There were however some men, especially 
 in the British Army and Navy, of independent thought and 
 action, such as Drs. Lind and Robertson, who drew their 
 inspirations from experience and not from the practice of any 
 
14 A HISTORY OF THE TREATMENT 
 
 Academic Institutions. The first edition of Cu lien's work was 
 published in 1772, and the second in 1777. All Cullen's 
 writings were exceedingly systematic and his treatment of the 
 continued fevers was no exception to the rule. Want of space 
 prevents me entering into all the minutiae of his treatment 
 and it must, therefore, suffice to say that he freely employed 
 such remedies as blood-letting, emetics, diaphoretics, and 
 purgatives, while he kept the patients on a low diet, and was 
 ,very sparing in the use of stimulants. About this time Cullen's 
 great rival. Dr. John Blown, was rising into fame. He looked 
 upon fevers as asthenic diseases which required stimulating 
 treatment. 
 
 In 1783 there was published a remarkable work " On the 
 Jail, Hospital, or Ship Fev^er," by Robert Robertson, M.D., of 
 H.M. Navy, and dedicated to Dr. William Hunter. He 
 prescribed bark very freely, (even when it was a guinea a 
 pound), and almost completely discarded blood-letting :— 
 " Scarcely one patient could bear the loss of a few ounces, 
 without either becoming languid or faint, and complaining 
 more afterwards of debility than other patients. Thus I was 
 taught to withhold the lancet, and am now thoroughly con- 
 vinced that it will not be necessary in one case among a hundred 
 of ship fever, to let blood." His practice was attended by 
 remarkable success ; on board the Juno he had one death in 216 
 cases, whereas the death rate under other methods was about 
 one in nineteen. On board the Edgar between July 1st, 1779, 
 and August 1st, 1780, he had 475 fever patients with six deaths, 
 whereas in the Gibraltar hospital between January 19th and 
 April 20th, 1780, there were 570 fever patients with 57 deaths, 
 under the antimonial and " camphire " treatment. His book 
 affords very pleasant reading, compared with the blood-thirsty 
 work of many of his predecessors and successors. 
 
 The use of cold water in fevers dates from a very early 
 period in the history of medicine, but its more methodical 
 application began about this time. It was claimed by Dr. 
 Robert Jackson that he used it as early as the year 1774, and 
 he mentioned it in his treatise on the " Fevers of Jamaica^," 
 
OF THE CONTINUED FEVERS. 15 
 
 published in 1791 . Although his claim to priority was disputed 
 by the Edinburgh Review, and by Dr. Currie who gave the 
 credit of the discovery. to Dr. Wright, it would appear to me 
 that Dr. Jackson in his " Exposition of the practice of affusing 
 cold water on the surface of the body as a remedy for the cure 
 of Fever," published in 1808, very fairly established his claim. 
 His works show him to have been a man of considerable resource, 
 and an original thinker of no mean order ; and although much 
 might be said in favour of his method of warm bathing 
 followed by cold affusion, yet his practice in other respects was 
 so objectionable, especially his free use of the lancet, that the 
 chief credit for the introduction of cold water bathing in fevers 
 must be given to Dr. Currie. 
 
 Dr. Jackson, in his work " On the History and Cure of 
 Febrile Diseases," published in 1817, strongly advocated and 
 extended the use of cold water affusions. He thought that the 
 precepts of Dr. Currie limited the remedy to a narrow sphere. 
 He did not allow the temperature of the patient to regulate its 
 use, and. generally prepared his patients for the application of 
 the affusion by the abstraction of several pounds of blood. He 
 taught that " disease is an enemy in all its presentations, not 
 to be repulsed from the citadel merely — it is to be attacked 
 and totally destroyed in the out-work; and this I conclude 
 will be the object with the provident and bold physician." 
 There was more boldness than providence in his practice. 
 
 In 1777, Dr. Wright, formerly of the island of Jamaica, and 
 afterwards President of the Royal College of Physicians, 
 Edinburgh, treated himself and a Mr. Kirk for fever, while on 
 a voyage from Jamaica to Liverpool, by affusions of cold salt 
 water. He published an account of the two cases in 1786, but 
 during the intervening nine years he does not seem to have re- 
 peated the experiment, and is therefore not entitled to very much 
 credit, for as Dr. Jackson justly observed, "a medical discovery 
 comprehends something more than a solitary experiment." 
 
 In 1787 this practice was adopted and very successfully 
 carried out by Drs. Currie, Brandreth, and Gerard, of Liverpool, 
 and it soon became the recognised treatment throughout 
 
16 A HISTORY OF THE TREATMENT 
 
 Lancashire. The method gradually spread throughout this 
 country, with the exception perhaps of London, where it never 
 seemed to have got a firm footing. Dr. Wright does not seem 
 to have contributed anything to the literature of the subject 
 beyond his first paper, but no doubt after his migration to 
 Edinburgh, he influenced Dr. Gregory, the Professor of the 
 Practice of Medicine, who enthusiastically took up this new 
 treatment. The cold water cure, however, had secured in Dr. 
 Currie a much abler apostle than either Drs. Wright or Gregory, 
 and it was thus brought into a prominence which it could 
 never have attained under its originators. When Dr. Gregory 
 wanted some information on the subject regarding the treat- 
 ment of the members of his own family who were sufiering 
 from scarlet fever, he was directed by Dr. Wright to apply to 
 Dr. Currie. Dr. Gregory seems to have had an excellent 
 method of impressing his students with his dogmatic teaching 
 and ex-cathedra statements, but he belonged to a very sang- 
 uinary school, and it is perhaps just as well for the medical 
 history of Edinburgh that only fragmentary evidence of his 
 teaching; is now extant. On the other hand Currie seems to 
 have been a man considerably in advance of his time, and even 
 at the end of the last century had to a great extent shaken 
 himself free from the traditionary trammels of blood-letting. 
 
 To Dr. Currie belonged the great merit of laying down 
 definite rules to govern the application of the affusion of cold 
 water, and as these rules are almost as definite as those 
 enunciated by our German colleagues in the present day I 
 cannot forbear quoting them. Dr. Currie says : — " The safest 
 and most advantageous time for using the aspersion or aff^usion 
 of cold water, is when the exacerbation is at its height, or 
 immediately after its declination has begun ; and this has led me 
 almost always to direct it to be employed from six to nine in the 
 evening, but it may be safely used at any time of the day, 
 when there is no sense of chilliness present, when the heat of 
 the surface is steadily above what is natural, and when there 
 is no general or ijrofuse perspiration. These particulars are 
 of the utmost importance." 
 
OF THE CONTINUED FEVERS. 17 
 
 "I. If the affusion of cold water on the surface of the body 
 be used during the cold stage of the paroxysm of fever, the 
 respiration is nearly suspended ; the pulse becomes fluttering, 
 feeble, and of an incalculable frequency ; the surface and extre- 
 mities become doubly cold and shrivelled, and the patient 
 seems to struggle with the pangs of instant dissolution. I have 
 no doubt, from what I have observed, that in such circumstances, 
 the repeated affusion of a few buckets of cold water would 
 extinguish life. This remedy should therefore never be used 
 when any considerable sense of chilliness is present, even 
 though the thermometer applied to the trunk of the body, 
 should indicate a degree of heat greater than usual." 
 
 " 2. Neither ought it to be used, when the heat, measured by 
 the thermometer is less than, or even only equal to, the natural 
 heat, though the patient should feel no degree of chilliness. 
 This is sometimes the case towards the last stages of fever, 
 when the powers of life are too weak to sustain so powerful a 
 stimulus." 
 
 " 3. It is also necessary to abstain from the use of this remedy 
 when the body is under profuse sensible perspiration, and this 
 caution is more important in proportion to the continuance of 
 this perspiration. In the commencement of sweating, especially 
 if it has been brought on by violent exercise, the affusion of 
 cold water on the naked body, or even immersion in the cold 
 bath, may be hazarded with little risk, and sometimes may be 
 resorted to with great benefit. After the sweating has con- 
 tinned some time and flowed freely, especially if the body has 
 remained at rest, either the affusion or immersion is attended 
 with danger, even though the heat of the body at the moment 
 of using it be greater than natural. Sweating is always a 
 cooling process in itself, but in bed it is often prolonged by arti- 
 ficial means, and the body is prevented cooling under it to the 
 natural degree, b}'' the load of heated clothes. When the heat 
 has been thus artificially kept up, a practitioner, judging by 
 the information of his thermometer only, may be led into 
 error. In this situation, however, I have observed that the 
 heat sinks rapidly on the exposure of the surface of the body 
 
18 A HISTORY OF THE TREATMEXT 
 
 even to the external air, and that the application of cold water, 
 either by affusion or immersion, is accompanied by loss of heat 
 and a deficiency of reaction, which are altogether inconsistent 
 with safety." 
 
 " Under these restrictions the cold affusion may be used at 
 any period of fever : but its effects will be more salutary in 
 proportion as it is used more early. When employed in the 
 advanced stages of fever, where the heat is reduced and the 
 debility great, some cordial should be given immediately after 
 it, and the best is warm wine." 
 
 The temperature of the water used by Dr. Currie ranged 
 from 40° to 70° Fahr., according to the season of the year. 
 " The solution of the fever depends chiefly on the sudden, 
 general, and powerful impression on the sensations, and this 
 impression is less affected by the difference in the temperature 
 from 40° to 65° as far as my observation extends, than might 
 on a first consideration be imagined. Within these limits the 
 efficacy of this remedy, as well perhaps as its safety, depends 
 on the suddenness and momentariness of its application. The 
 powerful impression on the sensations is much weakened when 
 the water is poured slowly on the body, and as the respiration 
 is suspended or convulsed during this application, as well as 
 durino- the act of immersion in the cold bath, it might in some 
 cases incur hazard to protract it." 
 
 The value of Dr. Currie's observations on fever is much en- 
 hanced by the fact that he regularly used the thermometer, 
 and he seems to have been the first physician to record the 
 thermometric observations throughout the whole Juration of a 
 case of small-pox. He strongly held views which pass current 
 in the present day. " It was a position of the celebrated 
 Boerhaave, that the morbid heat in fever, being a symptom 
 only, might therefore be disregarded. But can we suppose 
 that a heat, six or seven degrees greater than that of the blood 
 in health, however generated, will not have the most important 
 effects on the system, and if it stands in relation of effect to the 
 preceding symptoms, that it will not operate as a cause on those 
 which succeed ? " 
 
OF THE CONTINUED FEVERS. 19 
 
 " It is a serious error to suppose that the febrile poison, if so 
 we may call it, being received into the system, is the principal 
 cause of the symptoms, and that they consist of a strugo-le of 
 nature to expel it, without which health cannot be restored. 
 It is safer to consider it as an agent that excites the system 
 into fever, which however is carried on, not by the continued 
 presence and agency of this agent, but by the principles which 
 regulate the actions of life. We are not therefore to wait for 
 the sanative process by which nature is supposed to separate 
 this virus, and to throw it off, watching her motions and assist- 
 ing her purposes ; but to oppose the fever in every stage of 
 its progress with all our skill, and to bring it to as speedy a 
 termination as is in our power." 
 
 Dr. Currie explicitly stated, without any apparent doubt in 
 his mind about the diagnosis, that he aborted many cases of 
 typhus fever in the first, second, and third days of the disease 
 by cold affusion. The evidence which he adduced in support 
 of these cases being really typhus fever would scarcely be 
 accepted in the present day, though it was accepted so late as 
 1867 by the late Dr. Hudson, of Dublin, but this eminent 
 authority did not bring forward any cases of his own in support 
 of such conclusions. 
 
 It is probable that many of his cases of aborted typhus 
 were merely the effects of a drunken debauch. In epidemic 
 times, alcohol is frequently looked upon as a preventive of fever, 
 and for this and other reasons freely imbibed. Dr. Currie 
 used very little alcohol in the treatment of fevers, though in 
 many other diseases he ordered it with an unsparing hand. 
 
 The cold water treatment was very soon abused. In the 
 second volume of his work. Dr. Currie tells us : — " It has come 
 to my knowledge, that in two cases .of scarlatina, of the most 
 malignant nature, the patients have been taken out of bed, 
 under the low delirium, with the skin cool and moist, and the 
 pulse scarcely perceptible. In this state, supported by the 
 attendants, several gallons of perfectly cold water were madly 
 poured over them on the supposed authority of this work ! I 
 need scarcely add, that the effects were almost immediatelyfatal." 
 
20 A HISTORY OF THE TREATMENT 
 
 Dr. Currie himself exercised great caution over the use of 
 cold water in fevers, but he had such faith in the remedy that 
 he quickly extended its use to other diseases for which it was 
 in no way suited, and his want of success often made him 
 more bold in its application. In a case of tetanus, where he 
 says, " our proceedings being obstructed neither by the pre- 
 judices of ignorance, nor the weakness of affection, another, 
 and a last effort for his life was resolved on." This last effort 
 is thus described : — " Gardner was carried to the public 
 salt water baths of this town, then of the temperature of 
 S6° Fah., and thrown headlong into it. The good effects were 
 instantaneous. As he rose from the first plunge, and lay 
 struggling on the surface of the water supported by two of 
 his fellow soldiers, we observed that he stretched out his left 
 leg, which had been for some time retracted to the ham. But 
 his head did not recover the same freedom of motion, and 
 therefore he was plunged down and raised to the surface 
 successively for upwards of a minute longer, the muscles of 
 the neck relaxing more and more after every plunge. When 
 taken out, we felt some alarm ; a general tremor was the only 
 indication of life, the pulse and the respiration being nearly 
 if not entirely suspended." However the after treatment was 
 very successful, " and in less than a month we had the satis- 
 faction of seeing our patient under arms, able for the service 
 of his country." Several of his succeeding cases of tetanus 
 were not followed by such happy results, and there seemed to 
 to be a danger of cold water falling into disrepute in this 
 disease, until he superadded wine and bark, on the authority 
 of Dr. Rush, of Philadelphia. In one successful case, during 
 twenty-eight days, the patient " drank, mixed with nourish- 
 ment, and by itself, the extraordinary quantity of a hundred 
 and forty bottles of wine, being five bottles of Madeira a day, 
 besides some ale, and several gallons of brandy." Teetotallers 
 will be pleased to learn that afterwards this man took a 
 decided aversion to strong liquors. Such cases as those show 
 the necessity for a man not having too much faith in any- 
 thing, not even in himself. 
 
OF THE CONTINUED FEVERS. 21 
 
 In 1783, Dr. Haygarth, of Chester, almost stamped out typhus 
 in that city by a system of ventilation, isolation, and disinfec- 
 tion. His practice was afterwards adopted in most of the 
 large towns of Great Britain and Ireland. 
 
 In 1816, Dr. John Armstrong, Physician to the Fever 
 Institution of London, supported, in a modified form, the 
 practice of Currie. He also tried to revive venesection, which 
 had to a certain extent fallen into disuse, under the influence 
 of the Brunonian doctrines. He condemned the use of stimu- 
 lants in the first and second stages of typhus fever, but 
 admitted them towards the close. 
 
 In J 816, Dr. Robert Thomas, of Salisbury, in his practice of 
 physic, followed the teaching of Jackson rather than that of 
 Currie with reference to cold ablutions, and as a pupil of 
 Cullen and Gregory, he was an advocate of such evacuants as 
 bleeding, purging, and vomiting. 
 
 In 1818, Dr. Thomas Bateman recommended sponging with 
 cold water rather than afi'usion, and he was a strong advocate 
 for bloodletting in opposition to the Brunonian doctrine of 
 asthenia, with consequent stimulation. He also preferred the 
 antiphlogistic theories of Cullen to the views on antiseptics of 
 the chemical school. 
 
 At the beginning of the present century, Dr. Clutterbuck 
 ascribed fevers to a topical inflammation of the brain, and 
 reiterated his views in the second edition of his work pub- 
 lished in 1825. He refused to admit any essential difierence 
 between idiopathic and symptomatic fevers ; just as the pyrexia 
 of the latter was due to inflammation of some organ, so that of 
 the former was due to inflammation of the brain. This theory 
 as to causation was naturally followed by an active anti- 
 phlogistic treatment. He was willing to admit the value of 
 cold aflusions in the early stages of typhus fever as a means 
 of lessening the " inflammatory action in the vessels of the 
 brain," but he ascribed its beneficial efiects to the sudden 
 impulse on the nervous system and not to an abstraction of 
 heat from the body. 
 
 In 1822, Dr. Park reduced' the causes of fever to three, 
 
22 A HISTORY OF THE TREATISIEXT 
 
 "sympathy, irritation, and debility," and his treatment was 
 equally definite. " Thus bleeding, which is almost specific in 
 inflammatory fever, is rarely called for, and generally inadmis- 
 sible in acrue. Cold afiusion. which often cuts short an attack 
 of tpyhus, would be dangerous, if not fatal, in fever from local 
 inflammation. Bark, arsenic, and opium, if administered in 
 the same manner as in ague, would be injurious in typhus, 
 and wholly inadmissible in every form of fever with local 
 inflammation." 
 
 In 1824, Dr. Mills looked upon typhus fever as essentially a 
 phrenitis, and his views as to cause and treatment were very 
 similar to those of Dr. Clutterbuck, though he wished to claim 
 a certain amount of originality for himself. 
 
 In 1825, Dr. Mason Good in his standard work on medicine, 
 gave a cood account of the histor}^ of the cold water treatment 
 and strongly advocated its use. He also prescribed quinine, 
 and was very careful in the use of alcohol. " We must be 
 cautious however, in first administering it ; for its very stimu- 
 lus produces exhaustion, and consequently increased torpitude ; 
 and we should invariably recollect, that when we have once 
 commenced with its use, we can never leave it off; and should 
 hence begin with such doses as may be safely persevered in, or 
 even increased if necessary." 
 
 Dr. Cuming Askin has placed in my hands the unpublished 
 lectures of his grandfather. Dr. Thomas Cuming, which were 
 delivered in the Carmichael School of Medicine, Dublin, in 1826. 
 Dr. Cuming in simple continued fever employed emetics in the 
 early stage ; the cold affusion as carried out by Currie in the 
 second stage, together with active purgation ; while in the 
 stage of collapse he gave 4 to 12 ounces of Madeira wine daily, 
 and was careful that the patient should not then have more 
 than two motions daily. In the inflammatory types of the 
 disease, and where there was evidenee of visceral congestions 
 he employed general and local blood-letting. In cases of 
 internal haemorrhage he used opium freely. 
 
 In 1830 there appeared a treatise on fever by Dr. Southwood 
 Smith, a very vigorous writer and an equally bold practitioner. 
 
OF THE CONTINUED FEVERS. 23 
 
 He scorned the views of adynamia which were then beginning 
 to prevail, speaking of typhus fever, he says : — " The notion of 
 debility in the intense forms of fever I look upon to be an 
 error no less palpable in its nature than destructive in its con- 
 sequences ; and if the havoc it produces do not confer upon it 
 a pre-eminence as bad as that of the very disease of which it 
 is supposed to constitute the essence, it at least entitles it, in 
 comparison with every other error in medicine, to the distinc- 
 tion recognised in society, between the hero and the murderer ; 
 the one destroys a single human being now and then ; but the 
 other numbers its victims by thousands." " The only morbid 
 condition of fever, of which we have any knowledge, and over 
 which the medical art has any control is that of inflammation." 
 He held that the various types of fever differ in nothing but 
 in the degree of their intensity. Mild cases required very little 
 treatment except confinement to bed, the abstraction of stimuli, 
 a poor diet, and frequent calomel purgatives, but when the 
 fever passes beyond the mildest form, " it is never for a moment 
 to be neglected." 
 
 From many pages of vigorous writing and forced similes I 
 will cull a few sentences which will help to show the mode of 
 treatment to which Dr. Smith subjected his fever patients. 
 " The physician, in the first stage of fever, armed with his 
 lancet, is to his patient what the fireman with his engine, 
 before the flames have had time to kindle, is to a building that 
 has taken fire. At this early stage, the former can check 
 inflammation with almost as much ease and certainty as the 
 latter can prevent the flames from bursting out. On the 
 contrary, the physician who is called to treat inflammation in 
 the later staga of fever is in the position of the man who 
 arrives with the apparatus for saving the home when its 
 stories have been already consumed, and its roof has fallen 
 in." "During this early period the physician is master over 
 the disease ; if he allow it to pass away without obtaining the 
 victory, the disease becomes master over the physician. From 
 that moment his control over it is gone, never can he regain 
 his lost advantage. Fever is a process that advances with a 
 
24 A HISTORY OF THE TREATMENT 
 
 step as steady as time, and like time it never retraces a step." 
 " The abstraction of blood must be carried to the extent of 
 subduinoj the inflammation ; there is no other limit to the 
 quantity to be taken but that which is adequate to subdue the 
 inflammation. To attempt to measure the quantity by drachms 
 or ounces is wholly vain ; because, if the remedy be properly 
 employed, the quantity will vary in every individual case. To 
 take an ounce more than the subdual of the inflammation 
 requires is injurious ; to take an ounce less is still more 
 pernicious ; to take the quantity necessary to accomplish the 
 object, and no more, is to use the lancet — that powerful 
 instrument, so dangerous in rash hands, and no less dangerous 
 in weak, with the discernment and decision of a master." 
 
 " The best purgatives consist of one or two grains of calomel, 
 with six or eight of rhubarb, repeated every night or every 
 other night, and followed the next morning by two drachms or 
 half-an-ounce of castor oil, or by a common senna draught. 
 Cold sponging, if the skin be hot ; acidulated drink, if there be 
 thirst ; perfect quiet, a dark room, a silent nurse, aflbrding 
 prompt attendance, with a noiseless step, a cheerful countenance, 
 and no words — this, together with three teacups full of thin 
 arrowroot or gruel, in the twenty-four hours, given in divided 
 portions, at intervals of about two or three hours, comprises all 
 else that will be required or that will be useful, until the 
 period of convalescence." 
 
 When there were severe cerebral symptoms he employed the 
 " remedy known by the name of the cold dash." It consisted 
 of pouring a column of cold water upon the head in a continued 
 stream from a height of from six to ten feet. " Employed as a 
 remedy, there is no'degree of burning heat which the animal 
 economy is capable of producing, no intensity of vascular 
 action, and no violence of pain that can resist its continued 
 application. Sooner or later, usually in from ten to twenty 
 minutes, the heat, though most intense, disappears, the skin 
 becomes cold, the face pallid, the features shrunk, while the 
 pulse is reduced to a mere thread, and the pain of the head, 
 however violent and intolerable, entirely ceases." His friend, 
 
OF THE CONTINUED FEVERS. 25 
 
 Dr. Dill, while suffering from a severe attack of typhus fever 
 was subjected to this most rigorous treatment in its entirety, 
 and yet he recovered. 
 
 The reader will not now be surprised at the following statistics 
 of the London fever hospital. In 1825 there were 588 cases 
 with 104 deaths; in 1826, 676 cases with 110 deaths; in 1827, 
 676 cases with 87 deaths; and in 1828, 597 cases with 81 
 deaths. Dr. Southwood Smith's views on the nature of fever 
 were largely a compound of the inflammatory doctrines of 
 Clutterbuck and Broussais, and his practice was correspond- 
 ingly energetic. 
 
 In 1830 there appeared a work "On Clinical Illustrations of 
 Fever," by another physician to the London Fever Hospital, 
 Dr. Alexander Tweedie, who liveil to afterwards moderate his 
 antiphlogistic practice, though he did not lessen his opposition 
 to Dr. Currie's cold affusion. He noted the pathological lesions 
 which occur in typhoid fever, but a specific distinction between 
 typhus and typhoid fever was not drawn for another ten years, 
 " I have generally prognosticated ulceration of the bowels, 
 %vhen the fever has run on for a lengthened period, and has pro- 
 duced great emaciation, accompanied with peculiar, harsh, dry 
 or shrivelled appearance of the skin, black sordes on the teeth, 
 with sympathetic disturbance in the brain." The enteric 
 lesions had been previously described by Andral, Louis, and 
 Broussais, but typhoid fever seems to have been the prevailing- 
 disease in France, while typhus was most prevalent in this 
 country. 
 
 About this time there was a reaction in the Scotch and 
 Irish Schools against the grave errors of depletion, and the 
 teachings of Alison, Christison, Graves, and Stokes were to 
 support the vital powers and thus enable the patients to over- 
 come the morbid tendencies of fever. With the ideas of 
 support alcohol came more into vogue and the use of cold 
 water gradually waned. Alcohol was looked upon as a valuable 
 food, and such implicit faith was placed in it as a means of 
 support that it was largely used in acute diseases to the exclu- 
 sion of almost every form of nutriment except beef tea. 
 
26 A HISTORY OF THE TREATMENT 
 
 In 1839 we find Dr. Roupell, of St. Bartholomew's Hospital,. 
 still adhering to the tenets of the London School. He used 
 blood-letting, though not to a great extent, emetics, purgatives, 
 salines, antimony, and mercury. He, however, prescribed stimu- 
 lants, especially in the late stages of the disease. 
 
 In 1840, Dr. A. P. Stewart clearly distinguished between 
 typhus and typhoid fever. He was followed by Sir William 
 Jenner, Dr. Murchi^son, and Professor Gairdner, and owing to 
 the labours of these eminent men the specific distinctions 
 between these two diseases have been w^ell established. 
 
 In 1843, Dr. George Gregory, writing on scarlet fever, 
 thought that the aflTusion of cold water was only applicable in 
 a very limited number of cases. 
 
 In 1848, Dr. Ormerod of St. Bartholomew's hospital, had com- 
 pletely discarded blood-letting and was using stimulants in a 
 careful but tolerably free manner in continued fevers. 
 
 In 1852, there was published a valuable work "On the 
 History, Diagnosis, and Treatment of the Fevers of the United 
 States," by Elisha Bartlett. In the treatment of typhoid fever 
 he gives a summary of the views of others rather than any 
 express directions of his own. 
 
 Dr. Todd, in 1859, clearly stated a doctrine which is largely 
 held in the present day, viz. : " that disease is cured by natural 
 processes, to promote which, in their full vigour, vital power 
 must be upheld. Remedies, whether in the shape of drugs, 
 which exercise a special physiological influence on the system, 
 or in whatever form, are useful only so far as they may excite^ 
 assist, or promote these natural curative processes." 
 
 " It is a doctrine supported by our best physicians and 
 hio^hest authorities, that vou, cannot cure a fever ; that is that 
 you cannot cut it short; you can guide it through its, several 
 stages, you can support the patients strength, uphold his vital 
 powers, until the influence of the poison is worn out, and 
 combat any accidentp,! affections which may arise in the course 
 of ,the treatment, such as diarrhoea, pneumonia, &c. ; and by 
 such careful management you may save the patient, by prevents 
 ing him dying by exhaustion, and you may shorten his 
 
OF THE CONTINUED FEVERS. 27 
 
 convalescence considerably." Dr. Todd's great fallacy lay in 
 his belief that alcohol is a great supporter of vital power, and 
 unfortunately this is a fallacy which was very palatable both 
 to patients and their medical attendants. 
 
 At a time when Dr. Todd and his followers — who I think 
 were composed of the great bulk of the profession in England — 
 by their process of over stimulation were having a death-rate 
 of over 20 per cent, in fevers, Professor Gairdner of Glasgow, 
 by the use of milk rather than wine, and by the rational 
 method of treating the patients rather than their diseases, had 
 reduced the mortality to 10 per cent. It is not the first time 
 I have expressed the opinion that Professor Gairdner has done 
 more than any other man to reduce the death-rate in fevers, and 
 he merits the greater credit as he has been a pioneer in effecting 
 the great improvement which has taken place in the treatment 
 during the past quarter of a century. The principles enunciated 
 by Professor Gairdner have been gradually adopted in the 
 practice of this country, and nowadays I think there is not 
 much abuse in the use of alcohol, or in a too active medication, 
 in fevers. How long this great improvement, which has to 
 some extent been eff'ected by a process of masterly inactivity, 
 may be allowed to continue it is impossible to say. There have 
 recently been signs of unrest, and a tendency to actively 
 combat the fever with powerful antipyretic drugs, some of 
 which are about as lethal as the fever poison. 
 
 In 1862, Dr. Tweedie spoke unfavourably of the cold affusion, 
 and stated that, " it should, moreover, be kept in view that it 
 is applicable only to the more acute forms of fever in vigorous 
 subjects ; for, in the more delicate, the shock may be too great 
 and death may result from the practice — an event which 
 occurred many years ago in the family of a late eminent 
 professor, and greatly tended to throw the practice into 
 discredit, and ultimately led to its final abandonment." One 
 might have expected that it would probably have thrown the 
 professor, rather than the treatment, into discredit, for possibly 
 not following out the strict rules laid down by Currie. This 
 reasoning, at any rate, attributes great importance to the life,- 
 
28 A HISTORY OF THE TREaT]*IEXT 
 
 or death, of the professor's child, and is on a par with the 
 supposed effect that the death of a bishop would have in 
 stopping railway accidents. Possibly in these degenerate 
 days bishops' and professors' children may have fallen from 
 their high estate, but in the present day I don't think that the 
 abuse of a remedy in any particular instance would have 
 much effect on its stability. I am afraid it was not the death 
 of the professor's child, but many such deaths which effected 
 its discontinuance. Dr. Tweedie does not seem to have had 
 mucli faith in quinine, the use of which, in the continued 
 fevers, had been recently (1851) revived by Dr. Dundas, of 
 Liverpool. 
 
 At this time the cold water treatment had almost fallen into 
 complete disuse, but in 1861 it received a fresh impetus from a 
 work on the " Hydrotherapy of Typhoid Fever," by E. Brand, 
 of Stettin. The treatment was afterwards warmly espoused, 
 though the remedy was cold, by Bartels, Jiirgensen, Lieber- 
 meister, and Von Ziemssen, and it has now become the 
 recognised practice in Germany. 
 
 In " Ziemssen's Cyclopeedia," Liebermeister says :— " Quinine 
 digitalis, and the abstraction of heat by cold baths are among 
 the most important antipyretic agencies, and are positively 
 indispensable to the effective treatment of the fever." . . . 
 " The true danger consists in the deleterious influence of liigh 
 temperature on the tissues by means of which necrobiosis of 
 the same is brought about, manifesting itself anatomically as 
 parenchymatous degeneration. Paralysis of the heart is the 
 first in order among the conditions to be feared ; second in 
 order is paralysis of the brain ; and third in the category come 
 disturbances in other organs." From his standpoint, therefore, 
 the fever has to be combated at all hazards. " For adult 
 patients, the full length cold bath, of 68° Fah., or lower is to 
 be preferred." ..." The duration of the bath should be 
 about ten minutes. If prolonged much beyond that it becomes 
 unpleasant to the patient, and may even prove a danger to 
 him. If feeble persons are much affected by the bath, remain- 
 ing cold and collapsed for a long time, the duration should be 
 
OF THE COXTIXT'ED FEVERS. 29 
 
 reduced to seven or even to five minutes. A short cold bath 
 like this will have a much better effect than a longer one of 
 lukewarm water. Immediately after the bath the patient 
 should have rest ; he is, therefore, to be wrapped up in a dry- 
 sheet and put to bed (which may, with advantage, be warmed, 
 especially at the foot), lightly covered, and given a glass of 
 wine. In dealing with very feeble patients, one may begin 
 with baths of a higher temperature, say 75°, although, of 
 course, these will produce less effect. A method especially to 
 be recommended in such cases, if the surroundings permit, is 
 that recommended by Ziemssen, of baths gradually cooled 
 down, beginning with about 95°, and adding cold water 
 gradually until the temperature is reduced to 72°, or below. 
 These baths should be of longer duration." 
 
 He describes his usual plan of treatment as follows : — " If 
 the patient is admitted before the ninth day of the disease he 
 is first given calomel usually two to four doses, of eight grains 
 each, in the course of a few hours, to which, very often, one 
 or two doses are added the next day. From the time of his 
 admission, his temperature is taken every two or three hours 
 by day, and in somewhat severe cases, by night, too : and 
 whenever the temperature in the axilla reaches or exceeds 
 102°, or that in the rectum 103°, a bath of 68^^ in tempera- 
 ture and of ten minutes in duration is given. Patients who 
 require six or more baths during twenty -four hours, generally 
 receive on the second evening 22 to 37 grains of quinine, the 
 measurements of temperature, and the baths, as often as 
 required, being still continued. If towards morniog the tem- 
 perature falls to 100"5° in the rectum, and if this remission is 
 such that no baths are needed for twelve hours or lonofer, then 
 forty-eight hours after the first dose a second one of the same 
 size, or perhaps a smaller one is given; if, however, the fall of 
 temperature was not sufficient, then the second dose is made 
 larger, reaching 45 grains. If this prove sufi^cient, then the 
 same dose or a smaller one is repeated every second night as 
 lonof as the continuance of the fever seems to demand it. In 
 the very severe cases, in which even 45 grains of quinine seem 
 
30 A HISTORY OF THE TREATMENT 
 
 insufficient, recourse is had to digitalis as soon as the morning 
 after the administration of quinine. During the course of 
 the next thirty-six hours, from 11 to 22 grains of powdered 
 digitalis is used gradually, due regard being had to the state 
 of the pulse and temperature. Immediately thereupon, that 
 is, forty-eight hours after the last dose of quinine, 37 to 45 
 grains of the latter are given again. By the following morn- 
 ing the temperature has almost always fallen to 100"5° ; some- 
 times to 98"5°, or even below, and frequently the virulence of 
 the fever is broken for the rest of the attack, at least in so 
 far as that it can be controlled by a continuation of baths and 
 the use of quinine every other day. Under some circum- 
 stances it may be well to repeat the digitalis and quinine. If 
 it should happen, as it very rarely does, that no sufficient 
 remission is secured by the use of digitalis and quinine, we 
 may still have recourse to veratria, which sometimes succeeds in 
 sufficiently controlling the subsequent course of the fever." 
 
 This energetic treatment has found little favour in this 
 country, and I think very few of those physicians who have 
 adopted it have carried it out in its entirety. Even in Germany 
 " the majority of patients find the cold baths decidedly disagree- 
 able, no little persuasion and some authority on the part of the 
 physician being required to induce them to submit thereto as 
 often as is necessary." But it seems that towards the end of 
 the treatment they " have often begged for permission to take 
 a cold bath." The cold baths cannot be a very decided success, 
 or else they would not require such powerful accessories as 
 those enormous doses of quinine and digitalis and even veratria. 
 Anyone in possession of his rational faculties who took 45 
 grains of quinine I should think would not desire to repeat the 
 dose very soon, and if a patient of mine took 22 grains of 
 digitalis in 36 hours I would trust that the drug was not very 
 pure, or that the absorption from the patient's intestinal tract 
 might be defective. 
 
 This treatment seems however to be undoubtedly attended 
 with very great success in Germany, and Liebermeister shows 
 that the death rate has been reduced from 27 per cent, under 
 
OF THE CONTINUED FEVERS. 31 
 
 what he calls " indifferent treatment," and which as Professor 
 Gairdner has justly said must have been " very indifferent " to 
 8 per cent, under this complete antipyretic system. Recent 
 statistics would seem to show an even lower death rate, but I 
 will avoid quoting these as they are not accompanied with 
 sufficient evidence, as to the severity of the epidemics, and we 
 all know that typhoid fever is a disease which varies much in 
 intensity. In this country we have had no such death rate as 
 that recorded in Germany under " indifferent treatment," since 
 the days of Dr. Todd and the alcoholic school, and therefore we 
 have not had such headway to make up, which possibly may 
 to some extent account for our less heroic treatment. Possibly 
 also our less phlegmatic temperament may not be so well 
 suited for this German treatment. 
 
 In 1878, Professor Gairdner published in the Glasgow Medical 
 Journal a paper entitled " Caution in respect of the so-called 
 Antipyretic Treatment in Specific Fevers," in which he showed 
 equally good results by milder methods. Dr. Gairdner described 
 this antipyretic method as " a battledore and shuttlecock treat- 
 ment. It consists in keeping the patient, partly by means of 
 cold baths, and partly by those other remedies, in a state of 
 constant oscillation between fever and incipient collapse." 
 
 Among those in this country who have adopted the cold 
 water treatment may be specially^ mentioned Dr. Cayley, 
 Physician to the London Fever Hospital, who in the Croonian 
 Lectures, 1880, warmly advocated cold bathing. " In estimating 
 the value of any particular mode of treatment, we base our 
 judgment on two classes of facts. First, by the observation of 
 individual cases we see whether it appears to relieve the 
 symptoms and exercise a favourable influence on the course of 
 the disease. Secondly, we apply the test of statistics, and by 
 collecting a great number of instances, we ascertain the effect 
 on the general rate of mortality." He carefully points out the 
 fallacies to which both these methods are liable, and shows that 
 " before we are in a position to estimate the value of any par- 
 ticular mode of treating typhoid fever, we must be acquainted 
 not only with the natural course of the disease, but also 
 
32 A HISTORY OF THE TREATMENT 
 
 with the usual rate of mortality." The first method is 
 necessarily primary, and to my mind the most important, 
 because if the advantages of any treatment were not apparent 
 to my observation I would not carry it out for the sake of 
 accumulating statistics, but if any treatment really exercise a 
 favourable influence on the course of the disease in individual 
 cases, its value will be proved by the second method. After 
 judicially weighing the evidence I think he has clearly 
 established his points that the antipyretic method, especially 
 cold bathing, exercises a favourable influence on the course of 
 the disease, and diminishes the general rate of mortality. 1 am 
 quite willing, nay anxious, to concede all this, but I hope to 
 show further on that as judged by both these tests there is a 
 still better method. 
 
 To attempt to enumerate the writers on typhoid fever 
 during the last half century would be a herculean task, but 
 among those who have contributed to the general improvement 
 in the treatment of the disease, and who have led rather than 
 followed current thought may be mentioned — Alison, Bartels, 
 Brand, Broadbent, Bouchard, Brouardel, Chomel, Cantani, 
 Cayley, Collie, Christison, Nathan S. Davis, Dujardin-Beaumetz, 
 Dumontpallier, Austin Flint, Fenwick, Fereol, Fuerbringer, 
 Gairdner, Glenard, Grancher, Graves, Griesenger, Grimshaw, 
 Huchard, Immermann, Sir William Jenuer, Jiirgensen, Jacoud, 
 Libermann, Liebermeister, Leyden, Murchison, Nothnagel, 
 Neubauer, Ord, Peter, Raynaud, F. T. Roberts, Rossbach, 
 Rilliet and Barthez, Stokes, Arthur E. Sansom, Troussau, ^ 
 Traube, Vulpian, Wunderlich, and Von Ziemssen. / 
 
 I must not omit to refer to an admirable address on the 
 treatment of Typhoid Fever, in The Lancet, November 15th, 
 1879, by Sir William Jenner, the Sydenham of our own day. 
 His treatment is largely symptomatic, as may be inferred from 
 the following paragraph : — " I have never known a case of 
 typhoid fever cut short by any remedial agent — that is cured. 
 The poison which produces any one of the acute specific 
 diseases (to which order typhoid fever as much as small-pox 
 belongs) having entered the system, all the stages of the 
 
OF THE CONTINUED FEVERS. 83 
 
 disease must, so far as we know, be passed through before the 
 recipient of the poison can be well. If the patient can be kept 
 alive for a definite time the specific disease ends, and then, if no 
 local lesion remain to constitute a substantive disease, the 
 patient is well. The treatment of typhoid fever is essentially 
 rational. To treat a case with the best possible prospect of 
 success the physician ought to be acquainted with the epidemic 
 constitution of the period, the etiology of the disease, its mode 
 of attack, its natural course, the order of appearance, and the 
 natural duration of each of its symptoms, the way in which 
 each symptom influences the termination, the several patho- 
 logical lesions which produce or may produce each special 
 symptom, and the complications to be watched for at each 
 stage of the disease." 
 
 With the numerous peptonising agents at present in the 
 market, his condemnation of the free use of milk is not so 
 applicable as when his address was delivered ; and I should 
 not care to endorse the amount of alcohol which he found it 
 necessary to administer. 
 
 In this city, the original home of " the cold water cure," this 
 treatment has not found much favour. Dr. Robertson carried 
 it out in some cases, but he has now discontinued it. In cases 
 of hyperpyrexia from rheumatic fever, the cold baths have 
 been very successfully used by Dr. Waters, Dr. Carter, Mr. 
 Paul, Mr. Damer Harrisson, and others. Personally I never 
 approved of the cold water treatment of typhoid fever, because 
 mild cases did not require it, and in severe cases the patients 
 did not seem to me in a fit condition to bear such a series of 
 intermittent shocks, which too frequently have to be counter- 
 acted by a liberal allowance of alcohol. Even for hyperpyrexia, 
 I preferred to wrap the patient up in a sheet, and suspend him 
 on another sheet over an empty bath, or lay him on a sofa 
 which had been covered with waterproof sheeting, and then 
 pour a stream of tepid water over his body until the tempera- 
 ture in his rectum was reduced to 101° Fah. By this means 
 all shock is avoided, there is no inordinate chilling of the 
 surface, the primary increase of the internal temperature does 
 
34 A HISTORY OF THE TREATMENT 
 
 not take place, there is no production of internal congestion, 
 and the subsequent reaction occurs more slowly. When the 
 temperature was thus reduced I would now place the patient 
 in the continuous bath, and thus prevent any recurrence of the 
 hyperpyrexia. 
 
 Those who have adopted the cold baths have not unfrequently 
 found that in some cases they fail to make much impression 
 on the temperature ; this has been especially marked in large 
 stout individuals who are covered with a non-conducting layer 
 of fat, and in whom the cooling surface of the skin is compara- 
 tively much less proportionate to the mass to be cooled, than 
 it is in lean individuals. A slight knowledge of the physics of 
 water might have taught this without a number of useless 
 experiments on human beings. Water is a very bad conductor 
 of heat, and in fact its conducting power depends chiefly on 
 its varying densities at different temperatures. This difference 
 of density is so slight within the limited number of degrees 
 that the water can be applied below the temperature of the 
 body that the heat abstraction must take place comparatively 
 slowly. When cold water is applied to the skin, it diminishes 
 the circulation in the dermis, and thus lessens the supply of 
 heat for abstraction, and increases its retention in the internal 
 organs. For the foregoing reasons this is most marked in 
 large fat bodies. Tepid water — which does not lessen the 
 circulation in the skin — especially when it is brought into rapid 
 contact with the surface either by affusion or by agitation of 
 the water in a bath, abstracts the heat more quickly and 
 effectively than can be accomplished by cold baths. 
 
 In 1861, Hebra introduced the continuous bath for burns and 
 scalds, psoriasis, pemphigus, &c., and one of his patients was 
 immersed for a hundred days, during which time he gained 14 
 lb. in weight. It has since been used by many surgeons on 
 the Continent and in this country, but from the very limited 
 number of references to this treatment in The Medical Digest, 
 I conclude that it has not been frequently adopted. Perhaps 
 the continuous partial bath has been more frequently used. 
 Sir William Stokes, of Dublin, invented an excellent bath for 
 
OF THE CONTINUED FEVERS. 35 
 
 keeping a limb constantly immersed in water of a given tem- 
 perature. Mr. Rushton Parker, of this city, used a partial 
 boracic bath in several cases of operation for extroversion of 
 the bladder. Nearly 20 years ago, my colleague, Mr. Puzey, 
 successfully treated a case of pyaimia for nearly four months 
 in a continuous bath. In 1886 when I was physician to the 
 Stanley Hospital, I kept a patient who was suffering from 
 pyaemia, acute periostitis of left femur, acute arthritis of left 
 hip and knee joints, and extensive bed sores, for 17 weeks in 
 a continuous bath. Not only was the life of this patient saved 
 but she made a good recovery. This ease was published in The 
 Liverpool Medico-Chirurgical Journal, July, 1887. I then 
 dealt fully with the physics of the subject, to which I need 
 not now refer. Since then I have carried out this treatment 
 in many cases of acute diseases, but as in these cases the bath 
 only formed one, and perhaps not the most important factor 
 in the treatment, I will not refer further to them at present. 
 
 The continuous bath has been used by Liebermeister and 
 others for the treatment of bed sores following typhoid fever, 
 but so far as I am aware it has not hitherto been used by any 
 one for the fever itself. I find that a good many of those who 
 have used the tank, have interposed waterproof sheeting 
 between the patient and the water. This really converts the 
 tank into the original water bed of the late Dr. Neil Arnott, 
 and is quite distinct from the immersion treatment. The 
 water bed should never be used as an antithermic agent, as 
 water is an almost absolute non-conducter in a downward 
 direction, as anyone should know who has ever boiled the 
 superficial layer of urine in a test tube, and only conducts in an 
 upward direction on account of its fluidity — the warm layer 
 in contact with the heated surface becoming lighter rises to the 
 top, and is replaced by a colder and denser layer, and so on 
 until an equality of temperature is established. The result, 
 when the febrile patient comes in contact with this cold surface, 
 is, that a superficial film of the water may get slightly warmed, 
 but very little heat is abstracted from the body ; on the other 
 hand the cold bed chills the surface of the patient in contact 
 
36 A HISTORY OF THE TREATMENT 
 
 with it, contracts the bloodvessels, drives the blood to the 
 internal organs, and raises the internal temperature, thus 
 augmenting- the evil it was intended to remedy. 
 
 The antipyretic action of even the ordinary immersion bath 
 is frequently not well understood even by teachers of the art 
 of medicine. One man immerses his patient in very cold water, 
 another more cautious, but not less ignorant, places him in tepid 
 water, and slowly and cautiously lowers the temperature. Both 
 will tell you that you should be careful to employ the bath 
 before the temperature of the patient reaches 105° Fah., as the 
 internal temperature rises a degree or more after immersion. 
 These crude experiments are performed on patients often 
 with disastrous results, simply from the want of elementary 
 knowledge of physics. If it were simply understood that 
 water is a bad conductor of heat, and that consequently it 
 should be constantly agitated so as to keep changing that in 
 contact with the surface of the body, it would be found that 
 there is no necessity for lowering the temperature to such a 
 degree as to run the risk of producing collapse, and the necessity 
 for warm cordials. 
 
 For four years I have been using the continuous bath as an 
 antipyretic agent. From my observations in other cases I was 
 led to conceive that it would have a good effect in typhoid 
 fever, and in the cases which I have thus treated, my favour- 
 able anticipations have been more than realised. I do not 
 look upon the high temperature as the sole evil of fevers, and 
 therefore I have made no attempt to do more than moderate 
 the temperature. I have been more anxious to keep the 
 patient comfortable than to produce apyrexia. When the 
 patient's temperature is high I prefer to keep the temperature 
 of the tank water at 90° Fah., and as the temperature of the 
 patient approaches the normal I raise the temperature of the 
 tank to 95°. There is then no fear of producing a collapse 
 temperature as the heat of the patient cannot fall below that 
 of the tank. I liope also to show that the lowering of 
 temperature is not the only advantage to be gained by a 
 prolonged immersion. 
 
OF THE CONTINUED FEVERS. 37 
 
 It has been said with some degree of truth, though the 
 analogy is not strictly accurate, that, " you can no more cure a 
 fever than you can quell a storm ; but you can guide a case, as 
 you would guide the vessel, through the danger." A skilful 
 mariner will direct his vessel safely amid reefs and shoals 
 provided they are marked on his chart, or he can sail into 
 placid waters until the storm blows past, so the careful 
 physician should be on the look out for all danger signals 
 ahead, or he can place his patient in the warm water of the 
 tank, which has not merely the effect of allowing the fever 
 to subside but also of quelling the violence of the storm and 
 thus curing the fever. A clergyman referred to one of my 
 patients "as the man in the dock," to which I replied that at 
 at any rate we did not require a dry dock for effecting repairs. 
 
DIAGNOSIS. 
 
 For the effectual treatment of any disease it is important to 
 recognise not merely the state o£ the patient, but also the 
 morbid conditions which underlie and give rise to that 
 state. I may therefore be allowed to interpolate a few 
 remarks on the subject of diagnosis. Too frequently when the 
 case comes under the care of the physician the stages of 
 doubt and difficulty have passed and the disease is only too . 
 apparent. The ideas of aborting specific diseases have in the 
 present day been considerably altered, but there can be no 
 doubt that such diseases may be considerably modified by 
 early treatment, and often prevented from ever assuming a 
 grave character. The commencement of typhoid fever is 
 usually very insidious, and it is frequently only by a process 
 of exclusion that we can arrive at a presumptive diagnosis, 
 which, however, is generally soon clearly established by the 
 characteristic increments in the daily temperatures, with 
 marked evening exacerbations and morning remissions during 
 the first four days; by the dull listless aspect of the patient ; 
 the tongue furred in the centre with red tip and edges ; the 
 abdomen swollen: the spleen enlarged: the motions at first 
 dark brown and acid, afterwards becoming greenish yellow 
 liocculent " pea soup " character and alkaline in reaction ; and 
 by, in the majority of cases, the appearance of the 
 characteristic red lenticular spots on the abdomen and chest. 
 Other diseases are perhaps more frequently mistaken for 
 typhoid fever than the reverse, and many acute affections may 
 complicate, or be complicated by typhoid fever, in which cases 
 the diagnosis becomes correspondingly difficult. 
 
 Ehrlich has given us a valuable urine test in cases of typhoid 
 fever, and on this subject there is an interesting article in The 
 Therapeutic Gazette, February, 1891, to which I am under 
 some obligation for the following remarks. Ehrlicli made use 
 
THE TREATMENT OF TYPHOID FEVER. 39 
 
 of the fact that sulphanilic acid, when treated with nitrous 
 acid in a nascent state forms in solution the diazo-benzeue- 
 sulphonic acid, which thus becomes the active principle in the 
 mixture employed. When this compound is brought into con- 
 tact with some aromatic substance which occurs in the urine 
 of cases of typhoid fever, but of the nature of which we are at 
 present ignorant, a beautiful red colour reaction takes place 
 when the excess of acid is neutralized by strong ammonia. In 
 the preparation of this test two solutions are employed and 
 kept in separate bottles, the one containing a five per cent, 
 solution of ^hydrochloric acid saturated with sulphanilic acid, 
 and the other a five per cent, solution of sodium nitrite in dis- 
 tilled^water. One part of the sodium nitrite solution is added 
 to twenty-five parts of the sulphanilic acid solution, and the 
 whole mixed with an equal bulk of urine and rendered alkaline 
 by a strong solution of ammonia. I have usually found the 
 colour reaction best developed by adding five or six parts 
 of urine to one part of the mixed solutions, and afterwards 
 neutralizing with strong solution of ammonia. When the 
 whole of the contents of the test tube are well agitated, the 
 froth should have a pinkish tinge. The characteristic colour 
 reaction varies from an eosin to a deep garnet, or deep ruby 
 red, or port wine colour. 
 
 Dr. Charles E. Simon, in his paper published in The John 
 Hopkins Hospital Bulletin for November, 1890, only recom- 
 mends a half per cent, solution of sodium nitrite, and of this 
 solution he only uses one part to forty of the sulphanilic acid 
 solution. This mixture seems to me much too weak in nitrous 
 acid, and, moreover, nitrite of sodium is such an unstable salt 
 which undergoes rapid decomposition, that I am afraid unless 
 the solution was freshly prepared each time it was required, 
 the test would frequently fail from the absence of any nitrous 
 acid. Dr. Simon recommends the following modifications of 
 the test : — He adds five parts of absolute alcohol to one part of 
 urine, filters, and then runs into the filtrate the mixture of 
 sulphanilic acid and nitrite from a burette, and by this means 
 the amount necessary to develop the colour can be regulated. 
 
40 DIAGNOSIS. 
 
 The following method is said to be the most convenient, least 
 expensive, and most delicate. "A few cubic centimetres of 
 urine are taken in a small test tube, and an equal quantity of 
 the sulphanilic acid mixture added, the whole being thoroughly- 
 agitated ; one cubic centimetre of ammonia is then allowed to 
 carefully run down the side of the tube, forming a colourless 
 zone above the yellow urine, containing the acid ; at the 
 junction of the two a more or less deeply coloured ring will 
 be seen, the colour of which is readily distinguished and noted, 
 the slightest carmine tint being made out more readily by its 
 contrast with the colourless zone above, and the yellow below, 
 than when we are dealing with a uniform colour." 
 
 This colour reaction is almost invariably found during the 
 first two weeks of typhoid fever. It has also been found in 
 some cases of measles, phthisis pulmonalis, rheumatism, gout, 
 and some other diseases, but when it has occurred in these 
 aftections it does not seem to have been so well marked as it 
 is in typhoid fever. I have only been using this test for 
 about eighteen months, and, therefore, cannot speak definitely 
 as to its value, but although it is not pathognomonic, I believe, 
 as a corroborative test, it will be found of considerable 
 importance. 
 
 Drs. Hughlings-Jackson and Angel Money believe that in 
 typhoid fever the knee-jerk is never absent, whereas in tuber- 
 cular meningitis, its disappearance for a few hours, or a day, 
 or a few days, is by no means rare. In some undoubted cases 
 of typhoid fever there have been times when I have failed to 
 elicit the knee-jerk, and it should be remembered that some- 
 times meningitis complicates this disease. In a paper which 
 I published in The Liverpool Medico-Ghirurgical Journal, 
 January, 1891, on " The Treatment of Meningitis," I stated 
 that — " I have seen the knee-jerks exaggerated, and even ankle 
 clonus present in undoubted cases of meningitis, whereas it is 
 only in severe cases of typhoid that these conditions apper- 
 tain. If such observations be carried out for a more or less 
 lengthened period of time, it will be found that the knee-jerks 
 are much more variable in meningitis than in typhoid fever. 
 
THE TREATMENT OF TYPHOID FEVER. 41 
 
 In the latter disease the knee-jerks are much exaggerated 
 in severe cases, and this increases with the progress of 
 the disease, and is often accompanied by marked ankle clonus. 
 In meningitis, on the other hand, the knee-jerks and all the 
 reflexes are apt to be increased during the hyperaesthetic 
 stage, but when any cerebral effusion takes place the knee- 
 jerks are apt to be abolished, at least temporarily. As a 
 diagnostic sign, I attach far more importance to the hyper- 
 gesthetic condition itself, which, I may say, is invariably 
 present in the early stages of meningitis, whereas in typhoid 
 fever, although there is no abolition of reflex irritability, the 
 patient is apathetic, and does not present any inordinate 
 sensitiveness." 
 
 Neither will the tache cerebrale serve as a distinctive sign 
 seeing that it is often more marked in typhoid fever than in 
 meningitis. In meningitis — whether tubercular or simple — 
 the temperature is usually not so high as in typhoid fever, the 
 pulse is more variable in frequency, smaller, firmer, less com- 
 pressible, and ofteii rather irregular in rhythm if not in force ; 
 the headache and vomiting are more persistent, the bowels are 
 usually confined, and the abdominal walls retracted ; there is 
 frequently paresis of some of the ocular or other cranial 
 nerves, and not seldom double optic neuritis. 
 
 Acute pneumonic phthisis sometimes resembles typhoid fever, 
 but the respirations and pulse are much more frequent unless 
 the latter disease be complicated with pneumonia, and of 
 course the discovery of the tubercle bacillus, would settle the 
 point in favour of the former disease. 
 
 The onset of typhoid may in some cases be sudden, as in 
 case 7 of my series, where the temperature reached 104° on the 
 first evening, and in such a case if there be any harshness of 
 breathing pneumonia might reasonably be suspected. It should 
 also be recollected that in some cases of pneumonia the physical 
 signs do not rapidly develop, but even then the respirations are 
 usually quick and shallow. In typhoid fever there is very 
 frequently bronchial catarrh, or hypostatic congestion of the 
 lungs, or both, but these conditions, more especially the latter. 
 
42 DIAGNOSIS. 
 
 occur at a more or less advanced period of the disease, and, 
 unless accompanied by some acate inflammatory mischief, do 
 not give rise to any distress of breathing. Typhoid fever may 
 complicate many acute diseases or be thus complicated, and 
 when the patient first comes under observation at a late stage 
 of the disease it may be difficult to diagnose the underlying 
 typhoid condition from the pneumonia or other acute aflection 
 which has supervened. However a little time and patience will 
 usually clear up all doubts, and I shall not dwell further on 
 the subject. 
 
THE TREATMENT OF TYPHOID FEVER. 
 
 I am now in a fair position for describing my own method of 
 treatment. I may at once premise that typhoid fever is a 
 disease which varies very much in severity, and therefore I do 
 not believe in any routine system of treatment as apphcable to 
 all cases alike. If our object be to obviate the tendency to 
 death, we will find that all or nearly all mild cases do well., and 
 therefore require very little active interference. Of course the 
 severity of the case must not be under estimated, as I am 
 afraid too frequently happens, seeing we often hear of mild 
 cases ending fatally. On reading the history of various 
 epidemics of typhoid fever anyone must be struck with the 
 great difference in the intensity of the disease as it affects 
 various communities, and therefore similar methods of treat- 
 ment are often attended with very different results, and 
 frequently new methods of treatment get credit for results to 
 which they are in no way entitled. 
 
 Appended to this essay I have recorded fifty-five successive 
 cases, with only one death, so that any one can judge of their 
 severity. Thirty-three of the cases were severe or very severe, 
 while twenty-two may be reckoned mild as they did not require 
 any special treatment, and never gave rise to any anxiety as to 
 the ultimate result. The special treatment of the thirty-three 
 cases has fulfilled the conditions laid down/oy Dr. Cayley, as it 
 not only had a decidedly and very obviously beneficial effect on 
 the course of the disease in individual cases, but it has greatly 
 lessened the general mortality, and I have no doubt whatever 
 but that if it were generally adopted thousands of lives would 
 be annually saved. 
 
 Dr. Cayley, Dr. Broadbent, and Dr. Frederick Roberts 
 estimate the mortality in this country from typhoid fever under 
 the present expectant treatment at from 15 to 2.5 per cent., and 
 I am afraid their estimate is only too true. Dr. Hope has 
 
44 THE TREATMENT OF TYPHOID FEVER. 
 
 furnished me with the report of 677 cases treated in the fever 
 hospitals of this city with a mortality of 82, or 121 per cent., 
 of the cases treated. Dr. Hope feels justly proud of the com- 
 paratively low mortality in the Liverpool hospitals, but to my 
 mind all these death-rates are much too high for any disease, 
 the incidence of which for the greater part occurs under thirty 
 years of age. Dr. Hope has arranged the cases of the Liver- 
 pool Fever Hospitals according to the ages of the patients. 
 There were 303 cases under 15 years of age, with 22 deaths, or 
 a percentage death-rate of 7 "2 6. From 15 to 30 years of age 
 there were 209 cases with 30 deaths, or 14-35 per cent. At 
 30 years of age and upwards there were 79 cases with 18 deaths, 
 or 22-8 per cent. There were 86 cases in which the age was 
 not specified, and these gave 12 deaths, or 14 per cent. 
 
 Prophylaxis. Prevention is better than cure and when we 
 have got to deal with a case of typhoid fever we should, if 
 possible, find out the source of infection so that the patient 
 may not be further subjected to any deleterious influence, and 
 that others may not be exposed to the risk from which the 
 patient has failed to escape. Every possible precaution should 
 also be taken to prevent the patient from becoming, either 
 directly or indirectly, a cause of disease in others. In the filth 
 and overcrowding of former ages arose the fearful epidemics 
 of typhus fever which devastated this country, and then 
 typhoid fever though not unknown was comparatively rare. 
 In the present day we are able to quickly stamp out this 
 infectious pest, but with all our modern conveniences of water- 
 closets, baths, wash basins, &c., there is too often defective 
 plumbing and bad sewerage so that the typhoid poison is 
 directly introduced to our homes. We are not likely, however, 
 to give over these conveniences on account of any attendant 
 danger, it therefore behoves everyone to look to his own house, 
 and to see that it is in good sanitary condition. Special attention 
 should also be directed to the water and milk supply, and the 
 various articles of food should not be neglected, for, as has been 
 pointed out by Dr. Cayley, several epidemics have arisen from 
 the consumption of diseased meat. 
 
THE TREATMENT OF TYPHOID FEVER. 45 
 
 To prevent any spread of disease from the patient, all the 
 dejections, and soiled clothins^ should be thoroughly disinfected. 
 It would be rather hazardous to express a definite opinion 
 as to which are the best disinfectants, especially where economy 
 is a matter of some consideration, but for my own part I use 
 for the fseces a saturated solution of sulphate of iron with two 
 ounces of strong sulphuric acid to the quart: and the soiled 
 linen, &c., are soaked for two days in a solution of the perch- 
 loride of mercury (I in 1000), before being washed. After the 
 recovery, or death of the patient, all the bedding and wearing 
 apparel are disinfected by heat. 
 
 Dr. Cayley says that "the experience of the London Fever 
 Hospital pretty conclusively proves that the fresh stools are 
 innocuous." I might perhaps speak in a similar strain because 
 under my care the disease has never spread to any nurse or 
 other patient, but it seems to me a dangerous doctrine to incul- 
 cate. It is true that one of my cases arose in hospital, but I 
 clearly satisfied myself that he must have contracted the 
 disease before his admission. On the other hand Dr. Hope is 
 convinced that the disease is more readily communicable from 
 one to another than is generally supposed. I have had in suc- 
 cession four members of one family, and Dr. Hope tells, me 
 that he found the house in good sanitary condition, and 
 although he was unable to trace the original source of the 
 disease, he is strongly of opinion that the last three contracted 
 it from the first affected. Dr. Hope quotes many similar 
 instances in his paper, on " The Incidence of Typhoid Fever," 
 in The Liverpool Medico-Ghirurgical Journal, July, 1889. 
 
 If the poison be particulate, as it is almost universally 
 assumed to be, and if it be reproduced in the system, and 
 discharged in the fseces, then we should be very careful to 
 explain what we mean by the " fresh stools being innocuous." 
 It is highly probable that no harm can arise from the mere 
 smell of a fresh stool, and that the typhoid bacilli cannot be 
 thus communicated, but if, through carelessness on the part of 
 the nurse, a little of this fresh stool got introduced into the 
 food of others I should have grave apprehensions as to the 
 
46 THE TREATMENT OF TYPHOID FEVER. 
 
 consequences. An anaerobic germ like the typhoid bacillus is 
 not likely to assume any more virulent properties in the open 
 air, yet it is generally acknowledged that soiled linen and dry 
 pulverized excreta, may become sources of contagion. Such 
 conditions, as heat, stagnation, exclusion from air, concentration 
 of the poison, which are supposed to increase the virulence of 
 the germs are surely found not unfrequently in the intestinal 
 canal, and we often get recrudescences and relapses ; it seems 
 therefore to my mind very improbable that the fresh stools 
 are innocuous. 
 
 Acting on my conviction of the contagious nature of the 
 intestinal discharges from typhoid patients, I instruct the 
 nurses that the stools are to be well mixed with an abundant 
 supply of the disinfectant fluid and allowed to stand for a 
 short time before they are poured down the water closet, and 
 all utensils are to be washed with hot water and a disinfectant 
 "fluid. There are kept in each ward a ewer full of a solution of 
 perchloride of mercury (1 in 2000), carbolic soap, a nail brush, 
 and towels ; and the nurses are directed to wash their hands 
 well after every time they are in attendance on a typhoid 
 patient, and more especially before they handle any article of 
 food. I impress upon them the necessity for not allowing 
 " familiarity to breed contempt," and give them clearly to 
 understand that I shall be exceedingly displeased if any case of 
 disease should arise either among the staff or other patients. 
 
 The room or ward should be large, airy, well ventilated, 
 and kept at a temperature of about 60'' Fah. I prefer to have 
 the windows open both day and night. It is no doubt often 
 difficult in cold weather to maintain a uniform temperature 
 with open windows, but ventilation must never be sacrificed 
 for heat. In wards which are warmed by large volumes of 
 heated air constantly pouring in, there is not much risk of 
 draughts from open windows, but even where the only means 
 of heating is an open fire place, an abundance of fresh air may 
 be admitted from the outside. I am well aware that Dr. Currie 
 successfully treated a patient prostrate and delirious from 
 typhus fever by exposing him naked to a cold draught from 
 
THE TREATMENT OF TYPHOID FEVER. 47 
 
 an open window, and personally I would rather be treated in 
 the open air than in a close stuiFy room, but such extremes are 
 neither necessary nor desirable. In such a disease as typhoid 
 fever where the patient is liable to bronchitis and pulmonary 
 congestion or even pneumonia, from the effects of the poison, I 
 do not believe in increasing this mischief by making him 
 breathe cold air. The patient is dull, stupid, intellectual facul- 
 ties blunted, and pei-haps delirious, but the reflex irritability 
 remains intact. It may be occasionally necessary to arouse 
 the nervous energy by cold affusion, cold bath, or a blast of 
 cold air, but such powerful impressions should only be tempor- 
 ary, else they will soon exhaust the energy which they have 
 roused into existence. It is generally supposed that pneumonia 
 can be more readily induced by exposure while asleep than 
 when awake : it is therefore unreasonable to imagine that, in 
 a disease where the functions of the higher nerve centres are 
 to a great extent in abeyance, strong peripheral impressions 
 can be applied with impunity. Blasts of cold air, and cold 
 baths will undoubtclly cool and rouse the patient, but if too 
 prolonged, they must necessarily lead to internal congestions, 
 not merely by lessening the circulation in the periphery, but 
 by exhausting ami paralysing the reflex irritablity of the vaso- 
 motor nerves. In this disease there can be no objection to a 
 certain amount of carpeting on the floor, and as a means of 
 lessening noise it is decidedly useful. 
 
 The bedstead should be narrow and approachable from either 
 side. It should be fitted with spring and hair mattresses. 
 (Even in cases where the tank is used a bed will be necessary 
 at some stages of the disease). Flock and feather beds, eider 
 down quilts, and other non-conductors of heat should be strictly 
 avoided. The patient should lie between linen sheets, and 
 should only have an additional counterpane, or at most a single 
 blanket and a light quilt. There are of course many serious 
 cases, in which with a high internal temperature, the extremi- 
 ties are very cold, where the covering has to be considerably 
 modified, and it may be even necessary to supply hot bottles 
 to the limbs, and wrap them in flannel. All the clothing should 
 
48 THE TREATMENT OF TYPHOID FEVER. 
 
 be kept scrupulously clean. In many cases it is necessary to 
 use a water-bed to prevent bedsores, but from what I have 
 previously stated it should always be remembered that the 
 water-bed is, or should be, a warm bed, and it ought never to 
 be used as an antipyretic agent. The patient should be removed 
 each day, so that the water-bed and bedding may be aired, 
 and the condensed perspiration dried. If there be much 
 pyrexia the heating effect of the bed may be counteracted by 
 lessening the coverlets, but as a rule the water-bed is only 
 riecessary at the later stages of the fever when the temperature 
 is beginning to decline. 
 
 No matter how slight the attack the patient should be at 
 once put to bed, and kept in the horizontal position during the 
 whole course of the illness. In fact in all diseases bed is the 
 proper;place when the temp^J^ture is above the normal. The 
 bedpan should be used from the beginning, but especially 
 towards the later stages the patient should on no account be 
 allowed to assume the erect or even sitting posture for fear of 
 inducing fatal syncope. The patient should be kept very 
 quiet, fed at regular intervals, and encouraged to sleep. The 
 nurses should be kind, bright, cheerful, with noiseless tread, 
 well versed in their duties, and should keep an accurate record 
 of all events appertaining to the case. 
 
 Medicine. I have not much faith in giving a great quantity 
 of physic in typhoid fever, and some of my earlier cases in the 
 tank had almost none as I was anxious to simplify my 
 deductions, but the tank in no way interferes with any other 
 treatment which may be deemed advisable. If the patient 
 come early under observation, and there be much retching or 
 vomiting I am sufficiently old-fashioned to order an emetic, 
 and of all emetics the simplest is the best. I prefer two or 
 three tumblerfuls of hot water to anything else. If these 
 symptoms occur at a later stage of the disease they are 
 indicative of prostration with congestion of the stomach, or 
 perhaps some cerebral affection, and should be treated accord- 
 ingly, but no emetic should be administered. If the cause be 
 referable to the stomach a sinapism should be applied to the 
 
THE TREATMENT OF TYPHOID FEVER. 49 
 
 epigastrium, and an alkaline mixture, containing bismuth 
 administered, or a few small doses of charapagne given. If tiie 
 vomiting be cerebral a sinapism should be applied to the nape 
 of the neck, and a hypodermic injection of morphia, or morphia 
 and atropine, given. 
 
 I always begin the case with a good calomel purge, about 
 two grains, and throughout the illness when there is constipa- 
 tion I generally repeat the same remedy in about half -grain 
 doses. I can see no objection to the saline purgatives, or castor 
 oil, but I usually prefer calomel. It is however well not to get 
 into any routine habit of using it. In case 52, much larger 
 doses were administered than I am in the habit of prescribing, 
 and when I found her salivated I discovered that she had had 
 thirty-seven grains of the drug. 
 
 Constipation in this disease is frequently due to an inactive, 
 and a distended condition of the large bowel, of which the 
 natural secretion is defective, and consequently the liquid por- 
 tion of the faeces becomes absorbed. The hard scybalse may 
 cause irritation, and set up a catarrhal flux which, however, is 
 usually insufficient to effect their removal. The frequent 
 small liquid motions may give rise to the erroneous impression 
 that the trouble is diarrhoea rather than constipation. To 
 empty the large bowel and lessen its torpidity, small enemata 
 given daily or every alternate day will prove highly efficacious. 
 To effect this purpose a pint of warm thin gruel, or the same 
 quantity of soap and water, with, or without a little castor 
 oil and turpentine, may be administered. Glycerine, and 
 glycerine suppositories which induce hypersemia and consider- 
 able irritation of the lower bowel, are strongly contra-indicated 
 in this disease. 
 
 Sir William Jenner says : — " The most important, and a not 
 unfrequent, cause of inaction of the bowel in typhoid fever is 
 deep ulceration uf one or more Pyer's patches. Large super- 
 ficial ulcers favour the occurrence of diarrhoea, and are often 
 accompanied by catarrhal inflammation of the mucous mem- 
 brane. A single deep ulcer will paralyse the action of the bowel, 
 and so cause constipation, and this has to be kept in mind as 
 
50 THE TREATMENT OF TYPHOID FEVER. 
 
 a fact of the highest practical importance when it is proposed 
 to relieve the bowels by an aperient. A deep ulcer is usually 
 produced by the separation of a deep slough, and is often 
 unattended by any catarrhal inflammation of the small 
 intestine, or by any affection of the large intestine." Mild 
 laxatives are always the best, and for this reason I prefer 
 minute doses of calomel (which has a^so the advantage of being a 
 good antiseptic), or simple enemata. No strong purgative 
 should be given after the twelfth day, as the sloughs begin 
 to separate about the thirteenth to the fifteenth day. 
 
 When there is prolonged constipation, and reason to fear 
 deep ulceration with consequent greater liability to haemorr- 
 hage and perforation, it is most important to lessen or remove 
 the tympaniti'c distension of the bowels. This is best accom- 
 plished by an ice bag or cold compress to the abodomen, 
 or by immersion in the tank ; by the use of intestinal anti- 
 septics with small doses of calomel ; and by the administration 
 of turpentine both by the mouth and in the form of an enema. 
 If any haemorrhage should occur, turpentine and opium are 
 about the best remedies, while the efi'ects of perforation are 
 chiefly combated by the latter drug. We shall subsequently 
 deal more fully with these complications. 
 
 Diarrhoea, as the usual concomitant of the disease, carries off pec- 
 cant matter, and per se seldom requires any treatment. In some 
 cases it may be so severe as to produce exhaustion, and then 
 mild astringents with an antiseptic should be prescribed. About 
 the best drugs for this purpose are aromatic chalk and opium 
 powder, salicylate of bismuth, carbonate of bismuth, salol, cate- 
 chu, kino, and dilute sulphuric acid with small doses of opium. 
 
 Whenever the diarrhoea is profuse the motions should be 
 specially examined to see if there be any curds of milk, or 
 other particles of undigested food ; the milk and farinaceous 
 articles of diet should be peptonised; and all animal broths, 
 beef tea, fruit, vegetable juices, and excessive supply of liquids 
 should be stopped. If the motions are very alkaline and 
 strongly offensive, the necessity for intestinal antisepsis 
 becomes paramount. 
 
THE TREATMENT OF TYPHOID FEVER. 51 
 
 I am a strong advocate for the more or less routine adminis- 
 tration of intestinal antiseptics. I formerly used salicylic 
 acid suspended in milk, but since Rosenbach introduced 
 naphthaline in this disease, I have been in the habit of pre- 
 scribing it chiefly on account of its very slight solubility. More 
 recently I have been using ^-naphthol, and salol, and I now 
 prefer the latter drug. In the alkaline contents of the small 
 intestines, salol is decomposed into salicylic acid and phenol, 
 and I consider it one of the best intestinal antiseptics which 
 we possess. To an adult ten grains may be given every four 
 hours, and if there be much diarrhcea ten grains of salicylate 
 of bismuth should be added to each dose. When the bowels 
 are confined one-twelfth of a grain of calomel may be given 
 with each dose of salol. The great mistake in ordering 
 calomel is in giving it in too large doses; one-half grain in 
 twenty-four hours should be sufiicient for any ordinary mortal 
 who is suffering from typhoid fever. When I read of Lieber- 
 meister giving repeated doses of eight grains each, I am forced 
 to conclude that Germans and Englishmen require different 
 treatment. In a recent case /3-naphthol caused considerable 
 gastric irritation, which immediately subsided on the substitu- 
 tion of salol. The salicylate of quinine is a good antiseptic, 
 and being a very insoluble salt, it will probably pass a long- 
 way down the intestinal tract before it is absorbed. It had 
 better be used in small doses (two to four grains), and given 
 with some other antiseptic, such as the salicylate of bismuth, 
 salol, or salicylic acid. Quinine is said to be one of the best 
 antiseptics against the bacillus typhosus of Eberth. All the 
 antiseptics which I have mentioned can be given suspended in 
 milk, or they may be administered in cachets. 
 
 I think the above antiseptics will usually be found suf- 
 ficient, but I must not omit to mention some others which 
 have been recommended. Sir William Jenner ordered finely 
 powdered animal charcoal, but its bulk and appearance are 
 against its use. Bouchard's original mixture was so repulsive, 
 and offensively smelling, that I never tried it; but his more 
 recent combination of /3-naphthol and salicylate of bismuth is 
 
52 THE TREATMENT OF TYPHOID FEVEH. 
 
 certainly more palatable. Dr. Mitchell Clarke, of Bristol, has 
 had good results with h3^dro-naphthol, which, however, does 
 not seem to have much, if any, advantage over ^-naphthol (of 
 which it is largely composed), except that, being a patent 
 article, it is more expensive. Others again prefer o-naphthol. 
 Among the numerous other antiseptics which have been used, 
 may be mentioned sulphurous acid, eucalyptol oil, thymol, 
 and camphor. 
 
 Murchison, Xiemeyer, and Sir Thomas Watson ordered 
 chlorine water, and this treatment has been recently revived 
 by Dr. Bumey Yeo. The following is Dr. Yeo's prescrip- 
 tion : — " Into a twelve-ounce bottle put thirty grains of 
 powdered potassic chlorate, and pour on it forty minims of 
 strong hydrochloric acid. Chlorine gas is at once rapidly 
 liberated. Fit a cork into the mouth of a bottle, and keep it 
 closed until it has become filled with the greenish yellow gas. 
 Then pour water into the bottle, little by little, closing the 
 bottle, and well shaking at each addition until the bottle is 
 filled. You mil then have a solution of free chlorine, together 
 with some undecomposed chlorate of potash and hydrochloric 
 acid, and probabl}" one or two by-products." 
 
 '■' To twelve ounces of this solution for an adult, I add 
 twenty-four or thirty-six grains of c^uinine and an ounce of 
 syrup of orange peel, and I give an ounce every two, three, or 
 four hours, according to the severity of the case — that will be 
 from twelve to thirty-six grains of quinine in the twenty-four 
 hours, according to the case." In Dr. Biu-ney Yeo's practice 
 this treatment has been very successful, and under its use he 
 has noticed "a remarkable cleaning of the tongue and a 
 disappearance of the ofiensive foetor of the evacuations." 
 He looks upon this mixture as an intestinal and general 
 antiseptic. 
 
 Frontal headache is often a troublesome symptom during 
 the first eight or ten days, Ijut it then disappears spontaneously, 
 and, as a rule, does not require any very active medication. 
 The patient should be kept very quiet in a darkened room, 
 and not be subjected to any unnecessary reflex irritation 
 
THE TREATMENT OF TYPHOID FEVER. 53 
 
 Evaporating lotions, or even an ice-cap may be applied to the 
 head, and if there be much heat the body should be sponged 
 or placed in the tank according to the severity of the case. 
 The following drugs will often be found useful : — Five grains 
 of antipyrin with three of caffeine ; one drachm doses of the 
 elixir guaranse : or twenty grains of bromide of ammonium, 
 with three grains of caffeine. Attention should be directed to 
 the state of the bowels, and to the diet. 
 
 Sleeplessness is an important symptom which should never 
 be neglected, as the nervous system is sufficiently burthened 
 with the fever poison without this additional source of exhaus- 
 tion. I have generally left the choice of the hypnotic to the 
 House-Physician, but personally I am in favour of Dover's 
 powder. A good combination is a draught of chloral, bromide 
 of potassium, and tincture of hyoscyamus, or, if there be much 
 restlessness a small dose of morphia may be substituted for the 
 henbane. At an advanced stage of the disease, sedatives, when 
 employed, should be used cautiously. As a rule patients in 
 the tank sleep well — frequently both day and night. 
 
 I have no faith in any of the new antipyretic drugs in this 
 disease ; they can do no permanent good, and may do a great 
 deal of harm. Quinine and digitalis I prescribe, but not in the 
 huge doses administered by our German colleagues. As a 
 general tonic, especially towards the later stages of the disease, 
 I am very fond of quinine, or bark, and generally combine it 
 with caffeine. In some cases where the disease seemed to 
 assume a slightly malarial type, or where the spleen was very 
 large I have found benefit from three to five grain doses of 
 quinine given thrice daily, and occasionally I have given ten 
 grains at one dose, but this was rarely repeated on the same 
 day. In the early stage of convalescence, in many severe cases, 
 the temperature is easily disturbed from slight causes, owing 
 to defective control of the thermo-taxic mechanism. Under 
 such circumstances a powder composed of five grains of anti- 
 pyrin, three grains of salicylate of quinine, and two grains of 
 caffeine, may be given every four hours, or liquor ammonise 
 acetatis may serve the same purpose. With these exceptions I 
 
54 THE TREATMENT OF TYPHOID FEVER. 
 
 have never used quinine or digitalis in typhoid fever with the 
 view of lowering the temperature. 
 
 When there is any bronchial catarrh or hypostatic congestion 
 of the lungs, ammonia, caffeine, and digitalis are the most 
 effective remedies. Where there is pulmonary congestion with 
 general lividity I believe that peroxide of hydrogen may be 
 given with advantage. In two cases I used considerable 
 quantities with cold water enemeta, but when it is introduced 
 into the stomach, from which it is readily absorbed, the dose 
 should not exceed two to four drachms for fear of a too rapid 
 liberation of oxygen in the blood. To those who use quinine 
 and other antipyretics to diminish the oxygen carrying power 
 of the blood this may seem a doubtful remedy, but I believe it 
 will be found useful in such cases as I have indicated, and, 
 moreover it is one of the most powerful antiseptics which we 
 possess. The cases in which I used it occurred in October and 
 November, 1890; I am, therefore, highly pleased to find its use 
 in typhoid fever strongly commended by Dr. Benjamin Ward 
 Richardson, to whose researches we owe all our knowledge 
 respecting the peroxide of hydrogen. In the A sclepiad, October, 
 1891, Dr. Richardson says : — "The gas when liberated would 
 diffuse through the whole of the canal, and would decompose 
 and oxidize the decomposing exuded products, which, by 
 secondary absorption, are the cause of the relapsing febrile 
 seizures, with an efficiency possessed by no other remedy. It 
 would be like exposing the decomposing ulcerated surface to 
 sea air." 
 
 Diet. My early tank patients were kept chiefly on a milk 
 diet, not that I have unbounded faith in milk, as it is a simple 
 popular diet for such cases, and I was anxious that we should 
 be able to estimate the value of the tank with as few disturb- 
 ing influences as possible either from diet or medicine. Dr. 
 Lauder Brunton does not approve of farinaceous food in 
 typhoid fever as on several occasions it seemed to him " to 
 afford a more favourable nutrient medium to the bacilli : " 
 whether this be the result of more than a limited experience I 
 cannot say, but I know men who have had largely to deal 
 
THE TREATMENT OF TYPHOID FEVER. 55 
 
 with this disease, and who do not hold such an opinion. No 
 doubt when the sahvary and pancreatic secretions are much 
 diminished, ordinary farinaceous diet is not advisable until it 
 has been subjected to the amylolytic action of some of the many 
 ferments in the market, but in the tank these secretions do not 
 seem to be much diminished and the patients digest boiled 
 bread and milk very well. When not digested it may readily 
 increase the fermentation in the intestinal tract, but we have 
 previously seen that this should be corrected by the use of 
 antiseptics, and if there be reason to suppose that there is a 
 deficiency of the salivary and pancreatic ferments their action 
 should be assisted. I am convinced that in febrile diseases if 
 we wish to lessen the increased combustion at the expense of 
 the tissues, we must supply a fair amount of carbohydrates. 
 
 The best diet to prevent the wasting in typhoid fever has 
 not yet been determined. Latterly I have been ordering 
 carbohydrates very freely, and even butter with decided 
 advantage to the patients, in lessening the waste of tissue. The 
 loss of weight during the febrile process is to a considerable 
 extent due to the dehydration of the tissues, but the water is 
 afterwards quickly replaced, and this to a great extent accounts 
 for the rapid increase of weight which usually takes place 
 when the afebrile stage is reached. In the tank this dehydra- 
 tion is largely prevented, and I have seen the loss of weight 
 continue after removal from the tank when there was nothing 
 to account for it unless a loss of water which had been retained 
 in the system. During the fever there is little or no tissue 
 upbuilding and therefore the demand for nitrogenous food 
 cannot be great, but if the pyrexia, which is inevitable, is not 
 to be maintained at the expense of the tissues, we must supply 
 an abundance of other fuel in the form of easily assimilable 
 carbohydrates or hydrocarbons. _ . 
 
 Milk is generally looked upon as a model food, becau^ it 
 contains all the ingredients necessary for repairing waste Md 
 supplying heat, but it does not necessarily follow that because the 
 constituents are in the proper proportions for a growing infant, 
 it is best suited for a fever patient where the conditions are 
 
56 THE TREATMENT OF TYPHOID FEVER. 
 
 completely reversed. In the latter the anabolic functions are 
 in abeyance, and the katabolic exceedingly active. Where 
 milk is the only diet in fever, the tissue waste is exceedingly 
 great. The nitrogenous element of food may be readily 
 supplied by milk, but the sugar and fat are not in sufficient 
 quantity in that fluid, and require to be supplemented from 
 other sources. As Sir William Jenner has pointed out, a pint 
 of milk is often more difficult to digest than a mutton chop, and 
 whatever foods we order we should see that they are properly 
 digested. The stool should therefore be carefully inspected, and 
 when any curd of milk or other undigested food is present the 
 diet should be peptonised. The addition of lime water, barley 
 water, or isinglass- to the milk renders the curds smaller and 
 consequently more digestible. The milk had better always be 
 diluted. Dr. Burney Yeo says: "Vichy water is a good diluent 
 of milk; but a less expensive and very convenient method is to 
 add to each cup of milk-and-water ( half milk and half water ) 
 an alkaline tabloid composed of bicarbonate of soda, bicarbonate 
 of potash, carbonate of magnesia (each two grains), and common 
 salt, three grains. This will not only assist the digestion of the 
 milk, but it will add certain necessary salts to the food, which, 
 from the absence of vegetable foods, the patient does not get. 
 Common salt is also an excellent antiseptic." I always insist 
 on a liberal supply of chloride of sodium which is too frequently 
 omitted from febrile diets. 
 
 During the febrile stage, the food, whatever it be, should be 
 liquid and should be administered every two or three hours. 
 I place no limit on the quantity of liquid nourishment, so long 
 as it is retained in the stomach and properly digested, but for 
 an adult I usually find that about four pints of milk, eight to 
 sixteen ounces of bread, and two ounces of butter are appro- 
 priated daily, and there is no use giving any diet which is not 
 assimilated. The bread should be boiled with milk, or it may 
 be 'peptonised, and the butter added. In the tank the appetite 
 soon becomes very good and these quantities do not suffice. 
 Such farinaceous articles of diet as arrowroot, sago, tapioca, or 
 some of the numerous infants' foods in the market may be given. 
 
THE TREATMENT OF TYPHOID FEVEK. 57 
 
 If there be constipation or not much diarrhoea, extract of malt 
 will be found useful, and sugar may usually be given, also the 
 expressed juice of ripe grapes but neither the skins nor seeds. 
 If any stimulating effect is required, beef tea, mutton or chicken 
 broth with vegetable juices, but no cellulose, clear soup, beef 
 essence, kolatina, and coffee may be given and one or two raw 
 eggs may be administered daily during any stage of the disease.. 
 The patient should be allowed to quench his thirst at any time 
 with pure cold water, toast water, barley water, whey, or weak 
 lemonade. Under this diet there is often considerable loss of 
 weight, but the extreme wasting recorded by Cayley and others 
 is not likely to occur. The liquid nourishment should be con- 
 tinued until the temperature has been normal for a week or 
 ten days, and then we should begin cautiously with fish, 
 chicken, mutton, lightly boiled eggs, sweetbreads, boiled tripe, 
 game, etc. When the patient has been well fed during the 
 fever his temperature is not likely to be affected when he begins 
 solid food unless there be constipation, and this should not be 
 allowed to occur. Recrudescences and relapses are often 
 ascribed to the use of solid food when the occurrences are 
 merely coincidences. Constipation with retention and accumu- 
 lation of the fever poison is a more likely source of future 
 mischief. 
 
 Alcohol. With three exceptions none of these patients had 
 any alcohol during their residence in hospital. My views on 
 this question are no doubt, to a great extent, a refiex of the 
 teaching of my friend and master. Professor Gairdner ; but not 
 being a teetotaller myself, I am not likely to be accused of any 
 prejudice on the subject, though any prejudice, based on the 
 matured opinion of such a careful and accurate observer as 
 Dr. Gairdner, could not be far astray. Alcohol is not a food in 
 the proper acceptation of the word ; it is a sedative, or to use 
 a commoner though less accurate designation, a stimulant. It 
 causes vaso-motor paresis, which is usually sufiiciently accom- 
 plished by the fever poison without any assistance ; this effect 
 may be necessary during the chilly stage, during collapse, or 
 to counteract the effect of a cold bath ; but in a well-managed 
 
58 THE TREATMENT OF TYPHOID FEVER. 
 
 case, without any heroic treatment, such influence should not 
 be often necessary. In cases where there is a high body 
 temperature, with cold extremities, alcohol will do good, and 
 probably the best form of it for administration in such cases 
 will be found to be good draught bitter beer. In the case of 
 patients accustomed to alcohol, it may not be well to disturb 
 any long-acquired habit ; but this disease generally occurs in 
 the young before any such habit has been established. During 
 convalescence it may be, and no doubt often is, useful both for 
 the stomach's sake and to relieve an exhausted heart by lessen- 
 ing peripheral resistance. We frequently hear of patients 
 being " kept alive " for a certain number of days on brandy ; 
 but as these cases generally end in death, it would perhaps be 
 more accurate to say that the only nutriment they had during 
 the last few days of life was diluted brandy. The tenure of 
 life held under such conditions is usually dearly bought. 
 
 As the result of my observations in the fifty-five cases 
 recorded at the end of this essay, I think I have clearly shown 
 that the most severe cases of typhoid fever may be treated 
 throughout the whole disease without any alcohol. In the only 
 case of death which I have had, alcohol was administered, not 
 that I in anyway place these two facts in the relation of cause 
 and effect, but the alcohol did not save her, and I am not aware 
 that it did much good. In another case the champagne cer- 
 tainly did good by allaying the vomiting. The third case got 
 a pint of beer daily, for a short time, to reconcile her to what 
 she called "the cowld wather." A patient in the tank once com- 
 plained to me that he was "very dry," a condition under such 
 circumstances which none but an Irishman could understand, 
 but even that appeal could not induce me to moisten him with a 
 little whiskey. If I were convalescing from typhoid fever I 
 should enjoy a little '68 port, and I do not care to prohibit 
 others from what I would probably take myself. I have how- 
 ever established my point that typhoid fever can be treated 
 without alcohol, and about the only time that that agent is of 
 any value in a well managed case is during convalescence. As 
 a food or antipyretic agent it is of very little value, and should 
 
THE TREATMENT OF TYPHOID FEVER. 59 
 
 be avoided during the febrile stage, unless there be some special 
 reasons for its use. The large quantities of alcohol which are 
 frequently prescribed, must inevitably lead to asthenia and so 
 protract convalescence. 
 
 Antipyretic Treatment. We have seen the views of Currie 
 that "the febrile poison is the agent that excites the system 
 into fever, which however is carried on, not by the continued 
 presence and agency of this agent, but by the principles which 
 regulate the action of life," and we now know that high tem- 
 perature can work mischief irrespectively of the agent which 
 induced it. It is however a mistake to suppose that all the 
 evils of fevers are due to the high temperature, because 
 apyrexia might be maintained throughout the whole course of 
 the illness by the use of powerful antipyretic drugs, without 
 modifying the course of the disease, or improving the patient's 
 chance of recovery. The albuminous degeneration which 
 occurs in the striped muscular fibre of the heart and voluntary 
 muscles, in the cells of all the glandular organs and even in the 
 nerve cells, is no doubt largely due to the high temperature, 
 though I think the fever poison must also be partly credited 
 with this degradation, because evidence of its existence can be 
 found in all severe cases no matter how well the temperature 
 has been subdued. The temperature, however, is the one factor 
 in fever which can be most readily combated, and when this 
 has been efficiently carried out by the antipyretic action of 
 water the signs of degeneration are correspondingly lessened. 
 For example in my tank cases the heart's action improved and 
 there was no anxiety as to cardiac paralysis; the functions of 
 the glandular organs were restored, and although the nervous 
 irritability was heightened there were no signs of nervous 
 exhaustion, and consequently convalescence progressed rapidly. 
 Even in my only fatal case, which was that of the mother of a 
 large family, who was exhausted by a severe attack and an 
 equally severe relapse, all the organs were in a remarkably 
 good condition. I have discarded the use of drugs as anti- 
 pyretic agents, and I shall now consider the various methods 
 of applying water for the reduction of the temperature. 
 
60 THE TREATMENT OF TYPHOID FEVER. 
 
 Cold A fusion. To arouse the nervous system there is no 
 agent Kke the cold afiusion, but as an antipyretic agent its 
 action is very evanescent. It may be applied to the head with 
 much advantage when there is delirium or even severe head- 
 ache accompanied with high temperature, but for lessening the 
 fever other applications must be adopted. Currie's views on 
 its abortive action cannot be entertained in the present day. 
 
 Cold Sponging. To refresh the patient the body may be 
 sponged, even in mild cases, night and morning with cold water 
 or water and vinegar, but if it is wished to reduce the tempera- 
 ture by this means the sponging must be carried out every 
 hour or oftener while the temperature is high. The slight 
 exposure of the body during the act of sponging also tends to 
 reduce the temperature and stimulate the nervous system, but 
 I am strongly opposed to any coolino- process by exposure of 
 the body to draughts of cold air, because any such excessive 
 stimulation chills the body, exhausts the nervuus irritability, 
 and leads to vaso-motor paresis with internal congestions. 
 Cold sponging is only suitable for mild cases. 
 
 The Wet-Pack. This is an excellent antipyretic agent but 
 as generally carried out, by packing the patient for a very short 
 time, or as Dujardin-Beaumetz recommends for ten minutes, it 
 is absolutely useless. Case 2-5 was in the wet pack for five 
 days, case 27 for eleven days, case 28 for nineteen days, and 
 case 80 for twenty days. The patient should be enveloped in 
 a sheet wrung out of tepid or cold water, and covered with a 
 single blanket, or counterpane, or simply a linen sheet. As soon 
 as the sheet begins to dry it should be replaced by another. If 
 the circulation be feeble and the lower limbs cold, then they 
 should be wrapped in a blanket, and the wet sheet confined to 
 the trunk. The wet sheet is chiefly applicable to children and 
 young spare patients, where there is a comparatively large 
 cooling surface. It is a very convenient method but for severe 
 CELses cannot be compared with the tank. 
 
 Cold Compresses, the Ice-Bag, and Leiter's tubing. Such 
 applications to the abdomen have a decided efiect in lowering 
 the temperature, but they are not to be trusted in severe cases. 
 
THE TREATMEXT OF TYPHOID FEVER. 61 
 
 Of these three methods the ice-bao- is the most convenient, and 
 it is exceedingly useful in cases of abdominal distension, and 
 in intestinal heemorrhage. Case 33 was very protracted and 
 the ice-bag was constantly applied to the abdomen, from the 
 seventeenth to the thirty-ninth day, and its action was then 
 supplemented by that of the wet-pack for seven days. In case 
 22 Leiter's tubing was applied to the abdomen for four days 
 before immersion in the tank. It had at first a decided effect 
 in lowering the temperature, but it soon lost that control, and I 
 am afraid it may have had some causal relation to the double 
 pneumonia from which the patient afterwards suffered. The 
 ice-cap applied to the head has a controlling influence over the 
 body temperature. 
 
 Gold Water Ene'mata. I found iced water enemata very 
 useful in three cases, in two of which the tank had not a 
 sufficiently controlling influence. In order to obtain the cooling 
 effect, the water should be retained so as to be afterwards 
 excreted by the kidneys. Two and a quarter pounds of cold 
 water at a temperature of 37' Fah., will reduce one hundred 
 pounds at 105° Fah., a degree and a half, and in its passage 
 through the human body it must have a similarly cooling 
 effect. If the water injected be allowed to flow away immedi- 
 ately the effect will be veiy slight and transient. I therefore 
 raise the patient's hips, insert in the rectum the nozzle of a 
 syringe to which is attached a piece of india-rubber tubing 
 through which the water is ma.de to gravitate from a height 
 of two or three feet. Cold water enemata have been freely 
 employed by Cantani, but I think they will not be often 
 required except in cases of emergency where it is necessary to 
 rouse up the nervous system as well as to produce an anti- 
 pyretic effect. For antiseptic purposes a pint of cold water 
 with three or four ounces of the peroxide of hydrogen may be 
 introduced by an O'Byrne tube several times a day. 
 
 Gold and Graduated. Baths. I have already expressed my 
 opinion of these agents, and I shall leave their use to others. 
 
 Wayrin or Tepid Bath. At the very commencement of an 
 attack of fever, before we know the exact nature of the illness 
 
62 THE TREATMENT OF TYPHOID FEVER. 
 
 with which we have ^ot to deal, when the patient is chilly and 
 restless, I think the cleansing and soothing effects of a tepid or 
 warm bath will be decidedly beneficial. 
 
 The Tank. It consists of a well-made wooden box, about 
 6 ft. long, 2 ft. 10 in. wide, and 16 inches deep. It is lined with 
 lead which is painted white and coated with a thick layer of 
 shellac varnish. The shallac makes the tank, on other occasions, 
 a convenient medium for administering electric baths. Each 
 tank is provided with a large discharge pipe, which, in the case 
 of these tanks, communicates with a soil pipe which leads down 
 to the sewer ; the tank containing over 70 gallons of water can 
 thus be emptied in three minutes. During the treatment of the 
 first six, and partly of the seventh case w^e had only one tank 
 which was supplied with an ordinary tap, and hence the cleaning 
 each day was a rather slow process, and the patient was out of 
 the water longer than was desirable. Moreover having oqly one 
 tank each patient had to make room for his or her successor, 
 and hence the period of immersion was not so long as I could 
 have wished. We have now got two tanks in the ward, pro- 
 vided wnth a plentiful supply of hot and cold water, and good 
 discharge pipes, so that the labour of the nurses is considerably 
 lessened. Each tank is provided with a sheet of bedticken 
 which woulr] about allow the patient to be submerged, but at 
 the head there is a strip about a foot wide which does not sink 
 so deeply and on which rests an air pillow so as to keep " the 
 head above water," which is a most essential matter in most 
 conditions of human life. 
 
 The patient is wrapped up in a blanket and completely 
 immersed except the head. It is important to use a blanket for 
 this purpose rather than a sheet, because frequently a small 
 portion of the chest rises above the water, and the blanket 
 being a bad conductor of heat, this portion of the surface does 
 not get chilled, which would happen if a sheet were used. The 
 tank is covered with a half-lid, which prevents the weight of 
 the bed clothing resting on the patient, a waterproof sheet, and 
 bed clothing to keep in the heat of the water. The tanks could 
 easily be provided with a small circulating boiler to maintain 
 
THE TREATMENT OF TYPHOID FEVER. 63 
 
 a uniform temperature but this is quite unnecessary as we have 
 found that the removal of a bucketful of tank water, and the 
 addition of the same quantity of hot water every two hours is 
 sufficient to maintain a fairly uniform temperature, and a 
 variation of one or two degrees is a matter of no moment. A 
 thermometer is kept constantly in the tank. As long as the 
 patient's temperature in the mouth is over 100°, the temperature 
 of the tank need not rise above 90° to 93°, but as the body 
 temperature approaches the normal so should the tank tem- 
 perature. We have not found it necessary to lower the 
 temperature of the water below 90° nor raise it above 98°. A 
 rise of a few degrees in the tank temperature is sure to send 
 up the heat of the body though to a less extent, and by 
 regulating the heat of the water there is no fear of any 
 collapse, as the temperature of the body cannot fall below 
 that of the surrounding medium. 
 
 I have been anxious that these patients should be disturbed 
 as little as possible, and so have enjoined them to pass their 
 urine and faeces into the tank. The faeces are to a consider- 
 able extent retained in the blanket, and this is soaked for 
 some days in a strong solution of perchloride of mercury and 
 hydrochloric acid before being washed. A fresh blanket is used 
 each day. I know this is not a very aesthetic proceeding, and 
 it would be a very simple matter in cases where there was not 
 much diarrhoea, to swing the patient while his bowels were 
 being moved. In this case there would require to be a second 
 sheet, over the bedticken, with a hole in it for the buttocks. 
 Where there is much diarrhoea, or where there is incontinence 
 of faeces, as happened in some of these cases, I still think that 
 the less the patient is disturbed the better. Any day on which 
 there was no motion the tank was not cleaned. 
 
 So far as the patient is concerned plain water of a given 
 temperature is all that is required, but for the sake of others it 
 is as well to have it as antiseptic as possible. At first I simply 
 used boric acid, but latterly, for several reasons partly assigned 
 under the seventh case, 1 have tried to render the water 
 aseptic. This patient developed the disease in hospital, but 
 
64 THE TREATMENT OF TYPHOID FEVER. 
 
 after a careful and impartial investigation we were convinced 
 that he must have contracted it outside. We used sulphate of 
 iron with a small quantity of sulphuric acid, but the iron 
 oxidised, and the water was rendered so dirty in appearance 
 by the red oxide that we discontinued it. We then tried 
 perchloride of mercury with chloride of ammonium and 
 hydrochloric acid, but this began to mercurialize the patient 
 and so had to be discontinued. Those who are fond of 
 inunction in syphilis might find this a very convenient method 
 for introducing the mercury. Dr. Logan made some cultures 
 from the faeces contained in the mercurialized tank water, and 
 he reports, inter alia : — " But undoubtedly a very large pro- 
 portion of the germs in the first case were dead. You might look 
 upon the water as sewage water, but sewage water in which 
 there were actually fewer germs than there would be in the 
 same quantity of tap water." We also used boric acid, common 
 salt, and hydrochloric acid, but this mixture irritated the 
 patient's skin. Possibly if the patient's skin were well protected 
 by a coating of some mineral fat, such as vaseline, a strong anti- 
 septic might be used. This question requires solving ; probably 
 it will be found best in the majority of cases to raise the patient 
 above the water while the bowels are being moved. In the 
 ward there is a large supply of perchloride lotion (1 in 2,000) 
 for nurses and others to wash their hands after handling the 
 patient. 
 
 Such was my original description of the tank, but with 
 increased experience I have gradually effected various modifica- 
 tions which I shall now describe. Strong objections have been 
 urged against the faeces being passed into the tank, the force 
 of which objections I have fully recognised, and tried to 
 obviate. Mr. Thomas Duncanson fitted up for me his new 
 patent bed-lift, whereby the patient can be wound up as easily 
 as you would raise a window blind. Inside the tank there is 
 a light wooden frame which fits closely to the sides of the tank 
 but has sufficient play so as to be easily movable when raised 
 up or let down by the bed-lift. The frame is composed of four 
 strips of wood of about one and a half inches deep and three 
 
THE TREATMENT OF TYPHOID FEVER. • 65 
 
 quarters of an inch thick, and is provided with feet of about 
 six inches Idng to prevent it reaching within that distance of 
 the bottom of the tank : it is also provided with rings to which 
 the hooks from the bed-lift are attached when it is wished to 
 raise the patient. The frame had even better be constructed in 
 the form of a treble-inclined plane, like an Ilkley couch. The 
 bedticken is fastened on to the frame so tightly as just to 
 prevent the body of the patient from resting on the bottom of the 
 tank ; the strip of ticken, and the air or water pillow for the head 
 are also adjusted to the frame. By these means the patient can 
 be easily raised for sanitary purposes, or when from any cause it 
 is desirable to remove him from the tank. . After the patient 
 has been a short time in the tank the dia.rrhoea abates, so that 
 the trouble is correspondingly lessened. 
 
 Notwithstaading these appliances we did not succeed in 
 preventing the faeces from being passed into the water, for the 
 simple reason that I specially designed the tank treatment for 
 very severe cases, and such patients pass their urine and faeces 
 involuntarily, or are too ill to give any notice of such occur- 
 rences. The following means, however, allow the patient to pass 
 the f ^ces in the tank but prevent them mixing with the general 
 body of water. The discharge pipe is connected with a very large 
 funnel, or closet pan, which comes down from the centre of the 
 bottom of the tank, and there is a hole cut in the bedticken 
 over the pan. A water-pillow with a hole in its centre is fixed 
 in the sheet of bedticken to prevent the cut edges from fraying 
 the patient's skin. The patient's buttocks rest on the water- 
 pillow so that when any faeces are passed they immediately 
 gravitate into the pan, and they can be immediately discharged 
 by raising the plug or turning the tap of the discharge pipe. 
 When the water is flowing out it rushes round the buttocks 
 of the patient, and down the hole in the water-pillow so that 
 any excreta which may be adhering are washed away. 
 
 The porter is directed to place every morning a shovelful of 
 the chloride of lime on the grid of the wet water-trap into 
 which the discharge pipe empties the tank water. It is important 
 to disiufect the faeces and tank water, but in my experience this 
 
66 
 
 THE TREATMENT OF TYPHOID FEVER. 
 
 is not quite an easy matter when you have got the patient in 
 the water. However a few handfuls of some heavy disin- 
 fectant such as the sulphate of iron could be occasionally 
 dropped into the tank-pan. My friend, Major Beamish, of Her 
 Majesty's Prison service, has drawn my attention to the strong 
 disinfectant properties of " Ferozone." It is composed, accord- 
 ing to Sir Henry Roscoe, of : — 
 
 Ferrous Sulphate 26-64 
 
 Aluminium Sulphate 
 
 Calcium Sulphate 
 
 Magnesium Sulphate 
 
 Combined water 
 
 Moisture 
 
 Silica ... 
 
 Magnetic oxide of iron 
 
 2-19 
 
 3-30 
 
 5-17 
 
 8-20 
 
 24-14 
 
 11-35 
 
 19-01 
 
 100-00 
 
 The great objections to its use in the tank are the insoluble 
 constituents, silica, and magnetic oxide of iron, as thus the 
 cleaning would be rendered much more diflficult. A combina- 
 tion of the first four ingredients might prove a useful mixture. 
 The great dilution of the faeces together with a free supply of 
 any crude and cheap disinfectant is pretty certain to render 
 them innocuous : and the abundant supply of water will flush 
 the sewer, and prevent any risk of stagnation. 
 
 As I have previously stated still- water is a bad conductor of 
 heat, and to prevent or lessen the evening exacerbation of 
 febrile temperature it is frequently advisable to empty the tank 
 several times during the afternoon, and refill it with a stream 
 of water at 90^' to 95°, running over the patient. In fact the 
 most perfect system would be to treat the patient in a running 
 stream, and then it would not often be required to reduce the 
 temperature of the water below 95". The stream of warm 
 water could be introduced at the bottom of the tank, and an 
 equal quantity would be discharged from the surface by means 
 of an overflow pipe. This could be readily carried out in a 
 fever hospital where there are always a large number to treat, 
 and for the water supply I would have a large cistern in 
 which the water could be always kept at any requisite tern- 
 
THE TREATMENT OF TYPHOID FEVER. 67 
 
 perature. In warm climates, such as India, there should be 
 very little difficulty in keeping the water warm, and it would 
 be much more comfortable for the patient to lie in the tank, 
 than to swelter in an atmosphere of 90° to 100° in the shade. 
 When the patient is permanently taken out of the tank, there 
 is usually a febrile reaction, unless the temperature has been 
 normal for a day or two, and to prevent this occurrence it is 
 advisable to apply cold compresses, or an ice bag to the 
 abdomen. 
 
 Effects of the Tank Treatment, (a) — Temperature. We 
 are not here discussing the intimate nature of fever. Those 
 who wish to do so will find much original work in the writings 
 of Professor Wood, of Philadelphia, and in the Gulstonian 
 Lectures of Dr. MacAlister there is an excellent epitome of 
 current views on the subject with a good working hypothesis 
 as to the mechanism of the pyrexia. Increased temperature 
 is a natural phenomenon of fevers, and it is a disputed point 
 how far its mere reduction is beneficial, but the general con- 
 sensus of opinion attributes to high temperature the power of 
 working mischief irrespectively of its origin. So long as the 
 fever is mild there is no necessity for interfering with the 
 temperature, and in any case there is more to be lost than 
 gained by attempting to produce any continuous apyrexia. 
 With the patient in the tank, the body heat is to a great extent 
 under control, but so far as the temperature is concerned I 
 have made no attempt to do more than moderate the fever. I 
 have noticed again and again in the Weir-Mitchell treatment 
 that so long as the temperature in the axilla does not exceed 
 100° F., tissue upbuilding is easily effected, but once the body 
 heat much exceeds this the massage should be stopped and the 
 diet lessened, or in other words damp your furnaces, and lessen 
 your fuel. So in fevers the anabolic changes play a small part 
 in the tissue metamorphoses, and hence we get rapid wasting. 
 Life implies change, and the greater the change the greater the 
 ■ vkality so long as the anabolic changes compensate the kata- 
 bolic, but in fevers the increased combustion of the tissues tends 
 in the direction of their death rather than their renovation. 
 
68 THE TREATMENT OF TYPHOID FEVER. 
 
 In the continued fevers with a persistent hi^h temperature, 
 and no marked intermissions there is no period for upbuilding, 
 and hence it frequently becomes a question how long will the 
 vitality of the patient hold out ? It is therefore very important 
 to moderate the intensity of the pyrexia, and if possible to have 
 a prolonged daily remission with a reduction of the temperature 
 to at least 100° or 99° Fah. If the reduction of temperature 
 be accomplished by a mere abstraction of heat without any 
 diminution in the production, there cannot be much gain. We 
 want a true antipyretic action where the thermogenesis is 
 diminished, the thermolysis regulated, and the thermotaxic 
 mechanism improved. This is what, I am convinced, the tank 
 accomplishes. There has been no attempt to prevent, but only 
 to moderate the usual evening exacerbation, but this is gradually 
 lessened in intensity and duration, the remission becomes greater 
 and longer, and the mean dail^'- temperature is lowered, while, 
 when the patient is daily removed from the tank, there steadily 
 appears a diminished tendency to disturbance in the thermotaxic 
 mechanism. I hoped to have been able to give some evidence 
 of the tissue changes by an examination of the excretions in 
 the tank, but I soon found that the sources of error were too 
 o-reat to make this laborious process worth attempting. I will 
 again refer to this under the weight. 
 
 The seventh case was an exception to the dictum of 
 Wunderlich :— " When the temperature is 40° (104° Fah.) from 
 the first or second day of the attack, the disease is not typhoid 
 fever." In this case the evening temperatures of the first, 
 second, third, and fourth days were 104°, 103°, 104-6°, and 
 104"2°, while the morning temperatures of the second, third, 
 fourth, and fifth days were 101-8°, 101-2°, 101-4°, and 103°. 
 From this time till the evening of the eighth day when he was 
 placed in the tank there was a continuous fever between 103-2° 
 and 104°. Independently of the dysentery, this was one of 
 the most severe cases of typhoid fever, not even excepting the 
 fatal cases, which I have ever seen. The ninth case was only 
 admitted to hospital on the seventeenth day of the disease. 
 She was in a feeble condition with a pulse of 144, and a 
 
THE TREATMENT OF TYPHOID FEVER. 69 
 
 temperature o£ 104'4°. She was placed in the tank at 95°, and 
 her temperature fell about 2 degrees. On the morning of the 
 nineteenth day Dr. Wallace found that her temperature had 
 fallen to 98° and she appeared rather livid and collapsed. It 
 seemed as if the blood was not warm enough to stimulate her 
 exhausted heart. He removed her from the tank and applied 
 hot bottles to her surface and the lividity quickly disappeared. 
 She was then ordered a mixture of caffeine and belladonna. 
 The nurses should keep a careful supervision over both the 
 temperature of the patient and of the tank. In case 21 the 
 circulation was extremely feeble and the tank had not 
 sufficient control over the internal temperature, so that on one 
 occasion it rose to 105'4°, and was maintained at a high level 
 until she had some cold water enemata. During the relapse, 
 which in this case ended fatally, the iced water enemata had 
 to be frequently repeated. In case 22, which was very severe, 
 and complicated with double pneumonia there were several 
 very serious evening exacerbations which in his condition had 
 to be combated by iced enemata. In future I should treat such 
 patients more ia a running stream, the principles of which I 
 have previously enunciated. In case 21, it is quite possible 
 that she was two d^iys too long in the tank, because when her 
 temperature tended to become subnormal, her weak heart may 
 not have had sufficient stimulus, and she was not in a position 
 to stand any collapse temperature. It is probable that if I 
 had been present towards the end I might have transfused a 
 saline solution. 
 
 (/8) — Circulatory System. There is a marked improvement 
 in the vaso-motor tone ; the blood vessels become smaller and 
 firmer ; the pulse slower, fuller, and of improved tension — of 
 course you must not mistake the small firm pulse for a weak 
 pulse. The heart maintains its vigour, and the only cases 
 where the sounds have been dull have been those cases where 
 the patients were not put into the tank till a late stage of the 
 fever ; but in no case have I had any fear of cardiac paralysis, 
 not even in the dysenteric case with a pulse of 152. Of course 
 there might be a danger in placing a patient ia the tank at the 
 
70 THE TREATMENT OF TYPHOID FEVER. 
 
 end of the third week with an exhausted heart, as the weak 
 organ might not then be able to cope with the increased 
 peripheral resistance. Gaeteris paribus the greater the resist- 
 ance the less the frequency of thepulse, but when the resistance 
 almost overtops the reserve cardiac energy the frequency again 
 increases ; such was the case in the dysenteric patient, and he 
 then received tincture of belladonna for a few days. The 
 second case was placed in the tank at the beginning of the 
 third week, his heart was exhausted and he was much benefited 
 during convalescence by caffeine ; probably the addition of 
 belladonna or alcohol would have been useful. 
 
 There was haemorrhage in two' of these cases, but I am 
 inclined to think that the tank lessens the liability to that 
 complication, because, without doubt, the improved vaso-motor 
 tone extends to the abdominal vessels, as shown by the lessened 
 diarrhoea, the diminution in the distension of the abdomen, 
 and the rise in the arterial tension. Of course improved tone 
 and tension will not prevent haemorrhage from ulceration into 
 a blood vessel, and such I believe to have been the case in these 
 two patients. I may have something further to say on this 
 subject and also regarding the other cases of haemorrhage when 
 I come to speak of the treatment of complications. In the 
 production of the heightened tone of the blood vessels and 
 increased blood tension, there is one element which must be. 
 duly appraised, namely, the mechanical pressure of the water. 
 When the body is immersed, there is, in addition to the weight 
 of the atmosphere, a surface pressure averaging nearly one. 
 quarter-pound to the square inch. This pressure is transmitted 
 to every part of the body with the exception of the internal 
 surfaces of the air passages and vesicles, and it must greatly 
 aid in carrying on the venous circulation, and materially aid the 
 right side of the heart in propelling the blood through the 
 lungs. When the chest is expanded in inspiration, the venous 
 blood is driven into the blood-vascular thoracic cavity with 
 greater momentum, and the 'right ventricle is stimulated to 
 more vigorous contraction. 
 
 (y) — Respiratory System. The respirations lessen in fre- 
 
THE TREATMENT OF TYPHOID FEVER. 71 
 
 quency ; the bronchitis and congestion of the lungs improve 
 and soon disappear. In the fourth case both lower lobes were 
 almost solid from hypostatic congestion, and the heart's action 
 was very feeble. Under or-dinary circumstances I would have 
 prescribed caffeine and ammonia for this patient, but I was 
 anxious to elicit the effect of the tank, with the view of 
 deducing its probable influence in pneumonia, and 1 have been 
 so fully satisfied in this respect, that the first severe case which 
 comes under my care shall be treated in the tank. Such was 
 the statement which I made when the ninth case was under 
 treatment, and I now merely wish to supplement it. 
 
 Several of the cases since have had hypostatic congestion, and 
 incase 22 there was very pronounced double pneumonia. In all 
 cases the lung complications progressed very satisfactorily. If 
 I have not yet carried out this treatment in cases of simple 
 pneumonia it is because simpler measures have been successful. 
 Moreover I believe in treating cases of pneumonia in a dry 
 atmosphere, and it is difficult to prevent a certain amount of 
 vapour from rising from the tank, though this is quite possible, 
 and I intend to put some severe cases in the tank. I have very 
 little faith in the so called' " bronchitis kettle " for any affection 
 of the respiratory organs situated below the larynx. When there 
 is a tendency to oedema of the lungs the tank had, perhaps, 
 better be avoided. In such cases the constrained position in 
 the tank, and the weight of the water rather interfere with 
 free breathing. If, therefore, oedema of the lungs should super- 
 vene, I would take the patient out of the tank, and envelope 
 him, from the neck to the knees, in a linen sheet wrung of iced- 
 water. The circulation in these cases is invariably feeble, and 
 consequently the extremities readily become cold ; the feet and 
 legs should therefore be wrapped in a dry blanket. The only 
 other covering usually necessary is a dry sheet. The wet 
 sheet should be changed as often as may be required to keep 
 the rectal temperature under 103°, and not below 100"^. If it 
 be allowed to exceed 103', the high temperature exhausts the 
 feeble heart, and the oedema rapidly progresses ; on the other 
 hand, if it fall below 100^ there will be the danger of the stimu- 
 
72 THE TREATMENT OF TYPHOID FEVER. 
 
 lus being insufficient to keep a weak heart working. This may 
 seem heroic treatment, but it must be recollected that we are 
 dealing with one of the most fatal types of typhoid fever. In 
 these cases a moderate allowance of alcohol, and stimulants, 
 such as caffeine and ammonia, will do good.* 
 
 (?i) -Digestive System. The improvement in the digestive 
 tract is perhaps more marked than anywhere else. The tongue 
 becomes moist and clean, the salivary secretion increases, the 
 appetite and digestion improve, and the diarrhoea not only 
 lessens, but the character of the motions change for the better. 
 In the lifth case the diarrhoea alternated with the two periods 
 of immersion : and in the dysenteric patient the diarrhoea, 
 which had quite ceased towards the end of the period in the 
 tank, again returned to a certain extent after his removal. 
 With two exceptions, the diarrhoea lessened to one or two 
 motions daily soon after the patients were placed in the tank, 
 and not infrequently a small dose of calomel had to be 
 administered. In case thirteen the diarrhoea continued rather 
 profuse for seven days, and in case eighteen for four days. 
 The lessening of the diarrhoea, and the prevention of collapse 
 when the temperature of the tank is maintained, would suggest 
 it as a medium for the treatment of Asiatic Cholera. In this 
 case the temperature of the tank would require to be kept at 
 98° to 100°, and possibly higher in the algide stage. 
 
 (s) — Nervous System. The delirium disappears, and the 
 general well-being of the patient greatly improves. Cases four 
 and five were sufficiently roused up from their lethargic con- 
 dition to enable them to express, in no uncertain sounds, their 
 dislike of the water. The decided^beneficial effects of the 
 second immersion in each of these two cases spoke strongly in 
 favour of the tank. We have already referred to the increased 
 vaso-motor tone, and the very heightened neuro-muscular 
 irritability in many of these cases made us, at first, think that 
 the tank might have too stimulating an effect on the nervous 
 system. In the first case the knee-jerk was not tested, and in 
 
 * In a recent apparently hopeless case this treatment has been very 
 successfully carried out. 
 
THE TREATMENT OF TYPHOID FEVER. 73 
 
 the second and third cases only at a late stage of convalescence. 
 In the fourth, fifth, sixth, seventh, eighth and ninth cases there 
 were markedly exaggerated knee-jerks and ankle clonus. In 
 the tenth, eleventh, twelfth, thirteenth, nineteenth and twenty- 
 second cases there was well marked ankle clonus. In the 
 other cases it was absent, or not detected, as it was only 
 occasionally looked for. During canvalescence the clonus soon 
 disappeared, and the knee-jerks returned to normal. 
 
 In meningitis (cases 5 and 28) the knee-jerks were frequently 
 absent. The fifth case was not taken out of the tank on 
 account of the meningitis, as previously I had two very 
 successful cases of meningitis treated in the tank. The best 
 remedy for meningitis, in my experience, is the ice-cap while 
 the temperature is above normal, and this could not have been 
 well applied on this case in the tank. There is no disease 
 where improved vascular tone is more demanded, and this is 
 accomplished by the tank. Regarding internal medication, of 
 course the immediate condition of the patient must be treated, 
 but, as a general rule I prefer a calomel purge, followed by a 
 combination of salicylic acid and Dover's powder. In the early 
 stages of this case there was a question of diagnosis between 
 typhoid fever and tubercular menirfgitis; the absence of the 
 rash and knee-jerks told in favour of the latter, the bronchitis 
 did not decide either way, but the characteristic typhoid stools, 
 and distension of the abdomen settled the question in favour 
 of the former. The knee-jerk and ankle clonus afterwards 
 became very pronounced, though they slowly lessened during 
 the progress of the cerebro-spinal meningitis. A friend sug- 
 gested that possibly the tank may have given rise to the otitis, 
 and the otitis to the meningitis. This theory was bound to 
 receive due consideration, though I still held to my opinion 
 that these conditions were rare complications of the fever. 
 The otitis started and ended in the middle ear, without any 
 afiection of the throat or external ear. Although the cerebral 
 condition was somewhat relieved by the discharge of pus 
 through the perforated drums, it did not subside with the 
 healing of the ears, and the spinal mischief was in no way 
 
74 THE TREATMENT OF TYPHOID FEVER. 
 
 affected. When the patient was put into the tank a second 
 time, her cerebro-spinal, as well as her general condition, greatly 
 improved. The neuro- muscular irritability in typhoid fever 
 has been fully investigated by Dr. Angel Money, and I can 
 refer to his paper in The Lancet of November, 1885, and to 
 my own article on " The Treatment of Meningitis " in The 
 Liverpool Medico-Chirurgical Journal, January, 1891. 
 
 (11,) — Urinary System. The urine was passed into the tank, 
 and very few observations were made in any case. I had 
 hoped to have made a quantitative estimation of the amount of 
 urea in the tank, but this was found to be impracticable. The 
 albumen soon disappeared in those cases in which it was 
 detected. During the febrile stage of all cases, the urea is con- 
 siderably increased, and the chlorides diminished. Under the 
 head of diagnosis I have sufficiently referred to Ehrlich's test. 
 
 (yj) — Weight. The first four cases were not weighed before 
 being placed in the tank. The net weight of the fifth case on 
 admission to hospital was 43 lb., and during nine days, seven 
 of which were spent in the tank, she lost 7 lb. During the 
 second period of four days in the tank, she gained 1 lb. The 
 net weight of the sixth case fell from 97| to 92 lb., during the 
 six days in the tank. In the seventh case the net weight fell 
 from 115 to 951b., during the first 27 days in the tank, and 
 during the remaining four days he gained 3f lb. In the eighth 
 case the net weight fell from 127| to 117^ lb. in 10 days. In the 
 ninth case it fell in 25 days in the tank from 52i to 41^ lb. 
 In the tenth case from 95^ to 89^ lb. in 13 days. In the 
 eleventh case from 93 to 851b. in 11 days. In the twelfth 
 case from 50 to 471b. in 16 days. In the thirteenth case from 
 167 to 1501b. in 27 days. In the fourteenth case from 152 to 
 142 lb. in 17 days, of which 15 days were spent in the tank. In 
 the fifteenth case from 120 to 111 lb. in 6 days. In the seven- 
 teenth case from 73 to 69 lb. in 24 days. In the eighteenth 
 case from 131 to 1281b. in 15 days. In the nineteenth case 
 from 122 to 111 lb. in 8 days, of which he was only three days 
 in the tank. In the twenty-first case from IISJ to 96 lb. in 27 
 days. In the twenty-second case the weight fell from 151 to. 
 
THE TREATMENT OF TYPHOID FEVER. 75 
 
 139 lb. in 7 days before he was placed in the tank, and from 
 189 to 1191b. during 19 days in the tank. The loss c£ weight 
 in these cases has been very considerable, but the wasting did 
 not appear so extensive as I have previously seen it in severe 
 cases of typhoid fever, nor at all so great as has been recorded 
 in some cases by Cayley and others. The wasting is a natural 
 result of the fever, and should be prevented as far as possible 
 by a well-regulated dietary. 
 
 (6) — Skin. The horny layers of the palms of the hands and 
 soles of the feet get quite macerated, but on the skin of the 
 body generally there is very little effect, with the exception of 
 a slight roughness and elevation of the papillae. 
 
 (j) — The Tissues Generally. There is marked diminution in 
 the dehydration of the tissues, which takes place in all febrile 
 conditions ; this is very apparent in the case of the tongue, 
 which maintains its proper size and keeps moist. I know that a 
 great many eminent authorities state that there is a retention of 
 fluid in the system during the febrile process. There is an intra- 
 vascular retention especially in the veins, to fill up the paretic 
 vessels, but a retention in the tissues is quite inconsistent with 
 a high temperature ; dropsical conditions follow the fever, and 
 are associated with a feeble circulation. The intravascular 
 retention hampers the action of the heart, whereas the improved 
 vascular tone and tension associated with the use of the tank, 
 diminishes the bulk of fluid in circulation and so increases 
 the effective force of the heart. 
 
 Such are the effects which you may hope to derive from 
 the use of the tank in typhoid fever. It is not a specific 
 for that or any other disease, but it is a specific treatment 
 for the patient ; by placing him in an improved environ- 
 ment his system is better able to adapt itself to, and to 
 overcome, the altered conditions attendant on the fever. It 
 may be said that the number of cases is too limited to draw 
 conclusions, but if I can only induce others to put the method 
 in practice we will soon accumulate a sufficient number of cases 
 to satisfy the most ardent Baconian. Inductive philosophy is 
 all very well in its proper place ; it helps us to take stock of 
 
76 THE TREATMENT OF TYPHOID FEVER. 
 
 our progress and to remove any excrescences which may have 
 grown in our theories, but, so far as I am aware, no advance 
 either in science or anything else has ever been effected by this 
 process of reasoning. The method is too slow for the minds of 
 those who are moving in the van of progress. To wait for the 
 accumulation of observations from which a general law can be 
 affirmed may suit dullards, but progressive minds cannot wait 
 for nor submit to this levelling process. It may be said that 
 general laws can only be established by induction from observed 
 facts, but long before such laws are generally accepted they 
 have become axioms to the minds of those who have»_deduced 
 them from other well-known or ascertained facts. The mere 
 process of observing facts is not reasoning, and we must have 
 some deduction to guide the direction of our observations if 
 we do not wish to make our minds mere repositories for the 
 storage, perhaps, of rubbish. " Reasoning is nothing but the 
 faculty of deducing unknown truths from principles already 
 known." We are content with this definition of Locke; 
 deductive philosophy has been our guide in the past, and we 
 are satisfied when the accumulation of observations establishes 
 the truth of our inferences. Bacon and his philosophy we 
 largely leave to statisticians and to those who try to reap where 
 they have not sown. 
 
THE TREATMENT OF COMPLICATIONS. 
 
 Typhoid fever is specially liable to many complications and 
 therefore in every case we should be in a condition of "armed 
 expectancy," but we should not fold our arms and wait for 
 complications to arise. The temperature chart should be care- 
 fully watched, and any disturbance from the regular course of 
 the disease should make us look out for the cause. Any undue 
 rise of temperature with hurried respiration and quickened 
 pulse should direct our attention to the chest. The treatment 
 of such affections as bronchitis, hypostatic congestion of the 
 lungs, pneumonia, and pleurisy must be conducted on general 
 principles and will not detain us long. The three first of these 
 conditions can be well treated in the tank, but pluerisy may 
 demand some stimulating applications, such as a mustard and 
 linseed poultice to the affected side. These complications are 
 generally supposed to demand stimulants, but the stimulant 
 should be more especially ammonia, or ammonia, caffeine, and 
 bark or quinine, but not alcohol. In hypostatic congestion of 
 the lungs and pneumonia there is a vaso-motor paresis which 
 requires to be counteracted by a vaso-motor tonic, and not 
 intensified by alcohol. A good combination consists of fifteen 
 grains of carbonate of ammonia, two grains of caffeine and one 
 drachm of the ammoniated tincture of quinine given in an 
 effervescing mixture, with ten grains of citric acid, every four 
 hours. 
 
 Meningitis. This compartively rare complication is best 
 treated by an ice-cap, salicylic acid and Dover's powder, or 
 opium and calomel. With the treatment of Meningitis I dealt 
 very fully in The Liverpool Meclico-Gkiri<.rgical Journal, 
 January, 1891. 
 
 Hceniorrhage. A sudden fall of temperature, a blanched 
 anxious face, and a small weak pulse should direct our atten 
 tion to the occurrence of haemorrhage, even before the blood 
 has appeared in the stools. If the patient be in the tank, he 
 
78 THE TREATMENT OF TYPHOID FEVER. 
 
 need not necessarily be removed, thouc^h it is perhaps better to 
 take him out and keep him out, so long as the temperature 
 remains low. A large ice-bag should then be kept constantly- 
 applied to the abdomen. The peristaltic movements of the 
 intestines should be prevented by repeated doses of opium. 
 The best hsemostatic is perhaps turpentine, in ten minim doses, 
 every hour or two. In these cases there is usually defective 
 arterial tone, to counteract which ergot should be administered, 
 or ergotin injected hypodermically. If the patient is fainting, 
 he should have a little champagne or brandy. Stimulants 
 should only be temporarily used to prevent fatal syncope. 
 Until the haemorrhage has ceased, the stomach should not be 
 troubled with much food, and this should only consist of beef 
 essence, soup, peptonised gruel, and whey. If there be any 
 vomiting, the patient should have ice to suck or swallow, and 
 small nutrient enemata may be given. 
 
 Graves looked upon haemorrhage from the bowel as frequently 
 a critical evacuation which did not demand any interference, 
 and Trousseau latterly held that haemorrhages in typhoid fever 
 are usually of favourable augury. No doubt epistaxis, and 
 even haemorrhage from the bowel at an early stage of the fever 
 from congestion of the mucous membranes is not a matter of 
 much importance, but profuse haemorrhage about the end of 
 the third week from ulceration into a blood-vessel is a fact of 
 the gravest significance. The patient is not then in a position 
 to bear the loss of blood, and the sudden fall of blood -pressure 
 places his life in imminent danger. The horizontal position 
 should be strictly maintained, and if the loss of blood has been 
 great, the foot of the beadstead should be raised so as to 
 depress the patient's head below the rest of his body. All 
 unnecessary disturbance of the body should be avoided, and 
 the urine may be drawn off with a catheter. 
 
 Trousseau further says : — " I would not wish, however, to be 
 represented as saying that these haemorrhagic complications, 
 hitherto looked on as always serious, are really quite free 
 from danger. They are in too many cases exceedingly serious. 
 The haemorrhage may by its profusion destroy the patient, just 
 
THE TREATMENT OF COMPLICATIONS. 79 
 
 like any other loss of blood ; and you have heard of death 
 resulting from intractable epistaxis. Intestinal haemorrhages 
 are also formidable, when, by recurring they exhaust the 
 patient and cause him to fall into a state of anaemia and debility, 
 leading to extinction of vital power, and ataxic nervous 
 symptoms such as occurred in one of the three cases I mentioned. 
 Finally, intestinal hsemorrhages really are serious complications 
 of typhoid fever, when, occurring along with bleeding from 
 the nose, gums, lungs, urethra, or along with sub-cutaneous 
 haemorrhage, they are symptomatic of a dyscrasia against which 
 the resources of art are powerless. I am now speaking of 
 haemorrhages which constitute one of the characteristics of the 
 disease to which our predecessors gave the name of 'putrid 
 fever ' as a distinctive term, and which at present we call 
 ' haemorrhagic putrid fever ; ' but in these cases it is not, 
 strictly speaking, the loss of blood which kills : death is the 
 result of the peculiar morbid condition which constitutes 
 putridity." 
 
 In many cases a moderate epistaxis does good at the com- 
 mencement of an attack by lessening the general vascular 
 turgescence, and so relieving an overburthened heart. With 
 the diminution in the mass the effective force of the heart is 
 increased, provided the loss be not so great as to materially 
 affect the arterial tension. In the haemorrhagic cases the 
 cardiac contractions are invariably feeble, the arteries are 
 dilated and deficient in vaso-motor tone, the capillaries are 
 turgid, and the venous system is overloaded. To use an 
 engineering term, the head of the liquid is low, and conse- 
 quently the velocity is diminished. Again the velocity is 
 inversely as the sectional areas ; hence in the dilated and over- 
 loaded capillaries the velocity is lessened, and with the increase 
 in their fluid contents the lateral pressure within them is 
 augmented. The capillary resistance is directly proportional 
 to the length of the tubes, and inversely proportional to the 
 squares of their cross sections. Resistance tells backwards in 
 the course of the circulation. Obstruction to the flow of blood 
 into the arterioles and capillaries raises the arterial tension. 
 
80 THE TREATMENT OF TYPHOID FEVER. 
 
 and venous engorgement raises the pressure within the capil- 
 laries. The dilated arterioles and capillaries lessen the resistance 
 to the heart, and so the arterial tension, which is already low 
 from the feeble action of the central pump, is still further 
 reduced ; the head of the liquid is lowered, the velocity of 
 the blood diminished, and its statical condition within the 
 capillaries increased. The lateral pressure is still further 
 heightened within the capillaries by the overloading of the 
 venous radicles and general venous system. The conditions 
 are most favourable for the rupture of the capillaries, and 
 it is from these vessels that the blood comes in the hsemorr- 
 hagic cases. The temptation to enter fully here into the 
 physics of the circulation is very strong, but it would carry 
 me too far beyond the purpose of this work, and, moreover, 
 I have on several previous occasions dealt very fully with 
 the subject. 
 
 The indications for treatment in these hsemorrhagic cases are 
 to, {a) increase the force of the cardiac contractions, (b) 
 improve the vaso-motor tone, and (c) lessen the general venous 
 turgescence. Of course the general hygienic surroundings, 
 and the diet of the patient must receive due attention, as in 
 other cases. For the first two indications the best drugs are 
 ammonia, caffeine, nux vomica, and turpentine. To meet the 
 second and third (and also indirectly the first) indications, the 
 immersion in the tank will prove of invaluable service. The 
 stimulating effect of the tepid water increases the vaso-motor 
 tone, and thus contracts the arterioles and capillaries, augments 
 the resistance to the heart, and so calls forth more energy — 
 the velocity is quickened and the statical conditions diminished. 
 The pressure of the water (amounting on an average to about 
 a quarter of a pound to the square inch) hurries on the venous 
 circulation, lessens the resistance to the capillary flow, and 
 relieves the heart. Blood-letting in such cases would do much 
 harm by reducing the arterial tension (which is already far too 
 low) without any favourable effect on the other factors. In 
 fact in ordinary cases of intestinal haemorrhage, about the end 
 of the third week, the great fall of arterial pressure is fre- 
 
THE TREATMENT OF COMPLICATIONS. 81 
 
 quently followed by capillary hsemorrhages, so that the case 
 assumes a purpuric character. 
 
 Perforation. — Opium should be freely administered, and the 
 patient kept on a starvation diet. Surgical interference has been 
 proposed, but it is very doubtful if, under such circumstances, 
 it would do any good in the great majority of cases. I think 
 it will usually be best to trust to a natural process of inflam- 
 mation gluing this portion of the intestine to another coil. I 
 have, however, seen such excellent results from surgical inter- 
 ference in many cases of intestinal obstruction, that I would 
 certainly commend an operation if I thought the patient strong 
 enough to bear it. In the Medical News, November 21st, 
 1891, Dr. Weller Van Hook, of Chicago, records three cases of 
 laparotomy for intestinal perforation in typhoid fever, with 
 one recovery. Dr. Hook has collected the statistics of nineteen 
 cases of operation for perforation with four recoveries ; but in 
 seven of these cases (including three of the recoveries) it is 
 very doubtful that the patients were suffering from typhoid 
 fever. 
 
 Peritonitis. — When this follows on perforation the treatment 
 will be similar to that of the condition which induced it. 
 When it occurs as a rare complication of typhoid fever without 
 any antecedent perforation, it should be treated on general 
 principles. The circulation in the abdomen and the distension 
 of the bowel should be lessened by an ice bag or cold com- 
 presses applied to the abdomen. The intestinal congestion 
 should be diminished by small and repeated doses of calomel 
 and opium, and if there be constipation or only slight diarrhoea 
 small doses of some saline such as sulphate of soda should be 
 given as frequently as is requisite. It should be remembered 
 that peritonitis does well with free purgation, but no drastic 
 or irritating purgatives can be tolerated. The pain should be 
 completely subdued by opium. There is, no doubt, frequently 
 a certain amount of localized inflammation of the peritoneum 
 over the floors of the ulcers and the enlarged mesenteric glands, 
 but this is a conservative leison which, jper se, requires no 
 special treatment. Antiseptics should be freely administered, 
 
82 THE TREATMENT OF TYPHOID FEVER. 
 
 and as a rule I have more faith in the ice-bag in these cases 
 than in warm applications, especially when there is much fever. 
 In one case where the pain and tenderness over the spleen were 
 so great that an abscess was feared, great benefit and relief 
 were afforded by hot fomentations. 
 
 Tympanitis. There is always, or nearly always, a certain 
 amount of flatulent distension of the abdomen in typhoid fever, 
 but excessive tympanitis usually occurs when there is great 
 nervous prostration, and should be treated accordingly. Here 
 again an ice-bag, or cold compress to the abdomen does good. 
 Intestinal antisepsis should be practised to lessen foetor and 
 prevent decomposition of the contents of the bowel. The food 
 should be peptonised, and benefit will usually accrue from the 
 use of such nervine tonics as ammonia, quinine, and caffeine. 
 In the tank the tympanitis invariably disappears. Sir William 
 Jeuner says : — " Want of power to expel the flatus, and excess 
 in the quantity formed, reach their maximum as a rule about 
 the latter half of the third and during the fourth week of the 
 fever, for then the sloughing and ulcerative processes of the 
 walls of the intestine are at their height, the nerve power is at 
 its lowest, and the contractile energy of the abdominal and 
 intestinal muscles is consequenjbly at its minimum ; while, from 
 the state of the stomach and the secreting glands generally, 
 the antiseptic digestive processes are in a great degree arrested, 
 and the food that finds its way into the intestines mingling 
 with the foetid secretions from the diseased intestines, and with 
 the sloughing particles separating from the solitary and 
 agminated glands and from the floors of the ulcers, readily 
 undergo gas-generating decomposition." The causes which lead 
 to tympanitis are here well portrayed, but it seems to me that 
 in a well managed case any excessive distension should be 
 removed before the third week, and should not be allowed to 
 recur. The more distended the small intestine, cceteris paribus, 
 the greater the risk of haemorrhage and perforation. 
 
 Diarrhcea. This very seldom requires any treatment. It can 
 usually be kept within bounds by giving peptonised starchy 
 foods, diminishing the milk supply, and cutting off all flesh 
 
THE TREATMENT OF COMPLICATIONS. 83 
 
 juices. When the motions are very profuse and watery, opium 
 and chalk powder may be given, or starch and opium enemata. 
 Vegetable astringents may be prescribed, and antiseptics, such 
 as salol and salicylate of bismuth, should never be omitted. 
 
 Constipation. Sir William Jenner has pointed out that this 
 condition, when persistent, is frequently associated with deep 
 ulcerg-tion and a greater liability to haemorrhage ; and such is 
 my experience. It should be counteracted by mild laxatives, 
 such as calomel, salines, or castor oil, and any overloading of the 
 rectum should be removed by enemata. 
 
 Retention of Urine. The possibility of such an occurrence 
 should always be kept in mind, though it rarely happens. 
 
 Bed Sores. This is largely a question of good nursing. 
 When any such occurence threatens a water-bed should be 
 used. 
 
 Albuminuria. This is a valuable indication as showing the 
 state of the circulation. It indicates renal congestion, and is 
 associated with defective cardiac energy, diminished vis viva 
 in the circulation, and vaso-motor paresis. 8uch conditions 
 are improved by the tank, and vaso-motor tonics, such as 
 caffeine, digitalis, strophanthus, ammonia, and quinine. 
 
 Thrombosis and Embolism. In both these conditions the 
 part affected should be kept warm and at perfect rest. 
 Ammonia should be freely administered, and frequently opium 
 is of great service. 
 
 Peripheral Neuritis. This is usually best treated during 
 convalescence by massage, electricity, and nervine tonics. Tlie 
 condition which has been termed " the typhoid spine," is 
 due to wasbing of the erector spinge muscles, and perhaps to 
 inflammatory mischief about the smaller vertebral joints 
 and ligaments. It is best treated by massage, tonics, and 
 nutritious food. 
 
 Otorrhoea. The ears should be syringed with a weak warm 
 alkaline solution, to which a little peroxide of hydrogen or 
 sanitas has been added. They should be then dried and filled 
 with powdered boric acid. This should be done daily or 
 oftener so long as the discharge is free. 
 
84 THE TREATMENT OF TYPHOID FEVER. 
 
 Such sequelae as general debility, anaemia, neuralgia, imbe- 
 cility, or insanity should be treated, on general principles, with 
 good foo 1, fresh air, and tonics. Where there has been great 
 wasting, massage and good feeding soon renovate the muscles 
 and restore strength. 
 
 TABULAR STATEMENT OF FIFTY-FIVE 
 SUCCESSIVE CASES OF TYPHOID 
 FEVER, WITH ONLY ONE DEATH. 
 
 Twenty-two cases were treated in the tank. 
 
 Eleven cases received some form of special treatment, such as 
 the wet-pack, &c. 
 
 Twenty-two cases received symptomatic treatment. 
 
 Ages of Patients. — There were twenty-one cases under fifteen, 
 twenty-nine cases between fifteen and thirty, and five 
 cases over thirty years of age. 
 
 Day of Illness on Admission to Hospital. — Eighteen cases 
 were admitted before the ninth day : twenty-one cases 
 between the ninth and fourteenth days; eight cases between 
 the fourteenth and seventeenth days; six cases between 
 the seventeenth and twenty-first days; and in two cases 
 the day was not determined. 
 
TABULAR STATEMENT OF CASES. 85 
 
 Albuminuria. — Albumen was present in the urine at one 
 period or other in twenty-seven cases ; in nine cases the 
 urine was not examined, and in the remainder of the 
 cases, when the urine was examined, there was no albumen 
 present. 
 
 Lenticular Rose Spots. — These were found in thirty-five cases; 
 in the other cases they were either not present or not 
 noted. 
 
 Spleen. — The spleen was enlarged in forty cases : in ten cases 
 its size was not noted ; and in five cases it was apparently 
 not enlarged. 
 
 Ankle Clonus. — This was present in twenty-six cases, absent 
 in twenty-two, ani] not note.l in seven cases. 
 
 Hcemorrhage. — Intestinal haemorrhage occurred in four cases. 
 
 Meningitis occurred in two cases. 
 
 Lungs. — The respiratory organs were more or less afiected in 
 thirty cases. 
 
 Relapses. — In case 18 there was a recrudescence and an 
 indefinite relapse after he had been treated for the 
 original attack in the tank. Case 21 relapsed in the 
 tank. The tank, therefore, does not prevent relapses, 
 but, at the same time, I am of opinion that it does not 
 increase the liability to such occurrences. It must be 
 remembered that the most severe cases were treated in 
 the tank. In cases 15 and 16 the relapses, but not the 
 original attacks, were treated in the tank ; in the former 
 case the relapse began on the nineteenth day, and in the 
 latter on the thirty-eighth day. The 42Qd case relapsed 
 on the twenty-fourth day. 
 
86 THE TREATMENT OF TYPHOID FEVER. 
 
 Case 1. Severe case of Typhoid Fever; BronGhitis; Immersed 
 in the tank for nine days ; Cure. 
 
 T. C, aged 18, seaman, admitted June 14, 1889. He is a 
 well-developed, well-nourished, temperate youth, with a good 
 family and previous history. He took ill on June 6th, with 
 frontal headache which soon became so severe that he " could 
 scarcely see." He lost his appetite and became very weak and 
 unfit for duty, but there was no shivering, nor any diarrhoea. 
 Twelve days previously to this his vessel was lying in 
 Dunkirk, but he lived on board, and never slept in the town. 
 The water used on board was from a river in Germany, had a 
 bad taste, and was not boiled. 
 
 On admission he appeared very ill : lips parched ; tongue 
 tremulous, dry, brown, glaze J, and fissured ; fordes about teeth ; 
 he complained of thirst. There were slight pain and tenderness 
 over the abdomen and gurgling in the right iliac fossa. There 
 were about half-a-dozen, elevated, rose-coloured spots which 
 disappeared on pressure, scattered over the abdomen, and 
 about an equal number over the back. Pulse 92, soft, com- 
 pressible and fully dicrotic. 
 
 T. C, 15-6-89, Pulse 94, Pressure 2 ozs. 
 
 The temperature rose in the evening to ]04"6' Fah. Urine acid, 
 sp. gr. 1026, no albumen. He was placed on a milk diet, and 
 ordered six grains of naphthaline every four hours. 
 
 The following morning (9th day of disease), the temperature 
 had fallen to 102', but rose to 104-2' at 4 and 8 p.m. On the 
 10th day temperature was 102' at 4 a.m., and at 8 p.m. 105'8° 
 was recorded. On the 11th day the temperature was 104° at 
 4 a.m. and lOo" at 8 a.m. He had now been for two days in 
 the condition of low muttering delirium. His lips were dry 
 and cracked ; teeth cox'ci'ed with sordes ; tongue very tremu- 
 
CASES TREATED IN THE TANK. 87 
 
 lous, very dry, brown, glazed, and deeply fissured transversely. 
 There were numerous mucous rales all over chest, but no 
 consolidation, nor any expectoration. He was now in a very 
 serious state, and I was of opinion that very prompt measures 
 would have to be adopted to enable him to survive for ten days 
 or longer, until the attack had subsided. Accordingly at 4 p.m. 
 on the 11th day of the disease (June 17th) his temperature 
 being 105°, I had him immersed in the tank, the water of 
 which was 95' Fah. 
 
 The following are the four hourly records of temperature 
 during next 24 hours, 10<fc-2", lOSB", 102-6", 102, 102", 102\ 
 He was then taken out of the water for an hour to have the 
 tank cleaned, and at 8 p.m. temperature was 102'8°, but by 
 midnight it had fallen to 99°. 
 
 June 19th (thirteenth day of disease). .The delirium entirely 
 ceased within twelve hours after he was placed in the tank and 
 has not since recurred. His tongue is still tremulous, but moist 
 and covered with a white fur at the edges, dry and transversely 
 fissured in the centre. Pulse has fallen to 80, small and some- 
 what feeble but considerably increased in tension. His 
 temperature ranged to-day from 99'6° at 8 a.m., to 103° at 
 8 p.m. The evening rise was partly due to his being out of 
 the tank in the afternoon for about an hour, but the tempera- 
 ture still presents the usual diurnal variations with an evening 
 exacerbation. 
 
 June 20th. Patient is doing very well. Pulse 80, better 
 volume than yesterday. Respirations 24. Tongue moister. 
 His temperature to-day ranged from 101'4° to 102"8". He had 
 three loose motions to-day, but there has been at no time any 
 profuse diarrhcea, and in fact up to the 1 1th day of disease when 
 his bowels were opened by an enema, there was constipation. 
 
 June 2 1st. The patient this morning is very comfortable. 
 Pulse 80, regular, fair volume. Tongue less cracked transver- 
 sely but coated with a moist fur, and he takes nourishment 
 better. His temperature at 8 a.m. was 100'4°. When he was 
 out of the water at noon while the tank was being cleaned, his 
 temperature rose to 10.3'6 . Soon after being replaced in the 
 
88 THE TEEATMENT OF TYPHOID FEVER. 
 
 water, it fell to 101-8°, but rose at 4 p.m. to 103". The tem- 
 perature of the tank was now reduced to 90" Fah., and his 
 temperature fell to 101'2° at 8 p.m., but rose to 102-6° at mid- 
 night. There were an unusual number of fluctuations in the 
 temperature to-day, which I partly ascribed to a want of 
 uniformity in the tank temperature. Two motions to-day. 
 
 June 22nd. Tongue quite clean and moist. Pulse 80, regular. 
 He is taking nourishment well, and beginning to crave for 
 more substantial food. On examination of lungs there are still 
 some bronchitic rales. Two motions to-day. There was a 
 steady fall in the temperature to-day, except a rise at 4 p.m. to 
 102°, when he was out of the tank ; the records were 4 a.m , 
 101-4°; 8 a.m., 100-6°; 12 noon, 100°: 4 p.m., 102°; 8 p.m., 
 101° ; 12 midnight, 98-8°. The temperature of the tank was 
 again raised to 95° Fah. His body temperature remained 
 normal the following day except for an evening exacerbation 
 to 101-2°. One motion. 
 
 June 24th (eighteenth day). Progressing very satisfactorily. 
 Pulse 80, regular, fair volume ; tongue clean and moist. One 
 motion. Temperature ranged from 98-8° to 100°. 
 
 June 25th (nineteenth day). Doing well and feels well. 
 Pulse 80. One motion. Temperature ranged between 98-8° 
 and 99-2°. 
 
 June 26th (twentieth day). Tongue clean and moist. Pulse 
 80, regular and fair volume. One motion. Bronchitis nearly 
 well. He was ordered to-day, in addition to his milk diet, 
 chicken broth, fish, and one egg. A mixture of nitro-muriatic 
 acid and cinchona was substituted for the naphthaline. He 
 was taken out of the tank altogether this afternoon, having 
 been immersed for nine full days ; the temperature afterwards 
 rose to 100-6°, but fell the following morning to normal. 
 There was a slight evening exacerbation during the two 
 following days after which his temperature continued quite 
 normal. Convalescence was now quickly established. His 
 appetite became ravenous and on July 4th (the 28th day from 
 the onset of the disease) he was allowed ordinary diet. He was 
 not weighed on reception, but he seemed to me to lose less 
 
CASES TREATED IN THE TANK. 89 
 
 flesh than is usual during- a severe attack of typhoid fever. His 
 weight on July 12th was 1281b., and on the 19th 1321b. He 
 was discharged quite well, and fit for work on July 22nd. 
 There was very little diarrhoea in this case throughout, the 
 brunt of the illness at first fell on the nervous system and 
 lungs. The delirium disappeared ; the tongue became moist and 
 clean ; the lung phenomena improved ; the pulse became slower, 
 stronger, and of better tension ; the appetite returned ; the 
 temperature moderated ; and the general well-being of the 
 patient was very decided. 
 
 Case 2. Severe case of Typhoid Fever ; Immersed in the tank 
 for eleven days; Cure. 
 
 O. A., aged 22, Norweigian sailor, was admitted to hospital 
 on August 12th, 1889. When he left Odessa, seven weeks 
 previously, he was quite well, but five weeks later, or two or 
 three days before reaching Malta, he began to lose his appetite, 
 got out of sorts, ami felt sick. For eight days he has sufiered 
 from vomiting and diarrhoea, and has been confined to bed. 
 He is a tall, lanky, spare but muscular man, who seems to have 
 enjoyed good health previously to the present illness. It is 
 rather difficult to fix the exact date of the commencement of 
 this disease, but he seems to have become sick, in his own 
 words, "in his belly," about thirteen days auo, though he has 
 only been confined to his bed for the last eight days. 
 
 He is now suffering from well-marked typhoid fever. The 
 rose-coloured lenticular spots are fairly numerous ; there is 
 considerable tenderness in the right iliac fossa, and the motions 
 are liquid and of a pea- soup character ; the spleen is enlarged. 
 He is exceedingly prostrate, very apathetic, and lies on his 
 back in a listless manner regardless of passing events. His 
 tongue is tremulous, fissured, and covered with a dry brown 
 fur. Pulse quick, small, and dicrotic. His arteries are rigid 
 and rather tortuous. He was placed on a milk diet, and ordered 
 six grs. of naphthaline every four hours. At 8 p.m. on the 
 night of admission his temperature rose to 105'' Fah., and he 
 then received a dose of antipyrin. 
 
90 THE TREATMENT OF TYPHOID FEVER. 
 
 The following morning at 8 o'clock his temperature had 
 fallen to 101 '6°, but at noon it had reached 103°. He was soon 
 afterwards placed in the tank at a temperature of 95°, but 
 even then his temperature continued to rise a little, and at 4 
 o'clock, 103"6° was recorded. 
 
 August 14th (sixteenth day of disease), 8 a.m. temperature 
 97*8° ; noon 101°. He was now taken out of the tank, and his 
 temperature quickly ran up to 103° He was out of the water 
 about an hour, but at 4 p.m. temperature was 103*4° ; at 8 p.m. 
 103°. From this date the temperature kept steadily falling, 
 each morning and evening records being lower than those of 
 the preceding day. At no time after the twentieth day of the 
 disease did the evening temperature exceed 101° : while on the 
 twenty-first and succeeding days the morning records were 
 normal or[^subnormal. 
 
 The progress of the case was very satisfactory throughout ; 
 within 24 hours of his being placed in the tank, his dry, brown, 
 cracked tongue had become moist ; he was much livelier, and 
 there was no appearance of any delirium. He expressed him- 
 self as feeling quite comfortable. His pulse had become 
 slower and less dicrotic, and after the first day did not exceed 
 84 in the tank. He was taken out of the tank on August 
 24th (twenty-sixth day of disease), when the temperature had 
 been about normal for 24 hours. After this there was an 
 average rise of a degree to a degree-and-a-half, and the evening 
 temperature did not sink below 100° till the thirty-second day 
 of the disease. The temperature of the tank was throughout 
 between 90° and 95°. For four or five days before he was 
 taken out of the tank, there was a great craving for food, but 
 he was kept on milk till the twenty-fifth day, when he was 
 allowed bread and butter. 
 
 September 5th. — He is progressing very satisfactorily and 
 gaining flesh. Superficial arteries very rigid and tortuous ; 
 pulse feeble; heart sounds dull. The patellar reflexes are 
 present but not exaggerated. He was placed on ordinary diet 
 and given a caffeine mixture. 
 
 September 13th. — Weighed to-day for the first time 1231b. ; 
 
CASES TREATED IN THE TANK. 91 
 
 20th, 1241b. ; 2rth, 1291b. ; Oct. 4th, 181 lb. On the latter 
 date he was discharged quite well and fit for work. 
 
 The macerating effect of the water on the hands and feet of 
 this " horny-handed son of toil " was very marked and it was 
 a long time after he left the tank before they had assumed 
 their natural appearance, and during the process of exfoliation 
 the keratin smell was rather offensive. I have never previously 
 met with such atheromatous arteries at such an early age. 
 
 Case 3. Typhoid Fever ; Immersed in the tank for six days; 
 
 Cure. 
 
 O. O'N., aged 14, was admitted to hospital on August 1st, 
 1889, complaining of pain in the back and legs, and vomiting. 
 He looked very ill. His present illness began on the 17th, 
 with pain in the back and legs, vomiting, and headache, so 
 that we reckoned the day of admission as the tifth day of the 
 disease. His mother is phthisical. Pie is a tall, spare boy ; 
 has an anxious expression ; lips and nails livid ; tongue covered 
 with a thick white fur. The heart's impulse is very visible in 
 the 2nd, 3rd, and 4th interspaces, and is distinctly peristaltic; 
 the dull percussion extends to an inch and-a-half outside 
 nipple line, and reaches to the second costal cartilage ; sounds 
 clear, second rather accentuated. There are numerous rose 
 spots on the abdomen, which, however, has been rubbed with 
 a liniment by his mother. There is gurgling, pain, and 
 tenderness in the right iliac fossa. The motions are loose and of 
 the usual pea-soup character. Urine acid, sp. gr. 1030, distinctly 
 albuminous. Temperature 102"^. He was placed on a milk diet, 
 and ordered half a grain of calomel each day for four days. 
 
 24th (eighth day). At 4 p.m. yesterday the temperature 
 had reached its maximum since admission, viz., 103.2°, but 
 since then it has steadily fallen to 100"8'' at 8 a.m. At 10 a.m. 
 his pulse was 104, soft, weak, and fully dicrotic. At 11 a.m. 
 he was put in the tank at a temperature of -90°. After this his 
 temperature rose slightly, reaching 102° at 4 o'clock, but it 
 then began to fall. At 4.30 his pulse was 84, and improved 
 in tension. Respiration quiet, and lungs healthy. 
 
92 THE TREATMENT OF TYPHOID FEVER. 
 
 26th (tenth day). The temperature fell yesterday at noon 
 fco 97°, and rose in the evening to 99°. At midnight it had 
 again fallen to 96°, and the temperature of the tank was then 
 raised to 95°, and by 8 a.m. his temperature had reached 99° ; 
 the tank was again reduced to 90°. At 4 p.m. the temperature 
 in his mouth was only 97° and pulse 60, so the tank was now 
 raised to 95°, and maintained at that temperature. Tongue 
 clean and moist, one loose motion to-day. 
 
 27th. Craving for food. Temperature about normal ; from 
 this date till the time he was taken out of the tank on August 
 30th, the highest record was 99"4°. 
 
 29th (thirteenth day). He is progressing very favourably. 
 Pulse 84, small, compressible, and of moderate tension ; tongue 
 clean and moist. He complains much of hunger. Bowels 
 rather confined, motions solid, pale yellow, and not very 
 ofi'ensive. Allowed bread and butter. He was taken out of 
 the tank on August 30th (fourteenth day). The morning 
 temperature remained normal, but there was an exacerbation 
 of two or three degrees every evening till the 23rd day of the 
 disease. After his removal from the tank the frequency of his 
 pulse increased about ten to fifteen beats for a few days. 
 When his urine was examined on September 2nd, it was free 
 from albumen. On the 20th, he was placed on ordinary diet. 
 The following are the records of his weight : — September 13th, 
 741b.; September 27th, 781b.: October 4th, 831b.; October 
 11th, 86 lb. During his residence in the hospital his medicine 
 consisted of two grains of calomel. The patient was discharged 
 October 11th, quite well. 
 
 Case 4. Severe Case of Typhoid Fever ; Hypostatic Conges- 
 tion of the Lower Lobes of the Lungs ; Sixteen days in 
 the tank ; Cure. 
 Sarah K., aged 20, hawker, was admitted to hospital on 
 August 30th, 1889. This patient was in such a stupid lethargic 
 condition that it was impossible to get any information from 
 her as to the history of her illness ; but it was elicited 
 from her mother that eleven or twelve days previously she 
 
CASES TREATED IN THE TANK. 93 
 
 complained of loss of appetite, cough, and headache. She 
 continued at work till a week ago, since which time she has 
 been confined to bed, and has suffered from diarrhoea with 
 offensive motions. She suffered from sickness, and complained 
 of pain in stomach ; she has been very thirsty, and rambled 
 much at night. She was under medical treatment for a few 
 days before admission, and received large doses of quinine. 
 
 Her eyes are dull, countenance stupid and devoid of expres- 
 sion. Tongue exceedingly drj^ and deeply fissured transversely; 
 skin hot and dry ; temperature 104° ; respirations quick and 
 shallow: pulse 110, small, soft, dicrotic, and so very feeble as 
 scarcely to move the lever of the sphygmograph. Over the 
 lower lobes of both lungs, percussion dull, vocal resonance and 
 fremitus increase], breathing tubular, and a few crepitant 
 rales in inspiration — in short, well-marked signs of hypostatic 
 congestion. 
 
 There are many distinct rose-coloured lenticular spots over 
 the abdomen ; tenderness and gurgling in the right iliac fossa. 
 Spleen large. She was ordered milk diet, no medicine. She 
 was placed in the tank at a temperature of 90° Eah. 
 
 August .31st. She is now (3.45 p.m.) sensible, although still 
 very stupid and dull of hearing. She says she will be ill, " a 
 fortnight again Monday" — that is, she became ill on the 19th. 
 Her breath has a very heavy and offensive smell. Tongue is 
 becoming moist. Respirations 36. She says she is feeling 
 better, but does not like " the wather." Her temperature 
 fell this morning to noi'mal, and so the temperature of the 
 tank has been raised to 98°. It will shorten my remarks on 
 her temperature by stating that from this date till her removal 
 from the tank on the 1 1th (twenty -fourth day of disease), the 
 morning temperature was usually about 99°, and the average 
 temperature of sixty-three observations during this period 
 was 100-6°. 
 
 September 1st (3.30 p.m.). The patient is rather better 
 to-day. The tank has been maintained, as far as possible, at a 
 temperature of 95° to 98°. She is more sensible, but still very 
 deaf. Her tongue is moist, and the cracks are less. The 
 
94 THE TREATMENT OF TYPHOID FEVER. 
 
 breathing is not quite so hurried, respirations 80. Pulse 96, 
 small, weak, and compressible, but tension better. There is 
 slight cough, but no expectoration. The percussion over both 
 lower lobes still dull, but the breathing is less tubular, and 
 there are fewer rales. Her bowels were moved once this 
 morning, motion light yellow in colour, semi-solid, and not 
 very offensive. She did not sleep much last night, but has 
 done so to-day. It seems she has never had a bath since 
 infancy, and does not now take kindly to the water. Ordered 
 one grain of calomel. 
 
 2nd (fifteenth day). There is considerable improvement 
 though she passed a restless night. Tongue tremulous, fur 
 more moist, cracks less. She is sensible, but still very deaf ; 
 she is nervous and grumbles much at the bath. There is great 
 improvement in the lungs ; the percussion is clearer, breathing 
 less tubular though respiratory murmur is still very feeble ; 
 there are fewer rales. 
 
 Sixteenth day. The patient spent a much better night, 
 sleeping for the greater part of the time, but when awake she 
 is not reconciled to her watery bed. She is still apathetic and 
 deaf, but expresses herself that she feels "right enough." 
 Tongue moister and slightly fissured, feels thirsty, bowels 
 opened to-day. There is considerable improvement in the con- 
 dition of the chest, percussion clearer, respiratory murmur 
 fuller, and only very few rales. Repeat calomel powder. 
 
 Seventeenth day. Passed a very restless night, but has slept 
 well to-day. Her general condition is better, respirations 26. 
 Repeat calomel, and to have half-a-drachm of sulphonal to-night. 
 
 Eighteenth day. Slept well last night and during the 
 greater part of to-day. She is progressing favourably. 
 
 Twentieth day. She continues to progress favourably. Her 
 temperature is only moderately febrile ; to-day it rose to 
 102"2°, when she was taken out of the water to have the tank 
 cleaned. Tongue coated with a moist creamy fur; bowels 
 opened. She drinks freely. She sleeps very well at night, 
 and has had no sulphonal since the night it was ordered. She 
 is quite inteligent but still highly nervous and rather deaf. 
 
CASES TREATED IN THE TANK. 95 
 
 Twenty-third day. The temperature of the patient is main- 
 tained at a rather high level, having ranged for the last three 
 days between 100° and 102'6° The temperature of the tank, 
 which has hitherto been 98°, is now reduced to 90°. Tongue 
 moist, appetite good, bowels open ; she looks very well and 
 comfortable. 
 
 Twenty-fourth day. The temperature of the patient has 
 fallen, since the lowering of the temperature of the tank. Her 
 grumbling to-day about the " cowld wather," is so incessant, 
 that I complied with her request and had her removed from 
 the tank. She is now looking very well, and her temperature 
 (4 p.m., before removal from water), 99'2°. 
 
 Twenty-tifth day. This patient was taken out of the tank 
 yesterday at 7-30 p.m. After this her temperature steadily 
 rose till it reached 103"2° at midnight. To-day it is fluctuating 
 between 101° and 103°. She is drowsy, more stupid, and very 
 deaf, and the nurse reports that she has been delirious all day. 
 Tongue clean, but dry and parched. Pulse 132, small and 
 weak; respirations 30. She had a loose motion to-day, light 
 yellowish pea-soup appearance, and offensive smell. Her 
 abdomen is not distended, seems rather tender on pressure, 
 especially in the right iliac fossa. Splenic dulness measures 
 six by five inches. Hepatic dullness four and-a-half inches in 
 line of sternum. Percussion clear over the back, but breathing 
 is rather harsh, and there are a few rhonchi. Ordered six grains 
 of naphthaline and half-a-grain of calomel every four hours. 
 
 Twenty-seventh day. For the last two days her temperature 
 has ranged between 101° and 104°, and it is now (4 p.m.), 
 I04"2°. She is delirous, passes her urine and faeces uncon- 
 sciously. Motions loose and offensive. Ordered to be replaced 
 in the tank at a temperature of 90°. 
 
 Twenty-ninth day. Immediately after she was placed in 
 the tank her teniperature began to fall, and at 4 a.m., yesterday, 
 it had sunk to 98°. It has not since risen above 100°. She is 
 quite sensible to-day, but not at all reconciled to her new 
 quarters. Pulse 120, small and weak; respirations 20. Tongue 
 moist. She complains of thirst. Eyes bright and clear. Motions 
 
96 THE TREATMENT OF TYPHOID FEVER. 
 
 loose, dark -greenish colour. Urine and faeces still passed 
 unconsciously. She objects to the naphthaline, but says she 
 does not mind what she takes if she only gets something to 
 eat. The naphthaline is now stopped, and she is ordered half- 
 a-grain of calomel, and five grains of aromatic chalk, twdce 
 daily. From this time the progress was uninterrupted, and 
 she was finally taken out of the tank on the 31st day of the 
 disease, after having been immersed for two periods of twelve 
 and four days respectively. The temperature now became 
 subnormal, ranging between 97° in the mornings and 99° in the 
 evenings. 
 
 October 2nd (forty-fifth day). The patellar reflexes are 
 exaggerated and there is marked ankle clonus. 
 
 12th. Patellar reflexes about normal only slight ankle 
 clonus. The following are the records of her weight without 
 clothing : September 30th, 82 lb. ; October 7th, 85 lb. ; October 
 18th, 901b. : October 25th, 941b. 
 
 November 3rd. She is now and has been for some time 
 quite well. All her organs and secretions healthy. Discharged 
 to-day. 
 
 Case 5. Severe Case of Typhoid Fever; Cerehro-Spinal 
 
 Meningitis ; Double Otitis Media ; Immersed in the tank 
 for eleven days ; Cure. 
 
 Margaret O'B., aged 8, was admitted to hospital on 
 September 16th, 1889. The patient is a spare, fairly healthy 
 looking child, weighing 431b. She became ill eight days ago, 
 with chilliness and pains in the stomach. She has been since 
 in bed and for some days has suffered from diarrhoea. She is 
 easily roused up and gives intelligent answers to questions. 
 Lips dry and cracked, sordes on teeth. Tongue rather 
 tremulous, coated with a dry brown fur. Pulse 116, full, soft, 
 and compressible. Respirations quiet. No rose spots to be 
 seen on abdomen but numerous flea-bites all over the body. 
 Abdomen distended and tender, but no gurgling in right iliac 
 fossa. Splenic dullness three inches by two and three-fourth 
 inches. Heart sounds normal. Some bronchitic rales over the 
 
CA.SES TREATED IN THE TANK. 97 
 
 posterior aspect of both lungs. Skin dry and hot, temperature 
 102° Fah. in axilla. Motions very loose, offensive, and yellow 
 ochrey colour. Patellar reflexes absent. Milk diet. 
 
 September l7th (tenth day). Temperature 102*2°. Motions 
 very loose, pea-soup character, and offensive. Urine, 20 ozs. in 
 24 hours, alkaline, sp. gr. 1015, albuminous. 
 
 Eleventh day. The temperature fell this morning at 4 o'clock 
 to 99°, but afterwards steadily rose and at 4 p.m reached 104'6°. 
 Diarrhoei profuse. Body hot and dry, extremities cold, and 
 altogether the patient appears very ill. She was put into the 
 tank at 8 p.m. Temperature of water 95°. 
 
 Twelfth day. After she was placed in the tank her 
 temperature steadily fell, and at midnight had sunk to normal, 
 and remained so till noon to-day, when it began to rise and 
 reached 102'6° at 8 p.m. Her temperature has hitherto been 
 taken in the axilla, but while in the tank it is directed to be 
 taken in the rectum. Pulse small and compressible, but not 
 markedly dicrotic. Has a' slight cough, respirations 24. She 
 appears comfortable and sleeps most of the time. The bowels 
 are freely moved, but the diarrhosa has considerably abated 
 since she was placed in the tank. 
 
 Thirteenth day. Patient not quite so well, tongue is rather 
 dry, pulse quicker (140), small and weak, and she is more 
 fretful. Pupils large, face flushed and rather purple. She is 
 quite sensible. Tank to be lowered to 90° till her temperature 
 falls nearly to normal. 
 
 Fourteenth day. Her temperature was 100° at 4 a.m., 10l"4° 
 at 8 a.m. It then steadily fell to 97° at 8 p.m. It was now 
 decided that the tank should be kept at 95° during the night 
 and 90° during the day. Her lips and tongue were moister 
 to-day. Pupils not so large. She did not sleep well last night, 
 and coughed a good deal. 
 
 Sixteenth day. For two days her temperature has ranged 
 between 98*4° and 100"4°. Tongue clean and moist. Pulse 144, 
 tolerably firm. Pupils slightly reduced. Sleeps well, but has 
 cried herself hoarse when awake. 
 
 Eighteenth day. Tongue clean and moist, pupils moderately 
 
98 THE TREATMENT OF TYPHOID FEVER. 
 
 dilated. Pulse 144. fair tension. She has been found thrice 
 with one angle of her mouth just under the water. Her head 
 is much retracted on the spine. She is in a peculiar mental 
 condition, cries continually with a widely opened mouth, varied 
 by a dry cough and occasional eructations of gas. Refuses to 
 answer any questions. Protrudes her tongue as far as possible, 
 rotates it on its long axis, and then closing her mouth retracts 
 it slowly doubled up between the teeth. She slept well last 
 night. Cheeks not so flushed. Her temperature has been 
 slightly higher, reaching 101°, yesterday and to-day. There is 
 now evidently meningitis, and from the position of her 
 retracted head it was not considered safe to leave her in the 
 tank to-night so she was removed at 6 p.m. Her net weight 
 was then 36 lb., having lost 7 lb. during her nine days residence 
 in hospital. 
 
 Nineteenth day. The following is Dr. Wallace's note of 
 to-day. " Patient slept well last night and was quiet after 
 having been taken out of the tank, but was restless at times. 
 She lies on her right side with the head retracted. Pupils 
 large ; face flushed ; breathing pretty rapid and sighing, 
 frequently interrupted by a short dry cough. She often opens 
 her mouth widely and protrudes her tongue. There is a 
 considerable amount of frothy saliva in her mouth. She has 
 not taken any notice of any person or thing since yesterday 
 morning. She is thirsty. She passes both urine and fseces 
 involuntarily and there is increased diarrhoea. The abdomen 
 is slightly retracted. There is great increase of both patellar 
 reflexes, especially the right ; and there is marked ankle clonus, 
 which is long continued in the right side. The lower limbs are 
 rather rigid, the thighs are acutely flexed on the abdomen and 
 the legs on the thighs. There are no deep reflexes in the 
 upper limbs which are rather rigid and the forearms flexed on 
 the arms. Just at this moment she protruded her tongue four 
 or five times from her widely opened mouth, turned her head 
 slowly to the left and back again. Her eyes look mostly to the 
 right and downwards, but are not fixed. Could not find the 
 optic disc. Pulse 164, pretty firm. Respirations rather rapid 
 
CASES TREATED IN THE TANK. 99 
 
 but not easily counted on account of her almost constant cough." 
 Her temperature rose to-day to 103° in the axilla. I ordered 
 her hair to be cut, and an ice-cap to be applied to her head, 
 and to be given a powder, containing four grains of compound 
 ipecacuanha powder and six grains of salicylic acid, every four 
 hours. 
 
 Twentieth day. Dr. Wallace noted this morning that she 
 " Slept quietly for several hours last night after taking Dover's 
 powder and salicylic acid. She asked several times this 
 morning for drink and answered a few questions with apparent 
 intelligence ; she lies quietly with a rather vacant stare ; her 
 pupils are dilated. She does not protrude her tongue or turn 
 her head about so much as yesterday. She rolls her eyes 
 about a good deal, but won't now answer questions, though her 
 attention seems attracted by the voice. There has been a 
 quantity of pus discharging from both ears to-day, the right 
 membrana tympani cannot be distinguished owing to the 
 quantity of pus coming from the middle ear. The left 
 tympanic membrane is much inflamed, and in the lower 
 anterior quadrant is seen a recent perforation the size of a pin's 
 head from which pus of a very foetid odour flows. The 
 reflexes are still exaggerated. Pulse 164. Eespiration tranquil. 
 Dry powdered boric acid is used for the ears." 
 
 At 3 p.m., I noted that the cerebral symptoms presented by 
 this patient last night were found to have in part disappeared 
 this morning, when Dr. Wallace discovered for the first time 
 suppurative double otitis media with perforation of both drums. 
 The temperature has however been steadily rising and at noon 
 reached 103'6°. Her throat is not aflected. The pulse is again 
 becoming more frequent. She has now assumed a more natural 
 position, appears intelligent, and occasionally replies to questions 
 or gives indications that she does not wish to be troubled. Her 
 head is still very much retracted ; the muscles of the upper 
 limbs rigid, and the flexors so much contracted that the fore- 
 arms are acutely flexed on the arms, the thumbs are adducted 
 to centre of palms, and the fingers are flexed. The lower 
 limbs are drawn up, the thighs flexed on the abdomen, and the 
 
100 THE TREATMEXT OF TYPHOID FEVER. 
 
 legs on the thighs, ami the feet are extended. Ankle clonus, 
 and patellar reflex still marked ; plantar reflex increased, but 
 the other superficial reflexes are barely if at all elicited. The 
 liver is considerably enlarged, moves with respiration, and the 
 lower margin can be seen just above the umbilicus. There were 
 eight loose motions to-day. To continue the salicylic acid and 
 Dover's powders. The temperature was 103'8' at 4 p.m. ; 100° 
 at 8 p.m. ; and 99 '2' at midnight. 
 
 Twenty-first day. Dr. Wallace noted : " Patient lies in the 
 same position as yesterday, but the head is not so much or so 
 persistently retracted. The patellar reflexes are difficult to 
 elicit. Ankle clonus slightly marked on right side, easily 
 elicited and long sustained on left side. Patient has slept well 
 all night, and this forenoon, except when roused for her food 
 and medicine, when she calls for her mother, and answers 
 simple questions. She does not now gape and protrude her 
 tongue and cry. Her pupils are strongly contracted. There was 
 a copious discharge from the left ear during the night, the 
 perforation in the drum is not yet sufficiently large for the 
 efficient drainage of the tympanum, though it is slightly 
 increased since yesterday. The right tympanic membrane 
 shows a large ovoid perforation. Urine and f^ces passed 
 involuntarily, but the diarrhcea has lessened. Three loose 
 motions to-day, of a yellow colour, with bits of curd in them, 
 acid in reaction, and not very offensive. The respirations are 
 20 per minute deep and slightly snoring. Pulse 140, fair 
 tension. The upper limbs are not so rigid nor so much flexed 
 as yesterday afternoon." The temperature ranged between 
 99-4' and 102-8° to-day. 
 
 Twenty-second day. This patient seems to have improved 
 since yesterday : she is intelligent, frequently calls for her 
 mother; the cough is not very troublesome ; respiration quiet ; 
 pulse 136 ; tongue moist ; bowels open : motions light yellow, 
 and not very offensive. She lies on her side, with her thighs 
 and legs acutely flexed ; the rigidity is rather less. Pupils 
 normal. She is very much emaciated, and notwithstanding 
 the fact that she has lain on a water-bed since her removal 
 
CASES TREATED IN THE TANK. 101 
 
 from the tank, bed sores are beginning to appear over the 
 sacrum, trochanters, and elbows. Ordered to-day peptonised 
 bread and milk, and to have ten grains of aromatic chalk- 
 powder with opium when motions are very loose. 
 
 Twenty-third day. Dr. Wallace notes : — " This patient con- 
 tinues to improve. The attitude is still one of flexion, the 
 lower limbs being rigidly flexed, and any attempt to straighten 
 them is attended with pain. The upper limbs can be easily 
 straightened. It is difl&cult to estimate the patellar reflex 
 owing to the firm contraction of the flexors. Ankle clonus 
 hard to elicit. The threatened bed sores are not advancing. 
 Patient has become quite sensible, and answers questions 
 intelligibly. Her face is flushed ; pupils rather small. She 
 complains of pain in right ear, and there has been copious 
 discharge from both ears during the night. The tympanic 
 membranes have lost their red, congested appearance- She has 
 still diarrhoea, and passes urine and faeces involuntarily. She 
 slept moderately well last night, and takes her food well. The 
 temperature reached 101^ last night, being 2"' less than the 
 previous evening and 3^ less than three days ago. Pulse 112 
 good tension. Respirations 20 ; tranquil. Percussion of right 
 back clear. There are still some medium crepitations." 
 
 Twenty-fourth day. " At 3-30 yesterday afternoon, the 
 patient had a slight rigor, and at four o'clock the temperature 
 was 104*2^ Fah. From this time it steadily declined, and at 
 eight a.m. it had sunk to .99'6". She slept moderately well. 
 She is now particularly sensible and answers questions intel- 
 ligently, but is a little drowsy, probably from opium. She 
 complained last evening of pain behind the left ear, but there 
 was no pufiiness, and this was probably due to angular pieces 
 of ice, as she has lain much on the left side. The lower limbs 
 are still rigidly flexed, and cannot be straightened without 
 causing pain. Ankle clonus not obtainable. To-day, the head 
 is slightly retracted, the upper limbs are more rigid, and any 
 attempt to passively flex them is attended with pain. The 
 tongue is slightly furred. Pulse 132. Respirations 20, slightly 
 irregular, and accompanied by slight twitchings of the limbs. 
 
102 THE TREATMENT OF TYPHOID FEVER. 
 
 There is impairment of percussion note over the right back, 
 and medium crepitations all over it. She complains of pain 
 in the episternal notch when she coughs. There has been 
 copious discharge from the left ear and slight from the right. 
 The perforations of both drum membranes are healing up, that 
 in the left being now only a narrow slit." The temperature was 
 102-4" at noon, 103'2' at four and eight p.m. There were six 
 loose motions to-day. Her net weight was now 37|lb., show- 
 ing a gain of 1| lb. during the six days since she was removed 
 from the tank. She was again placed in the tank this evening 
 at a temperature of 95'" Fah. Her temperature at midnight 
 was 103 "6" in the rectum. 
 
 Twenty-fifth day. She slept well all the night, and is 
 looking very well this morning, being very intelligent, and 
 expresses herself as feeling well. Her temperature at 8 a.m. 
 101 '2', the tank being 95". It is now directed to keep the tank 
 at 90" during the day and 95" at night. Her temperature to 
 be taken in the rectum. Her attitude is still one of acute 
 flexion, but the retraction of the head has disappeared. Pulse 
 124. Respirations 24, tranquil; she did not cough much during 
 the night, and there was only slight discharge from the ears. 
 Only two motions to-day. 
 
 Twenty-sixth day. " This patient slept well all night ; is 
 very intelligent ; cough less troublesome ; lower limbs are 
 distinctly less rigid, and the patellar reflexes can only be 
 slightly elicited ; no ankle clonus." The temperature was lOS"" 
 at midnight, but sank to 99 "6° at 8 a.m. It rose to 102'' at 
 8 p.m. The mean temperature to-day was 100"9'". There 
 has been no diarrhcjea since she was placed in the tank, and 
 only two motions to-day. 
 
 Twenty-seventh day. "The patient slept very well last 
 night and coughed little, she says she feels well, and there is 
 now no pain in the head. There has been no discharge from the 
 ears. The limbs are rather more rigid than yesterday. There 
 is no retraction of the head. Respirations 24, tranquil. Pulse 
 118. The temperature has fallen gradually since she was 
 placed in the tank, and at 4 a.m. it was subnormal for the first 
 
CASES TREATED IN THE TANK. 103 
 
 time for nine days." The mean temperature to-day was 
 100"3^ Only one motion. Powders to be given every four 
 hours as hitherto, but Dover's powder to be increased to six 
 grains. 
 
 Twenty-eighth day. The mean temperature up to 6 p.m. 
 to-day was 100"3'. Only one motion. She was now taken out 
 of the tank as it was required for the seventh case in this 
 series. Net weight 38| lb., showing a gain of 1 lb. during the 
 four days in the tank. The temperature ran up quickly after 
 she was taken out of the water, and at 3 p.m. was 103*2°. She 
 is placed on a water-bed. Temperature now taken in the 
 axilla. 
 
 Twenty-ninth day. She slept well last night, but is fretful 
 and calls for her " Uncle John." Pupils normal ; tongue clean 
 and moist ; pulse 132, moderately full, soft, and compressible. 
 She moves her arms more freely, and there is less rigidity ; 
 the lower limbs are still acutely flexed and rigid. She takes 
 her food, which consists of milk and peptonised gruel, very 
 well. Her temperature ranged to-day from 102° to 103'6°, 
 mean 1027°. Two motions. 
 
 Thirtieth day. " She did not sleep well last night. Since 
 she was taken out of the tank her temperature has been 
 maintained mostly between 102° and 103°. Takes her food 
 well. Complains of slight pain at the back of her head. No 
 discharge from ears. Tongue quite clean and moist. Her 
 arms are quite mobile, and though her lower limbs are still 
 rather rigid, they can, with some force, be almost completely 
 extended. No patellar reflex or ankle clonus can be elicited. 
 Respirations 19, calm. Pulse 124." Mean temperature to-day 
 102"6°. Two motions. Ordered custard pudding to be added 
 to her present dietary. 
 
 Thirty-first day. This patient passed a very restless night, 
 notwithstanding 10 minims of chlorodyne. This morning she 
 is sleepy, pupils contracted. Her temperature, though still 
 high, shows signs of falling. The lower limbs cannot yet be 
 completely extended passively, but she can voluntarily extend 
 them to a considerable decree for the first time for the last 
 
104 THE TREATMEXT OF TYPHOID FEVER. 
 
 twelve days. Respirations 22. Pulse 1 24. Complains of slight 
 pain in left ear ; there is no discharge from either ear." 
 Mean temperature to-day 102''. No motion. 
 
 Thirty-second day. She passed a good night, and is pro- 
 gressing favourably. Mean temperature 101 "9'. One motion. 
 
 Thirty-third day. " Complains of pain at back of head ; 
 there is free movement of upper limbs. Bowels slightly 
 confined. She was sick this morning after her bread and 
 milk. Eespirations 30. Pulse 142. Coughs slightly." Mean 
 temperature to-day 101"9°. 
 
 Thirty-fourth day. " Slept well last night, and is rather 
 drowsy to-day ; uses her hands freely, and can move her 
 legs to a certain extent. Tongue clean ; pupils rather small. 
 Respirations 25. Pulse 136, of fair volume and tension. She is 
 tired of bread and milk, but drinks plain milk freely." Ordered 
 potatoes and gravy, and two eggs. Mean temperature to-day 
 101'; weight 38i-lb. net. Powders stopped. 
 
 Thirty-fifth day. " Patient slept very well. She has a 
 pustular eruption on the head. Pupils contracted. Tongue 
 slightly furred. Lower limbs in same condition, gentle exten- 
 sion to be applied to them. Diarrhoea ceased for five days. 
 Temperature subnormal this morning. Respirations 14. Pulse 
 100, of fair tension." The temperature ranged to-day between 
 97"2' and 101' ; mean 99"2\ Three motions. 
 
 Thirty-sixth day. Temperature ranged to-day between 
 97'8'' and 101' ; mean 98"6\ Five loose motions. Powders 
 resumed. 
 
 Thirty-seventh day. The elastic extension which was applied 
 two days ago to the lower limbs has considerably extended 
 them, but it is now producing a slight slough of the skin above 
 the right ankle, and it is discontinued. The diarrhoea has 
 ceased. She has taken her food better to-day than yesterday. 
 Respirations 16. Pulse 88, of good tension. Temperature normal. 
 
 Thirty-eighth day. Patient slept well last night, and is 
 taking her food well ; the lower limbs are drawn up, they are 
 not v'ery rigid and she can extend them to a considerable 
 extent. The patellar and plantar reflexes are active but there 
 
CASES TREATED IN THE TANK. 105 
 
 is no ankle clonus. Mean temperature 100°. Three motions. 
 Powders to be given every six in place of every four hours. 
 
 Thirty-ninth day. Slept well last night, feels well and 
 is very hungry. Syringing of ears discontinued. Pulse 
 88, lirm. Respiration calm, slight cough ; mean temperature 
 99-5°. 
 
 Forty-second day. Slept very well and feels well, she can 
 almost fiilly extend her lower limbs. The knee-jerk is rather 
 active, no ankle clonus. She eats well and is very hungry; the 
 sore over the sacrum looks healthy. Her net weight is 38 i lb. 
 having remained constant for the past fortnight. 
 
 Forty -fifth day (October 22nd). She was placed on ordinary 
 hospital diet, and two pints of milk. On October 25th her 
 net weight was 40^ lb. From this time the progress was 
 uninterrupted. 
 
 November 1st, weight 40|]b., November 8th, 421b., November 
 15th, 451b. She is now quite well. November 23rd, net 
 weight 46f lb. Discharged quite well. 
 
 Case 6. Typhoid Fever ; Bronchitis ; Immersed in the tank 
 for six days ; Cure. 
 
 Sophia H., aged 16, was admitted to hospital on September 
 23rd, 1889. She says her illness began on September 8th, 
 with dizziness and pain in the head, and she has kept to her bed 
 since then. The headache abated after the first week, and 
 three days ago she began to be troubled with cough. There 
 has been no diarrhoea. She is apathetic, but quite intelligent. 
 Lips dry and cracked ; tongue very dry, brown, glazed, and 
 fissured in the centre, moist with creamy fur along sides, red 
 and dry at tip Lower lip trembles. Pulse 126, weak and 
 dicrotic. Heart sounds dull. Loud dry rhonchus over the 
 whole front of chest ; over the lower lobes, the percussion is 
 impaired, breathing feeble, and expiration prolonged. Splenic 
 dulness measures four by four inches. Abdomen is not 
 distended nor tender except in the right iliac fossa ; no gurgling. 
 Numerous lenticular rose spots on the chest, abdomen, and back. 
 Hepatic dulness rather large, extending one inch below the 
 
106 THE TREATMENT OF TYPHOID FEVER. 
 
 margin of the ribs. Temperature on admission 102*4°, 
 extremities cold and finger-tips very livid ; pupils normal. 
 
 Says that she slept well until last night, when she was kept 
 awake by her cough. The medical man who sent her into 
 hospital reports that for the past four or five days the tempera- 
 ture has been 103° Fah., varying three or four points between 
 morning and evening. When he first saw her on September 
 13th, the morning temperature was 102.° Placed on six pints 
 of milk, and ordered four grains of calomel. 
 
 24th (seventeenth day). Patient passed a good night ; 
 cough still very troublesome but almost no expectora- 
 tion. She vomited a little bilious matter this morning. Bowels 
 have not been moved since admission. Pulse 120, soft, very 
 compressible and hyperdicrotic. Temperature ranged between 
 99-4° and 103-8°, mean 102-6°. 
 
 25th. Tongue very dry, cracked, and almost black 
 in the centre ; breath very foul ; slept well ; complains greatly 
 of pain behind the sternum when she coughs ; no expectoration. 
 Pulse 112 to 120. Temperature ranged from 100-2° to 103°, 
 mean 101-9°. She was placed in the tank at nine p.m., 
 temperature of water 98° Fah. Her net weight was at this 
 time 97 lb. (This patient was in the tank between the two 
 periods that the preceding case was immersed). She was 
 ordered a cough mixture, and a dose of castor oil. 
 
 26th. She did not sleep very well last night owing 
 to the novelty of her situation, but feels much better to-day. 
 Her tongue is still rather dry, but no longer black, and is now 
 only slightly furred. Cough not so painful. Pupils normal ; 
 respirations 28, quiet. Pulse 104, of fair volume and tension. 
 Temperature ranged from 99-6° to 102-6°, mean 101-1°. 
 Tank lowered to 98° 
 
 27th. Patient is much improved, tongue clean and moist, 
 but transverse fissures well marked. Pupils normal. Cough is 
 much less. Respirations 20, quiet. Pulse 108, very com- 
 pressible. First cardiac sound, dull. Average temperature 
 99-3°. Free motion, first since admission. 
 
 2Sth. Patient looks, and feels well. Pulse 108, fair 
 
CASES TREATED IN THE TANK. 107 
 
 tension. Her temperature fell to 97"^ at four p.m. The 
 temperature of the tank was then raised from 93" to 98"", and 
 her temperature soon rose, reaching 102 8° at eight p.m., and 
 continued at that till midnight. The tank was lowered to 95° 
 at ten p.m., and by four a.m. her temperature was 98^. Tank 
 to be kept at 95°. 
 
 30th. Average temperature to-day was 99*8°. Two loose 
 motions. Ordered peptonised milk and bread. 
 
 October 2nd. She was removed from the tank yesterday 
 evening, after having spent six days in it, during which time 
 she lost 5^ lb., her net weight being now 92 lb. Respirations 
 19, quiet, slight cough. Pulse 136, of fair tension. The 
 patellar-jerks are slightly exaggerated, and there is ankle 
 clonus. Since her removal from the tank her temperature has 
 maintained a higher level, the average to-day being 101.4°. 
 
 3rd. Pulse 128. Respirations 20. Mean temperature 99*4°. 
 Bowels confined. Ordered, calomel four grains. 
 
 4th. Pulse 116. Respirations 20. Mean temperature 99'2°. 
 Ordered one grain of calomel each evening. 
 
 10th. Ordered bread and beef tea. Urine normal. 
 
 14th. This patient is making rapid progress in convalesence. 
 The patellar reflexes are still rather active, ankle clonus well 
 marked, plantar reflex exaggerated. 
 
 18th. Net weight 98 lb. 
 
 22nd. Placed on ordinary diet. 
 
 23rd. Net weight 99 lb. 
 
 November 1st. 100 lb. 
 
 November 8th. 1071b. 
 
 Discharged, November 14th, quite well. 
 
 Case 7. Dysentery of eight months duration; Typhoid 
 Fever ,\ Immersed in the tank for Thirty -one days ; Cure. 
 
 George McN., aged 28, steward, was admitted to hospital on 
 September 9th, 1889. This is a fairly well-developed man of 
 medium height, weight 127 lb., with light clothing. For the 
 last eight months he has suffered from dysentery contracted in 
 the Brazils. The motions are watery and slimy, and often 
 
108 THE TREATMENT OF TYPHOID FEVER. 
 
 contain blood. Bowels are sometimes moved as often as thirty 
 times a day. At other times when taking chlorodyne he may 
 have only five or six motions. There is great pain and strain- 
 ing at stool. Constant borborygmi. He has been taking 
 ordinary diet. His tongue is large, flatly indented at the 
 edges, tremulous, and coated with a brown fur. Pulse 80, full 
 and tense. No tenderness over abdomen. He feels weak, 
 sleeps badly, and has no apetite. Temperature normal. He 
 was placed on milk and arrowroot. Ordered ten grains 
 each of compound ipecacuanha powder, and ipecacuanha 
 powder, with a drachm of the syrup of red gum every four 
 hours. On the loth, the following powders were substituted: 
 twenty grains of aromatic chalk and opium powder, and five 
 grains of ipecacuanha powder, one every four hours. On 
 September 19th, he was placed on bread and milk, lime water, 
 two eggs, and arrowroot. 
 
 Notwithstanding treatment, he got rather worse, and had 
 never less than twelve motions daily. Towards the end of 
 September he got dispirited, and talked about leaving the 
 hospital. His frame of mind was not improved by seeing 
 another patient under my care, who was suffering more severely 
 from dysentery than himself, rapidly improve under similar 
 treatment. His weight on September 20th and 27th was 
 126 lb. 
 
 September 28th (nineteen days after admission). In the 
 forenoon he had a rigor, he sweated all day, and in the evening 
 his temperature was 104° Fah. He complained of headache 
 and pain in the prsecordium. 
 
 29th. Liver cpnsiderably enlarged, and there is much 
 tenderness in the right half of the epigastric region. Bowels 
 very loose; temperature, M. 101 '8°; E. 104-6°. He is getting 
 into a very anxious, nervous condition, and is affected with 
 general tremor, 
 
 October 1st. The headache is less severe, and there is less 
 tenderness in the epigastrium. There is gurgling and tender- 
 ness in the right iliac fossa, and over the trunk are a few 
 elevated, rose - coloured, spots, disappearing on pressure; 
 
CASES TREATED IN THE TANK. 109 
 
 Tongue thickly coated with a white fur. Pulse 108, large and 
 very compressible. Temperature, M. 10r4° ; E. 1042; he got 
 ]0 grains of an ti pyrin. His gums are becoming rather tender, 
 which is ascribed to the deprivation of fresh vegetables, and he 
 is ordered a tablespoonful of lime juice, together with 2 grains 
 of quinine, and 80 grains of aromatic chalk, four times a day. 
 Leiter's tubes applied to the abdomen. 
 
 2nd. Temperature, 8 a.m. 102°; 4 p.m. 103-6°; 8 p.m. 
 104°. 
 
 4th. There is a copious elevated rose rash disappearing on 
 pressure. The pain in the right iliac fossa was very intense 
 last night. Notwithstanding the Leiter's tubes his temperature 
 for the last two days has ranged between 103"4° and 104°. 
 Patellar reflexes exaggerated, marked ankle clonus, 
 
 5th. This patient lies in a listless attitude and pays little 
 attention to his surroundings. He is sensible, complains of 
 headache and paius in the limbs, both of which have somewhat 
 abated during the last day or two. Very sleepless ; thirsty ; 
 pupils normal. Tongue very tremulous, coated in the centre 
 with a dry brown fur, the tip dry and rather denuded of its 
 epithelium. His hands and limbs are very tremulous. Pulse 
 132, moderately large, soft, and to finger, markedly dicrotic. 
 Skin hot and dry. Epigastric and cremasteric reflexes absent, 
 and only slight responses elicited of plantar reflexes. Patellar 
 reflex and ankle clonus very marked. Liver from fifth rib six 
 inches downwards ; lower border three inches below xiphoid 
 cartilage. Spleen six by four inches. Lungs resonant, breathing 
 at upper part of right lung puerile ; at both bases a few fine 
 crepitations at end of inspiration. Respirations 30. Temperature 
 103° to 104° ; net weight 115 lb. He was put into the tank at 
 a temperature of 95° at 9 p.m. 
 
 October 6th. There was a fall of 2° in his temperature during 
 the first twelve hours in the tank, but when taken out at 10 a.m. 
 for two hours, it rose to its former level. He is back again in 
 the tank at a temperature of 90°. Tongue less tremulous, brown 
 and dry, but beginning to get moist. Respirations 26. Pulse 
 126, markedly hyperdicrotic. Ordered naphthaline grains six, 
 
110 THE TREATMENT OF TYPHOID FEVER. 
 
 and aromatic chalk powder with opium, ten grains, every four 
 hours. 
 
 G. McN., 6-10-89, Pulse 126, Pressure 3 ozs. 
 
 7th. Did not sleep very well. Feels better to-day. Tongue 
 tremulous, brown fur, moist. Pulse 144. Respirations 34 ; no 
 cough. The tank has been kept at 90\ Patient's temperature 
 fell from 104"^ at noon yesterday to 100° at four p.m. ; it has not 
 since risen, and is nearly normal this morning. He was out of 
 the tank from 9-30 to 11 a.m., and at noon his temperature 
 was 102°, but by four p.m. it had fallen to 98'6°. Diarrhoea 
 still profuse but slightly abated since he was put in the tank. 
 
 8th. Slept well last night, but muttered most of the time. 
 Pupils normal. Pulse 146, firmer and smaller. Respirations 
 31. Mean temperature 99"5'' 
 
 9th. He had a quiet night, but he muttered a little while 
 he slept. To-day he says he feels very well. Tongue moist 
 and much cleaner. Pupils slightly contracted. Respirations 31. 
 Pulse 152, moderately full, very compressible. Diarrhcea less. 
 Tank not so offensive. Mean temperature to-day 100"8°. 
 Ordered one ounce of lime juice in half a pint of saccharated 
 lime-water twice daily. 
 
 10th. This patient did not sleep at all last night, and 
 shivered most of the time. This morning he says he feels very 
 well. The tongue is pretty clean. Gums improved. Pupils 
 normal. Respirations 33. Pulse 152, full and compressible. 
 Face flushed. Reflexes still exaggerated. Mean temperature 
 to-day 99"5°. Ordered, in addition to his other medicine, ten 
 minims of tincture of belladonna every four hours. 
 
 11th. Slept pretty well last night. Feels better. Pupils 
 rather wide. Respirations 36. Pulse 152 full, but compressible. 
 Temperature, midnight 99°; 4 a.m. 99-8°; 8 a.m. 97-8°. 
 
CASES TREATED IN THE TANK. Ill 
 
 He was taken out of the tank at 9-30 a.m. on account of altera- 
 tions in the ward, so as to convert it into a tank-room, and not 
 replaced till 7-30 p.m. His temperature at noon 1004° ; at 
 4 p.m. 102-6°; at 8 p.m. 102°, and at midnight 98-6°. 
 The temperature of the tank was now raised to 93°. 
 
 ,12th. He did not sleep much last night, but was quiet and 
 comfortable. When out of the tank yesterday he was hot, 
 perspired freely, and was very pleased to return to the water 
 again. His tongue is rather brown and dry, and also his 
 throat, probably from the effects of the belladonna. He takes his 
 food well. The diarrhoea is considerably less. Respirations 30. 
 Pulse 120, full and of good tension. Mean temperature 98'3.° 
 Tank raised to 95°. Urine normal. Placed on nine pints of 
 milk. 
 
 14th. Respirations 21. Pulse 124. Diarrhoea diminished. 
 Mean temperature for two days 9 9 '2°. Belladonna stopped. 
 
 16th. He was out of the tank yesterday from 8 a.m. to 
 7 p.m. during which time his temperature rose from 97'4° to 
 100-8°. It had fallen by midnight to 98-2°. He was taken 
 out of the tank to-day at 10-30 a.m. and replaced in it at 7. p.m. 
 During this time his temperature rose from 97*4° to 99-8°, 
 and fell at midnight to 98-2°. During the rest of his sojourn 
 in the tank his temperature remained normal, so there will be 
 no necessity to make further reference to it. 
 
 18th. Patient slept very well last night, and feels well 
 to-day. Tongue clean but still tremulous, appetite good, pupils 
 normal. Patellar reflexes exaggerated, moderate ankle clonus. 
 Plantar and cremasteric reflexes normal. The whole body is 
 covered to-day with a red papular rash, disappearing entirely on 
 pressure, this is probably due to common salt and muriatic 
 acid which have been added to the tank to increase the 
 antiseptic action of the usual pound of boric acid. All medicine 
 stopped, except lime juice. At this time it became necessary 
 to see that the tank water was thoroughly aseptic, as my 
 surgical colleagues were afraid that I was going to convert 
 this Institution into a fever hospital. This apprehension was 
 considerably intensified by a report that one of our nurses, who 
 
112 THE TREATMENT OF TYPHOID FEVER. 
 
 had gone away on her holidays, was suffering from typhoid 
 fever. The nurse returned to the hospital, and I found she was 
 only suffering from febricula, which passed away in a few days. 
 
 On October 19th and 20th, I had the tank water converted 
 into a solution of the perchloride of mercury, 1 in 2,000, which, 
 owing to the interchange of water, was reduced, at the end of 
 each day, to 1 in 3,000 or less. Dr. Logan, who kindly tried 
 some cultivations of bacilli for me, found that this rendered 
 the faeces antiseptic, but by the end of the second day we 
 found that it was beginning to sterilize the patient. His 
 gums began to get red and spongy, there was slight ulceration 
 around the teeth and on the inner surface of both lips opposite 
 the canines. The mercury was of course stopped The patient 
 feels very well, the diarrhoea has almost ceased, the motions 
 being reduced to two or three in a day. 
 
 October 25th. The motions were more formed yesterday 
 than the day before, but to-day are not so well formed. Slept 
 well and feels well ; gums and lips improving. He was put on 
 a mixture of iodide of potassium. 
 
 October 29th. The motions are reduced to two daily but are 
 not yet formed. Papular rash improving. Gums slightly 
 improved. The patellar reflexes are still exaggerated, ankle 
 clonus well marked, left plantar reflex normal, right nearly 
 absent. 
 
 November 1st. Net weight 9o lb. 
 
 November 5th. He was taken out of the tank to-day, 
 having been immersed for thirty-one days. Net weight, 
 98f lb. 
 
 November 10th. Net weight, i04| lb. 
 
 November 16th. He is now quite better of the typhoid, but 
 is still very weak. There was a slight return of the dysenteric 
 diarrhoea after his removal from the tank, but it is now con- 
 trolled by ipecacuanha. 
 
 January 4th, 1890. He was discharged to-day, quite strong 
 and healthy, except that his bowels are rather loose. Net 
 weight, 11 6f lb. 
 
 February 5th, 1890. He returned to the hospital to-day, as 
 
CASES TREATED IN THE TANK. 
 
 113 
 
 he was not keeping very strong, and his bowels were loose, 
 three or four motions daily. He remained in the hospital to 
 the 13th, and was then sent to the Convalescent Institution at 
 Woolton for two weeks. 
 
 April 23rd, 1890. He was re-admitted to-day, suffering 
 from a recurrence of the diarrhoea. Since he left hospital he 
 has had an insufficient supply of food, and what he got was of 
 a very rough character. He has fallen from 116|lb. to 1071b. 
 in weight. He was now placed on hospital diet, with chicken, 
 two eggs, and two pints of milk. I^ Pulvis Ipecacuanhas, 
 grains x, Pulvis Ipecacuanhse Compositae, grains x, Naphtha- 
 line, grains iv, Fiat pulvis. Mitte tales duodecim. Sig: 
 one every four hours. On the 27th, there were substituted 
 for these powders others composed of Dover's powder and 
 aromatic chalk. 
 
 June 2nd. He progressed favourably until the 31st ult., 
 when his temperature ran up without any assignable cause. 
 Pulse rapid and dicrotic. He was red and flushed about the 
 face and chest, but there was no distinct rash ; his throat was 
 red and congested but no ulceration, nor any appearance which 
 could account for the high temperature. He has been taking 
 half-a-drachm of the sulphocarbolate of soda every three hours, 
 and has been on milk diet since the 31st. There was slight 
 diarrhoea yesterday morning and he was ordered a repetition of 
 his opium and chalk powders which stopped the diarrhoea ; but 
 the temperature ran up in the evening to 105° ; this morning it 
 was 100"2°. Yesterday afternoon his face began to swell, and 
 there is now well marked acute local oedema of the nose and 
 cheeks, of a distinctly erysipelatous character. Pulse 108, 
 soft, full and compressible ; the diarrhoea has lessened. 
 
 
 wS^ES^SiSBS^^SISmBu^^SsS^kwBISBS^SSSSBIBL 
 
 A==A^J\ 
 
 G. McN., 31-5-90, Pulse 108, Pressure 3 and 6 ozs. 
 
114 THE TREATMENT OF TYPHOID FEVER. 
 
 June 9th. This patient's temperature kept constantly febrile 
 with marked evening exacerbations up to the 7th instant. His 
 whole face and scalp were thea much swollen, red and tender, 
 and I ordered Leiter's tubing to be applied to the head. It 
 was kept applied from 6-30 p.m. to 11-30 a.m. yesterday when 
 his temperature had fallen to normal. To-day the swelling has 
 almost disappeared, and there is no tenderness except in the 
 nose, which is still rather red and inflamed. The diarrhoea has 
 also abated. Pulse 92, soft, full and regular. From this time 
 he steadily improved, and he was discharged in good condition 
 on July 21st, 1890. His net weight was 112 lb. Since then he 
 has reported himself many times at the hospital and has kept 
 quite well and fit for work. 
 
 Case 8. Severe Case of Tyijhoid Fever ; Immersed in the 
 tank for ten days ; Cure. 
 
 Mary Ann P., aged 21 years, housewife, admitted to hospital 
 Nov. 4th, 1889, on the ninth day of the disease. On October 
 27th she took to bed on account of pain in the back, and 
 headache which have continued more or less since, but are now 
 abating. On October 30th she first felt pain in the right side 
 of the abdomen, and for the last few days has suffered from 
 diarrhoea. 
 
 The patient now looks very ill, and lies in a very apathetic 
 condition, answering questions slowly and with reluctance. 
 The pupils are about normal size, the eyes look dull" and have 
 dark rings around them. Pulse 112, small and compressible. 
 Respirations 26, tranquil. Tongue furred, dry in the centre, 
 and tremulous. Sordes on teeth, and lips dry. Motions loose, 
 dark brown, and very offensive. She was rather collapsed 
 on admission but in the evening the temperature ran up to 
 104° F. There is tenderness in the right lumbar, upper part 
 of umbilical, and left iliac regions, but not in the right iliac 
 fossa although there is slight gurghng felt there occasionally. 
 Over the body are about a score of elevated rose-coloured spots 
 disappearing on pressure. The patellar reflexes are present but 
 not increased ; there is slight ankle clonus on both limbs, and 
 
CASES TREATED IN THE TANK. 115 
 
 the plantar reflexes are much exaggerated. No response from 
 umbilical or epigastric reflexes. There is slight cough, and harsh 
 breathing, but otherwise lungs healthy. 
 
 Tenth day (November 5th). Her menses began to-day. The 
 temperature this morning was 101 "4°, but in the evening it 
 reached 104-8°. She was then placed in the tank at a 
 temperature of 95°. Net weight 127| lb. She receives four 
 pints of milk and peptonised gruel. Naphthaline six grams 
 every four hours. 
 
 Eleventh day (November 6th). She passed a very comfortable 
 night and her temperature steadily fell from 104*8° when 
 placed in the tank to 100° at 8 this morning. Her tongue 
 is now moist, eyes brighter, and the headache has disappeared. 
 Pulse 92, much firmer. Respirations 22. Temperature in the 
 evening reached 103'2°. 
 
 Twelfth day (November 7th). Patient comfortable but did not 
 sleep well. Tongue moist and furred ; pupils slightly dilated ; 
 appetite good. Pulse 100, of fair tension (see tracing). 
 Respirations 22 ; cough not troublesome. The temperature 
 yesterday from 4 p.m. to midnight kept about 103°, but this 
 morning it has fallen to 100°. The temperature of the tank 
 was 95°, but it is now reduced to 90°, and in this evening's 
 exacerbation her temperature only reached 102'2° at 8 p.m., 
 and then quickly declined. 
 
 :,I. A. p., 7-11-89, Pulse 100, Pressure 2 ozs. 
 
 Fourteenth day (November 9th). Menses ceased to-daj^ The 
 maximum temperature yesterday was 108°, and occurred at 4 
 p.m. This morning it was 100*6°, and in the evening it only 
 reached 102°. 
 
 Sixteenth day (November 11th). The morning temperature 
 yesterday was 99°, and to-day 98°. Each evening it reached 102°, 
 
116 THE TREATMENT OF TYPHOID FEVER. 
 
 Tongue moist and furred, but not tremulous. Pulse 104, 
 moderate tension. Cough easier, slight sore throat. 
 
 Eighteenth day (November 13th). Sore throat well; cough 
 nearly gone; patient fells well; motions formed. Pulse 108. The 
 morning temperatures are now about normal, and there is an 
 evening exacerbation of about 2 degrees. 
 
 Twentieth day (November 1 5th). Her temperature yesterday 
 evening was 100°, and since then it has been normal. She was 
 taken out of the tank this afternoon. Her net weight is now 
 117| lb., showing a loss of 10 lb. during the ten days immersion. 
 
 November 19th. Temperature has been normal since last 
 note. Tongue almost clean ; pupils normal ; slight ankle clonus 
 on both sides ; pulse 96, soft. 
 
 November 23rd. Net weight 1231b. Ordered one egg daily. 
 She is still on milk and farinaceous diet. 
 
 November 25th. Ordinary hospital diet. 
 
 November 28th. Net weight 127 lb. 
 . December 5th. Discharged quite well. 
 
 Case 9. Very severe case of Typhoid Fever; Bronchitis; 
 Hcemorrhage from hoivels; Monoplegia of left forearm ; 
 Twenty-six days in the tank ; Cure. 
 
 Helen D., aged 12, admitted to hospital November 13th, 1889. 
 Patient took to bed on October 27th, complaining of headache, 
 and feeling ill. She was up on the 28th and 29th, but felt 
 sick and hot ; since that time she has been confined to bed. 
 On November 1st, she received a worm powder which was 
 followed by diarrhoea for three days, and she passed a round 
 worm ; subsequently her bowels have been moved once or twice 
 a day. She has been troubled with a slight cough for about a 
 week. 
 
 Present condition. Face flushed, eyes bright, pupils widely 
 dilated, lips dry and ragged : tongue covered with a thick white 
 fur, moist, and tremulous ; appetite poor; bowels regular. There 
 is no abdominal tenderness or gurgling in right iliac fossa. 
 There is one red spot on lower part of sternum, which disappears 
 on pressure, but is not very characteristic. No other spots. 
 
CASES TREATED IN THE TANK. 117 
 
 All over the back of the chest there are rhonchi and bubbling 
 rales with the addition of some fine crepitations at the left base. 
 The heart's action is very rapid, 144 per minute. The patellar 
 reflexes are not exaggerated, but there is slight ankle clonus, 
 and active plantar reflexes. 
 
 Splenic dulness large, measuring 3f by 3| inches. Her tem- 
 perature as recorded twice daily by the District Nurse during 
 the past 8 days has usually ranged between 102° and 103°, but 
 last night it reached 103-8°. On admission she was rather 
 collapsed, and her temperature was 101°, but at 8 p.m. on that 
 evening immediately before she was placed in the tank it had 
 mounted to 104*4° F., the temperature of the tank water was 
 95°. Her net weight was 52| lb. Diet : 4 pints of milk and 
 peptonised gruel. 3 grains of naphthaline every 4 hours. 
 
 November 14th (eighteenth day). This morning the patient 
 says she feels better. The flush has disappeared from her 
 cheeks ; the pupils are not so widely dilated. Her temperature 
 fell to 101"2° at midnight, and this morning it is 102'2°, and 
 during the day it remained at the same level. Kespirations 
 30. Pulse 138, much firmer than it was last evening. No 
 motion to-day. 
 
 November 15th.' Patient says she feels better to-day. The 
 bowels acted this morning, and the motions were very loose 
 and offensive. The temperature of the tank was allowed to 
 fall during the night, and at 4 a.m. her temperature was 98 '2°, 
 the patient, however, says that she was quite comfortable, and 
 she slept well during the night. Pupils less dilated. Tongue 
 clean but rather dry. Respirations 32, very little cough. Pulse 
 140. About 2 p.m. her temperature fell to 9 7 '2°, she was then 
 very cold and blue about the face. She was taken out of the 
 tank, and with the application of hot bottles and a dose of 
 brandy, she soon recovered. At 4 p.m. her temperature was 
 101° ; at 4-30 p.m. she was replaced in the tank at 98°, and by 
 8 p.m. her temperature had fallen to normal. This morning 
 she was ordered the following mixture in addition to the 
 naphthaline ; I^. Tinct. Digitalis, ITj^iii, Cafleinae, gr. iss. Tinct. 
 Belladonnas n|_v. Aq. Menth. Pip. ad §i., four times a day. 
 
118 THE TREATMENT OF TYPHOID FEVEK. 
 
 November 16th. From midnight to 8 a.m. her temperature 
 remained at 104"2", but at 10 a.m. it had fallen to 102''. She 
 looks rather pale, but says she feels comfortable. Tongue 
 moist. Respirations more tranquil and less frequent ; cough 
 slight. Pulse 144, very feeble. Her temperature remained 
 during the rest of the day at 101 '4°. One motion to-day. 
 
 November 17th. The nurse took the patient out of the 
 tank this morning at 5-30, as she thought her rather collapsed, 
 but Dr. Wallace afterwards considered that as the patient's 
 temperature remained high, the apparent collapse was merely 
 the muscular tremor which has been frequently noticed in the 
 tank. She was replaced in the tank at 1 p.m., her temperature 
 having fallen from 103^ to 1006^. During the day she 
 trembled a good deal, but was quite comfortable. Her tem- 
 perature did not fall below 100'. She vomited twice to-day. 
 
 November 18th. Temperature, midnight, 102*2'^ ; 4 a.m. 
 101° ; 8 a.m., 104" : noon, 103-6" ; 4 p.m., 101-8" ; 8 p.m., 1022". 
 Tongue clean and moist. There is general tremor of the 
 muscles. Respirations tranquil, cough has disappeared. Pulse 
 148, fair tension. She refuses the gruel, but takes the milk 
 readily ; ordered boiled bread and milk. 
 
 November 19th (twenty -third day). Patient feels better 
 this morning and looks it. Pupils moderately dilated. Tongue 
 clean. The whole body trembles, although the tank is 92", 
 and her own temperature 100". The pulse cannot be counted 
 on account of the trembling. Heart beats 148, and forcible. 
 There was a slight amount of blood in the motion to-day. 
 
 November 20th. At midnight her temperature fell to 97", 
 the tank being 95". She was not collapsed, and on the tank 
 being raised to 98", her temperature rose to 100-8". The nurse 
 says she rambled slightly during the night, but she is now 
 intelligent and says she feels better. Pupils dilated, cheeks 
 and lips rather cold and livid. Tongue clean, but rather dry. 
 She has a slight cough. Pulse 144, good tension. The muscular 
 tremor is much less marked. No blood in motions to-day. 
 
 November 21st. Says she feels well; pupils dilated; tongue 
 clean, rather dry. No more blood in motions. Pulse 144, 
 
CASES TREATED IN THE TANK. 119 
 
 moderately strong. Slight cough. Lung percussion clear, 
 slight rhonchus at base. Reflexes not exaggerated. Tender- 
 ness in right iliac fossa. Temperatures, midnight, 97 '6° ; 4 a.m., 
 100°; 8 a.m., 99-6°; noon, 99-4°; 4 p.m., 97-8°; 8 p.m., 98-8.° The 
 tank was kept at 95°, when patient's temperature was above 
 normal, and at 98° when below normal. 
 
 November 22nd. This forenoon the motion was found to 
 contain blood clot representing about 3 or 4 fluid ounces of 
 blood. Patient says she feels well, but she is rather cold and 
 livid about the cheeks. The trembling of the hands has 
 returned. Pulse 152, tension not so good. Temperature, mid- 
 night, 98-4° ; 4 a.m., 98-6° ; 8 a.m., 100-4°; noon, 97.° She was 
 then taken out of the tank till 3 p.m., and as her temperature 
 was running rapidly up she was replaced. At 4 p.m. it was 
 101 '8°, but at 8 p.m. had dropped to 98-2.° She was ordered 2 
 eggs daily, and 5 grains of gallic acid every 4 hours. 
 
 November 23rd. Patient feels comfortable ; pupils dilated ; 
 eyes suflused ; cheeks rather cold and slightly livid ; tongue 
 moist. She does not take her food well, and seems to have 
 emaciated considerably since admission. Blood clot in stool to- 
 day. Heart beats 148, sounds clear. Temperatures, mid- 
 night, 98-2° ; 4 a.m., 99° ; 8 a.m., 100-6° ; noon, 100-8° ; 4 p.m., 
 100-8° ; 8 p.m., 101°. 
 
 November 24th. Patient seems rather better. Bowels 
 freely moved, but motions contain no blood. She is taking 
 her food badly and was sick after her milk ; coughs a little. 
 Pulse 148-156, rather feeble. Temperatures, 101-2°, 99-8°, 
 100-4°, 100-8°, 103-2° (when out of the tank for sanitary pur- 
 poses), 1004°. She Avas ordered 6 ozs. of champagne daily. 
 
 November 25th. Seems rather better to-day. Pupils 
 slightly dilated. Pulse 164 ; temperatures 101°, 100°, 101-2°, 
 101-2°, 97-8°, 100-8°. ^ Lac. Bismuthi, 3i. Soda3 Bicarb, gr. 
 V. Tinct. Belladonnse ]\y. Syrupi Tolutani, 5«s- Aq. ad 5ii- 
 Every four hours. Stop other medicine. 
 
 November 26th (thirtieth day). She takes her food better 
 and has not been sick since she began the champagne. Pulse 
 152. Temperatures 98-4°, 100°, 97-6°, 99-4°, 100°, 98°. 
 
120 THE TREATMEXT OF TYPHOID FEVER. 
 
 Xovember 30th. She looks well ; tongue moist and slightly 
 fiUTed. She has taken her nourishment well for the last three 
 days. Pulse 152. Temperature has varied between 99' and 
 100". 
 
 December 2nd. Patient sleeps well and looks well : she 
 takes her food well. The pulse is 140 (the lowest recorded 
 for the last 10 days), good tension. Heart sounds clear. As 
 her temperature shows a tendency to rise the tank is now 
 reduced to 93'^ 
 
 December 3rd. The patient has for some time lain with 
 her thighs and legs flexed, and now they can be with difficulty 
 straightened. Pulse 144. Temperature, 98° to 99"6''. Xet 
 weight 43 lb., showing a loss of 9 j lb. in 20 days. 
 
 December 5th (thirty-eighth day). Feels well and takes 
 her food well. Pulse 136 ; heart sounds clear. Temperature 
 normal. Beef tea one pint, raw meat 8 ounces. Stop champagTie. 
 
 December 6th. Temperature has not been above 99'^ for two 
 days. Tongue clean and moist. Takes food well. Legs stiff, 
 tender, and covered with a papular rash. Motion formed. 
 
 December 7th. Patient is yevy well and bright to-day. 
 Tong-ue clean, takes food well. Pulse 136. Temperature 98^ 
 to 99-4°. 
 
 December 9th (forty-second day). Heart beats 112, strong, 
 and sounds clear. Temperature normal. She was taken out 
 of the tank at 4-30 p.m., ha^dng been immersed twenty-six 
 days. Her net weight is now 41ilb.; shoAving a loss of lOf lb. 
 during the 26 days. 
 
 December 10th. Patient cries very much about her lower 
 limbs which are acutely flexed and painful : any attempt to 
 straighten them causes her much suffering. The skin is covered 
 wdth a red papular rash from the effects of the tank water. 
 She did not sleep well last night, and is not taking her food so 
 well. Patellar reflexes active, slight ankle clonus on left side. 
 Pulse 124, moderately strong. Temperature this evening 
 100-6^ 
 
 December 12th. She has been out of the tank for three 
 days, and the temperature which at first ran up a little is now 
 
CASES TREATED IX THE TANK. 121 
 
 nearh^ normal. The lower limbs are not so painful and can 
 be further extended. There is wrist drop on the left side. 
 Pupils almost normal. Tongue pretty clean. Bowels confined. 
 Appetite very good. Patellar reflexes present, no ankle clonus. 
 
 December 20th. Temperature has been normal, and the 
 general condition of the patient is improving, but her net weight 
 is now only 40.^ lb. The paralysis of the extensor muscles of 
 left hand is getting better under the influence of massage and 
 electricity. Placed on ordinary diet, and 3 pints of milk. 
 
 December 28th. Net weight 42^ lb. 
 
 January 3rd, 1890. Net weight 451b. 
 
 January 7th. The patient is getting fat and rosy, eats and 
 sleeps well, and sits up most of the day. When the extensors 
 of the fingers of left hand began to resume power the hand 
 assumed the position of main en griff e, showing paralysis of 
 the lumbricales. These as well as the extensors have now 
 greatly recovered their power, and are getting rapidly well. 
 
 January 10th. Net weight 48 lb. 
 
 January 15th. She was discharged to-day in every respect 
 quite well and strong. 
 
 Case 10. Typhoid Fever; Ancemia; Pleurisy ; Thirteen 
 days in the tank ; Cure. 
 
 Harriet J., age 22, admitted November 15th, 1889. Her 
 present illness began on November 4th, with severe headache, 
 pains in the back and limbs, sore throat, and anorexia. On the 
 7th diarrhoea began and has since persisted. 
 
 Present condition. She is slightly flushed ; pupils dilated ; 
 tongue clean but red and dry in centre ; she is very anaemic, 
 lethargic, and apathetic. Motions loose and off^ensive. Tem- 
 perature 102''-103^ Net weight 95J lb. Ordered naphthaline 
 grains 6 every 4 hours ; milk diet and peptonised gruel. Put 
 into the tank at a temperature of 95°. 
 
 November 18th (fifteenth day). She feels better; tongue 
 moist ; pulse 112, fair tension. Temperature 100''-102°. 
 
 November 19th. Patient feels and looks better. Tongue 
 clean, but tremulous ; face rather flushed ; pupils dilated: slight 
 
122 THE TREATMENT OF TYPHOID FEVER. 
 
 cough ; pulse 120. At the bases of both lungs the percussion is 
 impaired, and there are crepitant and sibilant rales. No patellar 
 reflex or ankle clonus can be elicited ; no rose spots. Tempera- 
 ture 99-8° to 102°. Urine acid, sp. gr. 1027, no albumen. 
 
 November 21st. Temperature this morning rose to 102'4°. 
 The tank was reduced to 93°, and patient's temperature 
 gradually fell to 98-8° at 4 p.m., rising to 100-6° at 8 p.m. 
 
 November 23rd. Patient feels well, and takes her food 
 freely. There is one distinct typhoid spot found to-day. 
 
 November 28th (twenty-fifth day). This case has progressed 
 very favourably, and she is taken out of the tank to-day. 
 There have been daily fluctuations of temperature of two 
 degrees with a prolonged remission each day to normal. It 
 has been normal for two days. There are now increased 
 patellar reflexes, and ankle clonus. Net weight 892 lb., showing 
 a loss of 5 1 lb. in 13 days. 
 
 December 5th. I^^. Mist. Ferri Co., fl. §xii. Decoct. Aloes 
 Co., fl. §viii. Sig. §ii., thrice daily after meals. 
 
 December 9th. Net weight 94 lb. 
 
 December 11th. Ordinary diet. She has greatly improved, 
 but is still weak. The patellar reflexes are normal, and the 
 ankle clonus has disappeared. 
 
 December 28th. Net weight 102f lb. 
 
 January 3rd, 1890. Net weight 107^ lb. 
 
 January 7th. She was out yesterday, got wet, and at 8 p.m. 
 she had a rigor : her temperature ran uj) to 1024°, and she 
 complained of severe pleuritic pain in left side. Under the 
 influence of fomentations and a diaphoretic mixture this soon 
 subsided, and in a couple of days she was practically well again. 
 Her menses began on January 10th, and ceased on the 13th. 
 • January 17th. Net weight 108 lb. 
 
 January 23rd. Dischargd to-day, quite well and strong. 
 
 Case 11. Typhoid Fever; Eleven days in the tank ; Cure. 
 Bridget W., aged 17, admitted to hospital December 4th, 
 1889. Patient became ill on November 16th, with sickness and 
 headache. She took to bed on the 18th, and has been confined 
 
CASES TREATED IN THE TANK. 123 
 
 there since. She has had diarrhoea since the commencement 
 of the illness, and for the past two weeks has had pain in right 
 side of the abdomen. 
 
 Present condition. Pupils dilated ; breathes rapidly and 
 heavily ; respirations 34 ; eyes suffused ; lips dry and cracked ; 
 sordes on teeth ; tongue red and glazed. She is very stupid, 
 and it is with great difficulty that she can be roused to answer 
 questions. There is gurgling, but no tenderness in right iliac 
 fossa. There are about a score of elevated rose-coloured spots 
 which disappear on pressure. The motions are loose, yellow, 
 and offensive. There are a few rhonchi in both lungs. Pulse 
 124, soft and full : temperature 104°. The patellar reflexes 
 cannot be elicited ; there is slight ankle clonus, but most 
 marked on the left side. Urine acid, sp. gr. 1015, a trace of 
 albumen. Milk and peptonised gruel. Naphthaline grains 6 
 every 4 hours. 
 
 December 5th. Her temperature fell to 100° this morning, 
 but in the afternoon it rose to 103°. She was placed in the 
 tank at 95°. Net weight 93 lb. 
 
 December 6th (twenty-first day). Patient is not nearly so 
 stupid and says she feels much better. Pupils moderately 
 dilated; tongue getting moist at the edges; sleeps well; and 
 takes her food well. Respirations 29; pulse 124, soft; tem- 
 perature 99-4° to 102°. 
 
 December 7th. She does not feel so well to-day, rambled a 
 o-ood deal during the night, and the nurse had some difficulty 
 in keeping her in the tank. Takes her milk well. Tongue dry. 
 Pulse 120, rather firmer. The first sound of heart is dull. No 
 knee-jerks, but slight contractions of the right vastus externus 
 can be elicited on percussing the outer border of the corres- 
 ponding patellar tendon. 
 
 December 8th. Tongue moist ; pulse 140 ; face flushed ; 
 pupils dilated. 
 
 December 9th. Patient very fretful, and craves greatly for 
 beer, and promises to take her gruel as her taste is now 
 gratified by one pint of beer daily. Tongue very dirty, but 
 quite moist. Respirations 22. Pulse 124, soft and feeble. Her 
 
124 THE TREATMENT OF TYPHOID FEVEE. 
 
 temperature averaged to-day 9 9 '7°. She was taken out of the 
 tank at 6 p.m. Net weight 91^ lb. 
 
 December 10th. Her temperature this morning has ranged 
 from 100"6'' to 101"4'^. Tongue dirty and becoming dry in 
 centre. Pulse 124, very compressible. Says she feels worse, 
 and she does not take her food so well. There is consider- 
 able diarrhoea. At 4 p.m. her temperature reached 102'4°, 
 She was replaced in the tank at 5 p.m., and by 8 p.m. her tem- 
 perature had fallen to 99 •4''. Boiled bread and milk. 
 
 December 11th. She slept well. Pulse 112, much firmer. 
 Tank reduced to 93'', after which her temperature fell from 
 101° to 99°, rising at 8 p.m. to 100". 
 
 December 12th. She slept well; pupils normal : pulse 112 ; 
 diarrhoea less ; mean temperature 9 8 •4°. 
 
 December 13th. Patient looks bright ; tongue cleaner ; takes 
 food better ; smiles frequently ; and complains of the " cowld 
 wather." Pulse 96. Mean temj)erature 98-6°. 
 
 December 16th. Taken out of the tank to-day at 11 a.m., 
 the temperature having been subnormal for 3 days. Her net 
 weight the following day was 85 lb. 
 
 December 19th. She has been three days out of the tank, 
 and feels very well. Temperature normal ; pulse 84 ; pupils 
 still dilated ; tongue furred with a slight tendency to dryness ; 
 takes food well : bowels rather confined. There is well 
 marked clonus, especially on the left side. 
 
 December 28th. Net weight 84^ lb. 
 
 January 2nd, 1890. Two eggs and milk diet. 
 
 January 3rd. Net weight 89| lb. 
 
 January 10th. Net weight 98 lb. 
 
 January 15th. Ordinary diet. 
 
 January 18th. Net weight 106 lb. 
 
 January 28th. Discharged well and strong. 
 
 Case 12. Typhoid Fever ; Sixteen days in the tank ; Cure. 
 Edward K,., aged 10 years, admitted to hospital February 
 10th, 1890. Present illness began on February 2nd, with head- 
 ache and sickness : and afterwards pain in right iliac region. 
 
CASES TREATED IN THE TANK. 
 
 125 
 
 There has been diarrhoea from the commencement, and a 
 cough for the last three days. 
 
 February 11th. The patient is a well-nourished boy with 
 flushed face. Pupils moderately dilated ; lips dry and coated 
 with sordes ; tongue tremulous, its sides are coated with a thick 
 white fur with the large papillfe showing through, it is dry 
 and brown in the centre. Heart normal, except that the first 
 sound is dull. The percussion over the upper lobe of the 
 left lung is impaired, and there is occasionally a fine crepitant 
 rale at the end of inspiration, but no tubular breathing. There 
 are rhonchi all over the chest. Respirations 36. Pulse 108. 
 There is gurgling and tenderness in the right iliac fossa, but 
 the abdomen is not much distended. There are a few elevated 
 lenticular rose spots which disappear on pressure. Knee-jerks 
 rather active, slight ankle clonus, plantar reflexes exaggerated. 
 Temperature has ranged from 101"8° to 103'6° since admission. 
 Ordered 6 pints of milk daily, and 3 grains of naphthaline 
 every four hours. 
 
 February 12th (eleventh day). Temperature this morning 
 102 '8°. He was placed in the tank at 2 p.m. ; temperature of 
 water 95°. 
 
 E.^R.;_12-2-90, Pulse 108, Pressure 2 ozs. 
 
 February 13th. Patient slept well last night, and finds the 
 tank very comfortable. He has now no cough, the lung per- 
 cussion is clearer, and the crepitations are less numerous. 
 Pupils normal ; tongue furred, but moist ; cheeks and lips rather 
 cold and livid. His temperature remained about 103° during 
 the night, but at noon it had fallen to 101-4°, and at 4 p.m. had 
 further decreased to 100°. He takes his food very well ; 
 diarrhoea moderate. Net weight 50 lb. 
 
 February 14th. Patient slept well. Pulse 100, stronger. 
 
126 THE TREATMENT OF TYPHOID FEVER. 
 
 There are a few fresh rose spots on back. Temperature main- 
 tained at a lower level, ranginpj from 100° to 102°. 
 
 February loth. Patient did not sleep so well last night, 
 and is beginning to be fretful. He takes his milk well. His 
 temperature is gradually declining, cheeks flushed and hot. 
 Pupils normal. Tongue moist, and cleaning at the edges. The 
 pulse and respirations are somewhat increased in frequency. 
 Ordered malted milk. 
 
 February 17th. Patient sleeps well and takes his food well, 
 but is fretful and complains of pain in palms of hands and in 
 sole of right foot. The temperature has been steadily declining, 
 and this morning it sank to OS"". Pulse 116, tension improved. 
 Respirations 24. 
 
 February 19th. Slept well last night, and says he feels 
 better. Pulse 96, good tension. He feels hungry, and is now 
 ordered boiled bread and milk. 
 
 February 21st. Slept well. Pulse 96. Temperature normal, 
 but in the evening it ran up to 101'2°. 
 
 February 24th. Temperature is now practically normal. 
 Pulse 92, good tension and fair strength and volume. Net 
 weiaht 48 lb. 
 
 E. R., 24-2-90, Pulse 92, Pressure 2 ozs. 
 
 February 28th. His temperature has been about normal for 
 past week. He feels very well. Pulse 96. Net weight 47 lb. 
 Taken out of the tank at 5-30 p.m., after sixteen days 
 immersion. 
 
 March 10th. Three days ago there was a rise in the tem- 
 perature owing to constipation, but since he had 2 grains of 
 calomel it has returned to normal. Ordered 2 eggs daily. 
 
 March i.lth. Net weight 51 lb. 
 
 March 24th. Net weight 52 lb. 
 
CASES TREATED IN THE TANK. 127 
 
 March 25th. Placed on ordinary hospital diet, and 2 pints 
 of milk. 
 
 April 14th. Net weight 66 lb. 
 
 April I7th. Discharged quite well, fat, and rosy. 
 
 Case 13. Severe case of Typhoid Fever ; Hypostatic Conges- 
 tion of Lungs ; Bronchitis ; Numerous Boils and 
 Abscesses; Relapse; Debility with Ancemia ; Immersed 
 in the tank for tiventy -seven days ; Cure. 
 
 Edward McK., aged 23, labourer, admitted to hospital, 
 March 17th, 1890. He was in good health till the 6th instant, 
 when he says he got wet going home from work. He felt 
 pains all over his body, and has since been confined to bed. 
 He has had diarrhoea from the commencement, and on the 8th 
 and 9th he suffered from epistaxis ; on the 10th, he began to 
 suffer from cough, which has since continued. 
 
 Present condition. He complains of severe headache, pains 
 in his legs and abdomen. He is rather stupid, but answers 
 questions intelligently. Face flushed, skin hot and dry ; 
 pupils dilated ; tongue dry, coated with a white fur at edges, 
 brown, and transversely fissured in centre. Breathing rapid 
 and laboured ; respirations 36 ; cough troublesome, mucous 
 expectoration, streaked with bright red blood. Pulse 104 soft. 
 Patellar reflexes exaggerated. There are a few rose spots. 
 Splenic and hepatic dulness enlarged. Tenderness in right 
 iliac fossa. Over the front of lungs percussion clear, but there 
 are mucous rales : the percussion is impaired over the posterior 
 aspect of both lungs, and over the right back it is almost 
 absolutely dull. Crepitating rales over whole back, but most 
 numerous over right side, and here the vocal fremitus and 
 resonance are increased. Motions loose and offensive. Tempera- 
 ture, 4 p.m., 10:3-6" ; 8 p.m., 104-4° ; 12 p.m., 104". After 10 
 grains of antipyrin it then fell to 102°. Ordered four pints 
 of milk and arrowroot, 2 grains of calomel. 
 
 March 18th (twelfth day). He passed a very restless night, 
 moaning nearly' all the time, and complaining of severe pain 
 all over his body. He rambled during the night, and is now 
 
128 THE TREATMENT OF TYPHOID FEVER. 
 
 very despondent ; says he is going to die. He is thirsty ; 
 tongue dry and fissured ; cough troublesome ; sputum consists 
 of dirty brownish mucus, tinged with blood. Urine and feces 
 passed unconsciously. Motions loose, dark greenish colour, 
 alkaline reaction, and very offensive. Heart's action feeble, 
 sounds dull. Pulse 116, soft and weak. Lung phenomena as 
 noted yesterday. Temperature reached 104"4^' at noon. He 
 was placed in the tank at 4-o0 p.m. ; temperature of water 90°. 
 Net weight 1671b. 
 
 March 19th. Patient's temperature sank at midnight to 
 97'4'^. The tank was then raised to 98". and at ] a.m. his 
 temperature was 98"8\ The patient was very delirious, and at 
 2-30 a.m. got out of the tank into a vacant bed. He was then 
 very restless and with difficulty was kept in bed, Urine and 
 fasces passed unconsciously. Motions very frequent, loose, and 
 offensive. Pulse 120, small, soft, and weak. Respiz-ations 32. 
 Urine acid, sp. gr. 1015, no albumen. He remained out of the 
 tank until my visit in the afternoon. His temperature at 
 4 p.m. 104''. Ordered 2 grains of calomel, and was replaced 
 in the tank at 5-30 p.m. 
 
 March 20th. Passed a very restless night although he had 
 30 grains of sulphonal. During the last 24 hours he has had 
 13 loose motions of a light yellow colour, and alkaline reaction. 
 Tongue cleaner and moister. Temperature steadily fell after 
 he was put in the tank, and at 4 a.m. it was normal. At 
 8 a.m. it was 100'8", and while the patient was out of the 
 tank for sanitary purposes, from 9-30 a.m. to 1 p.m., it 
 rapidly rose to 104"2\ It fell to 97'4' at 8 p.m., but when the 
 temperature of the tank was raised it mounted to lOL'G" at 
 midnight. 
 
 March 21st. He had 30 grains of sulphonal, and 20 grains 
 of bromide of potassium during the night, but he was very 
 restless up to 3 o'clock, when he slept for half-an-hour. There 
 is profuse diarrhoea. Pulse 118, small, and compressible; 
 cough much easier. He takes his nourishment freely. At 
 4 a.m. his temperature fell to 9 6 '4'", but at 8 a.m. it was normal, 
 and when out of the tank, from 9-30 to noon, it reached 
 
CASES TREATED IN THE TANK. 129 
 
 102"2°. During the rest of the day it fluctuated between 
 101-2° and 102-8°. 
 
 March 22nd^. He was restless up to midnight. He then 
 had 10 grains of Dover's powder and slept quietly till 4 a.m., 
 only roused to take a drink, at intervals. Temperature of tank 
 93'. He seems much better to-day. Cough less troublesome, 
 Tonorue cleaner. Pulse 112. Reflexes exaggerated. 
 
 March 23rd. He had 10 grains of Dover's powder last 
 night, and slept well. Diarrhoea still continues, but motions are 
 not quite so ofl*ensive, and are less liquid. Pulse 116. During 
 last 24 hours he has had six pints of milk, and four rounds of 
 bread soaked in milk. Temperature fluctuated to-day between 
 99-2° and 102°, and the rise during the time he was out of the 
 tank was less marked. 
 
 March 24th. He had a very good night after 10 grains of 
 Dover's powder. He appears much better, is now contented 
 and hopeful. Tongue moist. Slight dulness at bases of both 
 lungs, most marked on left side, there are many crepitating 
 rales : anteriorly the breath sounds are normal, with the 
 exception of a few fine rales on left side. Pulse 128 after 
 examination. Ankle clonus and knee-jerks well marked. Eight 
 motions since yesterday morning. I^ Ammon. Carbonatis, grs. v. 
 Caffeinse, grs. ii. Aq. Chloroformi, ad. gss. Every four hours. 
 
 March 25th. He had only 8 minims of laudanum last night 
 and did not sleep so well, but this morning he says he feels 
 " first rate." Tongue fairly moist and clean with the exception 
 of two narrow bands of yellowish fur at the sides. Pulse 120, 
 soft and feeble. Some very ofiensive motions. He was out of 
 the tank to-day from 9- 30 a.m. to 5 p.m. as one of the water 
 pipes had burst. At 4 p.m. his temperature was 104°, but by 
 midnight it had fallen to 1006°. 
 
 March 26th. He had a good night. Motions are more 
 formed and not so offensive. Cough not so troublesome. 
 Tongue moist, yellowish fur at edges. 
 
 March 27th. Slept fairly well last night. Pulse 1 12. Cough 
 still troublesome. There is now only one motion daily. 
 Temperature shows less fluctuations, mean 101.5". 
 
130 THE TREATMENT OF TYPHOID FEVER. 
 
 ' March 28th. He had a good night. Pulse 116. Respirations 
 88. Cough seems to be much better. Breath sounds anteriorly 
 are rough and accompanied by a few rales. Posteriorly breath 
 sounds are rough and rasping: crepitant rales, prolonged 
 expiration, and dull percussion at both bases. No abdominal 
 pain 01- tenderness. Motions more formed and not very 
 offensive. Knee-jerks exaggerated, ankle clonus present. Mean 
 temperature to-day lOO'O". 
 
 March 29th. Slept well. Cough more troublesome, and 
 expectoration more profuse. Lungs, anteriorly some crepitant 
 rales, and harsh breathing; posteriorly dull percussion over both 
 lower lobes, but most marked over left, over right there are 
 numerous mucous rales, over left lung the breath sounds are 
 louder and higher pitched than those on the right side, and 
 expiration is markedly prolonged. Bowels not much moved 
 since yesterday. Pulse 108. Temperature 100"4'' to 101 "G", 
 mean 100-9°. 
 
 March -SGth. At 4 a.m. his temperature was 99'0°. At 4-45 a.m. 
 he got out of the tank and was found by the nurse sitting on 
 his locker, she put hiin to bed, and he was out of the tank till 
 8-30 a.m. At 8 a.m. his temperature was 102'8'. He now says 
 that he had " the horrors," saw things in the air, and thoug-ht 
 people were running after him. He is very sorry that he got 
 out of the tank, and is glad to get back to it. Tongue moist. 
 Pulse 120, small. Two motions, formed. Temperature steadily 
 fell to 100-6° at 8 p.m. and 100-8° at midnight; pulse 108. 
 
 March 31st. Slept well. Cough troublesome, and expecto- 
 ration more profuse. Lung phenomena much as last noted. 
 When he was out of the tank this morning his temperature 
 reached 102-4°, but otherwise it kept at a low level, the mean 
 of six observations, including that when out of the tank, being 
 100-6°. 
 
 April 1st. Slept well. Tongue moist. Pulse 112, small, 
 firm, and rather wiry. Cough still rather troublesome ; over 
 anterior aspect of chest breath sounds normal; over back, 
 coarse crepitant rales, and dull percussion at both bases. 
 Temperature to-day 97-8° to 100-8°, mean 99-7° 
 
CASES TREATED IN THE TANK. 131 
 
 April 5th. He has progressed favourably since last note. 
 His temperature has been almost normal, the mean of 18 
 observations being 99 '2^ He has slept very well, and last 
 night was the best which he has had. Tongue moist. Pulse 
 110. Cough much better. Bowels have not acted for 36 
 hours. Some dulness at base of right lung ; breath sounds 
 nearly normal, a few crepitant rales ; in front breath sounds 
 are rough, but otherwise normal. Knee-jerks and. ankle clonus 
 present. 
 
 April 8th. Slept very well last night. He had 2 grains of 
 calomel yesterday and bowels acted freely. Cough much 
 better. Tongue moist and clean. Pulse 100. For three days 
 there have been greater fluctuations of temperature, and when 
 out of the tank it ran up to about 102" each day. 
 
 April 9th. Ordered kolatina, boiled bread and milk. Add 
 to each dose of mixture 5i- of tincture of cinchona. 
 
 April 11th. His temperature ran up yesterday afternoon, 
 and he wandered a good deal. He thought he saw men walk- 
 ing on the wall, and he imagined that there were rats in the 
 tank. His bowels were freely moved in the evening; the 
 motions were loose and very offensive. He passed a rather 
 restless night, but this morning he says that he is all right. 
 Cough very much better. Pulse 100. Tongue moist, and 
 slightly furred. Temperature was subnormal the whole of to- 
 day. Naphthaline grains vi., thrice daily. 
 
 April ]2th. Sleeps well. Tongue moist. Pulse 96. 
 Temperature about normal, mean 99'3°. Bowels not moved for 
 two daj^s. 
 
 April 14th. His temperature was normal to-day, and he was 
 taken out of the tank at 5 p.m. His temperature afterwards 
 ran up to 102" at midnight. Ordered fish diet. 
 
 April loth. To-day his temperature reached 103'4'' at 4 p.m. 
 Pulse 132. Bowels confined. Net weight 150 lb. There are 
 three abscesses in right gluteal region, which were opened to- 
 day. 
 
 April 16th. His temperature was normal this morning, but 
 rose to 100'6" in the afternoon. Three abscesses in the left 
 
132 THE TREATMENT OF TYPHOID FEVER. 
 
 gluteal reojion opened to-day. He has perspired profusely since 
 he was taken out of the tank. Ankle clonus marked ; knee- 
 jerks exaggerated. Contraction on tapping the supinator 
 longus muscle in the forearm. For the mixture of March 24th, 
 the following is substituted. 1^ Acid. Nitro-Mur. dil., n\^x. 
 Tinct. Belladonnge, Tl\^x. Tinct. Chinchonse Co., 53S., Syrupi 3i- 
 Aq. Chloroform!, ad §i. Every four hours. 
 
 April 17th. Seems much better this morning, but still per- 
 spires freely. Temperature normal. Pulse 100. Tongue fairly 
 clean. Bowels acted twice during the night : motions formed. 
 Abscesses are looking well. Respiratory sounds normal. 
 Placed on ordinary hospital diet, kolatina, and one pint of 
 milk 
 
 April 28th. He progressed favourably until the 25th inst., 
 when he began to complain of pain over the lower ribs on the 
 left side, in the rigion of the spleen where there seems to be 
 some fulness. Breath sounds are feeble on both sides, especially 
 at base of left lung where the percussion is impaired. Tongue 
 moist and furre^l. He does not care for his food and he is very 
 dull and apathetic. Bowels moved this morning. The diaph- 
 ragm is not acting well. Temperature last night 103°, this 
 morning 99'2°. Poultices. I^ Sodse sulpho-carbolatis, 5^^. 
 caffeinse, gr. ii. Syrupi, 3i- Aq. Chloroformi, ad §i. Every four 
 hours. Stop mixture of 16th. 
 
 April 30th. The pain has been much worse since 3 a.m., 
 and there is now distinct bulging of the lower ribs on left side, 
 and some tenderness on pressure just below the ribs. 
 
 May 8th. His temperature has been normal since the 1st 
 inst., and he now feels well and free from pain. Tongue clean. 
 Pulse 84. Ordered 2 eggs daily. 
 
 May 9th. He is doing well, ordered to revert to mixture of 
 Aprilieth. 
 
 May 16th. Since the 12th, there has been continuous febrile 
 movement with marked evening exacerbation, and this evening 
 it reached 103*8°. Pulse 116, soft, full and dicrotic. Respirations 
 34. He complains of headache, and a dull aching pain in left side 
 over lower six ribs. Tongue coated with white fur; no appetite. 
 
CASES TREATED IN THE TANK. 133 
 
 He is very thirst}^ ; the diarrhoea has returned, motions bright 
 yellow and oifensive. Heart sounds feeble, no murmur. The 
 respiratory sounds all over the chest are very feeble ; the 
 diaphragm does not seem to be acting ; there is some bulging of 
 the left lower ribs. Area of hepatic dulness increased. Urine 
 alkaHne, sp. gr. 1023, no albumen. On the 13th he reverted 
 to the sulpho-carbolate of soda and caffeine mixture. On May 
 17th he was ordered in addition 6 grains of naphthaline every 
 four hours. 
 
 May 20th. Condition not much altered ; there are several 
 boils over his body which are poulticed. He has four or five 
 loose motions daily. He is now placed on milk diet and soda 
 water. 
 
 May. 23rd. Yesterday and to-day the morning temperature 
 has been normal, but there has been an evening exacerbation 
 of two degrees. Pulse 92, small and weak. Heart's action very 
 feeble and sounds almost inaudible. Respiratory sounds very 
 feeble. He is troubled with cough, and muco-purulent expec- 
 toration. On the 21st he coughed up a small quantity of 
 bright arterial blood. Knee-jerks present ; no ankle clonus. 
 Ordered charcoal. 
 
 May 29th. Improving. Temperature to-day 98° to 99'8°. 
 From this time it remained normal. The febrile movement 
 extended over eighteen days. During the first live days it 
 remained at a lower but more continuous level, and for the last 
 eight days the morning temperatures have been normal, but 
 there has been an evening exacerbation of two or three degrees, 
 chere has also been considerable diarrhoea, so the whole course 
 of the affection has pointed to a relapse though it was 
 complicated with numerous boils over the body, arms, and in 
 the axilla. Ordered two eggs. 
 
 June 7th. His temperature has remained normal since last 
 note, and he is progressing favourably. Placed on ordinary 
 hospital diet. 
 
 June 9th. Ordered mutton chop and two pints of milk. 
 
 June 12th. Ordered roast slice. Net weight 1521b. 
 
 June 19th. Net weiuht loSi lb. 
 
134 THE TREATMENT OF TYPHOID FEVEK. 
 
 June 20th. He has heen up part of each day for some time. 
 ffis heart's action has been feeble and his lower limbs have 
 been considerably swollen. Ordered the following mixture, and 
 all others to be stopped. J^ Tinct. Ferri Perchloridi, n]_x. Liq. 
 Ammon. Acetatis, 5ii- Tinct. Digitalis, vi\_x. Syrupi, 5i- ^q- 
 ad §i. Quarta quaque hora sumenda. He continued to 
 improve rapidly, and was discharged, quite well, on June 30th. 
 
 Case 14. Severe case of Typhoid Fever ; Pericarditis ; 
 Pleuritic Effusion ; Bronchitis ; Fifteen days in the 
 tank; Cure. 
 
 Joseph McT., aged - 28, - fireman, admitted to hospital June 
 3rd, 1890. He has been an intemperate man, but enjoyed fair 
 health till the commencement of the present illness. He 
 arrived in Liverpool yesterday, from New Orleans. For last 
 fourteen days he has suffered from diarrhoea and headache. 
 He has had rigors almost every day, and says he has lost a lot- 
 of flesh. He now complains of frontal headache, and restless - 
 nights. Tongue coated with a yellow fur, appetite bad, feels 
 very thirsty. There is profuse diarrhoea. There are several 
 rose-coloured lenticular spots on abdomen and back. There 
 is distinct pericardial friction heard over the sternum, and in 
 the 3rd and 4th left intercostal spaces. There are crepitant 
 rales at the bases of both lungs. Hepatic and splenic dulness 
 increased. Temperature 103°; pulse 108. Ordered milk and 
 soda water. 
 
 June 4th (sixteenth day). The pericardial friction is to-day 
 inaudible. At the bases of both lungs the percussion is im- 
 paired, breathing feeble, vocal fremitus diminished : diarrhoea 
 profuse, motions liquid, brownish colour, very offensive, and 
 acid in reaction. Temperature, 102''- 103°, pulse 92, respira- 
 tions 34. 1^ Ammon. Garb., gr. v. Tincturee Cinchonse flav., 
 TTl^xx. Aq. Chloroformi, ad §i. Every four hours. 
 
 June 5th (seventeenth day.) His temperature this afternoon 
 reached 104°.- Net weight 152 lb. He was placed in the 
 tank at 6-30 p.m., the temperature of the water 90° Fah. 
 
 June 6th. He had a good night-; this morning he complains 
 
CASES TREATED IN THE TANK. 135 
 
 of feeling cold, but is otherwise comfortable. Tongue moist, 
 pulse 100, respirations 32. One formed motion. He took his 
 milk freely during the night. His temperature steadily- 
 declined, and at 4 p.m. to-day it had fallen to 99'2'. There 
 was then a slight rise to 1008^ at midnight. 
 
 June 7th. He was very restless last night, and had 10 
 grains of choral, and 10 grains of potass, bromici. Tongue 
 moist ; only one motion. Pulse 92 ; respirations 28. Add to 
 each dose of mixture, of June 4th, two grains of caffeine. 
 
 June 9th. Slept well. Tongue moist. He feels comfort- 
 able. Bowels have not acted since the 7th. There has been a 
 steady fall of temperature since yesterday morning, and at 
 noon to-day 96'2'' was recorded. The temperature of the tank 
 was then raised to 95°. 
 
 June nth. Slept well. Tongue moist; one motion. His 
 temperature gradually mounted up to 102'4° at noon yester- 
 day, and the tank was then lowered to 90°. There has been a 
 gradual decline since, except a temporary rise to-day, when he 
 was out of the tank. At 4 p.m. 98-6"; 8 p.m. 101-2°; mid- 
 night 98 8°. Ordered 6 grains of naphthaline every four hours. 
 
 June 18th. There has been daily rises of temperature when 
 the patient was out of the tank for sanitary purposes, but a 
 low level has been maintained, and his general condition is 
 improving. Ordered bread and milk. 
 
 June 20th. He was taken permanently out of the tank 
 to-day. Pulse 92, weak. Heart sounds normal, except that at 
 the apex the first sound is very indistinct. No friction nor 
 evidence of pericardial effusion. Respiratory sounds normal, 
 except a little roughness at both bases. Knee-jerks exagger- 
 ated. No ankle clonus. 
 
 June 23rd (thirty-fifth day). After he was taken out of the 
 tank there was an evening rise of temperature on the 20th 
 and 2 1st to 102"2° ; yesterday, and to-day it only reached 101°. 
 
 June 28th. Since last note his temperature has been about 
 normal. He is to-day placed on ordinary diet. 
 
 July 5th. Net weight 150 lb. July 12th. Net weight 152 lb. 
 
 July 14th. Discharged quite well. 
 
136 THE TREA'raiENT OF TYPHOID FEVER. 
 
 Case 15. Case of Typhoid Fever ; Relapse for which he was 
 treated in the tank for six days ; Cure. 
 
 Thomas W., apjed 19, fireman, admitted to hospital June 
 24th, 1890. This man's illness began a.bout 9 days ago on 
 board ship, while returning from Alexandria. For last six 
 days he has been confined to bed with general malaise, head- 
 ache, and pains in the back and limbs. On admission he was 
 found to be suflPering from a mild attack of typhoid fever. He 
 was ordered 4 pints of milk. He progressed favourably until 
 the 19th day, when there was a marked evening exacerbation 
 to 103°. The following morning it was 101°, and in the 
 evening 103-8'. On the 21st day, M. 102" ; E. 104-8°. MotioES 
 loose, yellow, and alkaline. ^ Hydrarg. Sub-chlordi, gr. \. 
 Naphthalinee, gr. vi. Every four hours. 
 
 Twenty-second day. He was placed in the tank to-day. 
 Net weight 1201b. He progressed favourably, and was taken 
 out of the tank on the twenty-eighth day (July 13th). On 
 the following day his net weight was found to be only 111 lb. 
 For the following week there was an evening exacerbation. 
 He was discharged quite well on August 7th, 1890. 
 
 Case 16. Case of Typhoid Fever ; Relapse ; Six days in the 
 
 tank; Cure. 
 
 Carl O., aged 30, sailor, admitted to hospital July 15th, 1 890, 
 on his arrival from South America. His illness began 14 days 
 previously, with shivering, headache, and sleeplessness. On 
 admission he presented well-marked symptoms of typhoid 
 fever. He complained of bad frontal headache, thirst, and loss 
 of appetite. Tongue dry and slightly furred ; pulse 92, soft, 
 and moderately full ; temperature 102° ; heart and lungs 
 healthy ; hepatic dulness normal ; splenic dulness increased. 
 Many well-marked lenticular rose spots over the abdomen. 
 Knee-jerks exaggerated ; no ankle clonus ; no diarrhoea. 
 Ordered 4 pints of milk daily. 
 
 July 17th (sixteenth day) He did not sleep well. Tongue 
 dry ; pulse 88, weak. Heart sounds feeble. Temperature, 
 last night and this morning, 103°. Motions loose, yellow, and 
 
- CASES TREATED IN THE TANK. 137 
 
 offensive. Net weight 1031b. Ordered him to have, in 
 addition to his milk, peptonised bread and milk, and kolatina. 
 1^. Naphthalinae, gr. vi., every four hours. 
 
 July 19th. He did not sleep at all last night, though he 
 had one drachm of paraldehyde, and 10 minims of nepenthe. 
 He is now quiet and apathetic ; perspiring profusely There 
 are a few rhonchi heard over the chest. 
 
 July 21st. He slept very little last night, though he had 
 fifteen minims of nepenthe. He is taking nourishment badly, 
 and had only two pints of milk and a little bread during the 
 last 24 hours. 
 
 July 22nd. 1^ Caffeinse, gr. ii. Tincturse Belladonnge, ]\x. 
 Tinct. Cinchonse Co., 5ss. Syrupi Simplicis, 5i- -^4- Chloro- 
 formi, ad §i.. Every fourth hour. Porridge. 
 
 July 24th (twenty-third day). He had no draught last 
 night, but slept fairly well. He was sick last night, for which 
 he had several doses of bismuth, and two ounces of brandy. 
 Heart sounds feeble ; pulse weak. There is dulness at base of 
 right lung. ; He coughs occasionally, and the expectoration 
 consists of mucus tinged with blood. Knee-jerks lively : 
 no ankle clonus. Temperature has been normal for three 
 days. Add to each dose of mixture, of July 22nd, Sodee 
 Sulpho-Carb., 5ss. 
 
 From this time the patient progressed very favourably, and 
 at the end of the month he was out of bed. From August 4th 
 to 8th, inclusive, he was out of doors for a short time each 
 day. On the latter day he had some currant cake from a 
 friend, and on the morning of the 9th he had a relapse. The 
 temperature that evening reached 104°, and from this time to 
 the 12th it ranged between 102° and 104°, the mean of 18 
 observations being 103"2°. 
 
 On the evening of the 12th he was placed in the tank at 
 90°, and by the following morning his temperature had fallen 
 to normal During his stay in the tank there was a slight 
 evening exacerbation of one or two degrees. His net weight 
 when placed in the tank was 99 lb. His tongue,- which was 
 dry .and tremulous, became moist ; his headache disappeared. 
 
138 THE TREATMENT OF TYPHOID FEVER. 
 
 His tongue remained tremulous, and there was general 
 muscular tremor, as also some fibrillar contraction about the 
 angles of his mouth. His pulse became slower and stronger ; 
 his appetite and general condition"[improved. He was put on 
 the mixture prescribed on July 22nd and 24th. The liberal 
 diet of porridge, fish, chicken, eggs, &;c., which he had been 
 receiving, was reduced to bread and milk. 
 
 August 18th (tenth day of relapse). To-day his tem- 
 perature ranged between 98° and 99" ; pulse 84. He felt very 
 well, and at 7 p.m. he was taken out of the tank. 
 
 August 19th. Immediately after being taken out of the 
 tank his temperature began to rise, and at 4 p.m. this afternoon 
 it reached 103°. He became drowsy and apathetic. His tongue 
 became dry and furred. Heart sounds feeble. Lungs fairly 
 healthy, except a little harsh breathing at left base. There were 
 a few typhoid spots over abdomen. No ankle clonus. Knee-jerks 
 exaggerated. His bowels were more or less confined through- 
 out, and he required frequent doses of calomel. From this 
 time the morning temperature was about normal, but there 
 was a daily exacerbation of two to three degrees, up to the 
 twentieth day of the relapse. 
 
 Auoust 30th (twenty-second day of relapse). His diet, to- 
 day, was supplemented by the addition of fish, and on 
 September 7th he was also allowed chicken. 
 
 His net weight on September 4th was 93i lb, and on 
 September 11th 106 lb. He was discharged on September 11th 
 quite well. 
 
 Case 17. Severe case of Typhoid Fever; Free HcEmorrhage ; 
 Twenty-three days in the tank ; Cure. 
 
 Edward G., aged 14, admitted to hospital August 29th, 1890, 
 on the fourth day of an attack of typhoid fever. He was a 
 healthy looking boy, who had enjoyed good health prior to this 
 illness. A brother, aged 18, had typhoid fever in June, and 
 recovered ; a sister, aged 5, died from the same diaease in the 
 Royal Infirmary in July. 
 
 On August 2oth, he took ill with headache and general 
 
CASES TREATED IN THE TANK. 139 
 
 malaise ; and since the 26th, he has been confined to bed. His 
 temperature, as recorded prior to admission, ranged from 102"^ 
 to 103"8^, and on that evening it reached 104"2^. He complains 
 of headache, thirst, and loss of appetite. Face flushed, pupils 
 dilated, right more so than left. Tono;ue moist, white fur in, 
 centre, clean at tip and edges ; motion formed, yellow, alkaline, 
 and offensive. No abdominal distension, but tenderness on 
 pressure ; no gurgling in right iliac fossa. No rose spots. 
 Hepatic dulness normal, splenic dulness increased. Pulse 108, 
 full, soft, and compressible. Heart sounds normal. There are 
 a few rhonchi, but otherwise lungs healthy. No ankle clonus, 
 cannot elicit knee-jerks. Ordered four pints of milk daily, 
 and five grains of naphthaline every four hours. 
 
 E. G., 30-8-90, Pulse iiiO, Pi'essure -1 ozs. (before being put in tank). 
 
 August 3 1st (sixth day). He was placed in the tank yesterday 
 afternoon at 90% and at 8 a.m. this morning the temperature 
 was 97*4", the tank was then raised to 95''. He slept fairly 
 well, and felt comfortable. Pulse 104. Tongue moist, coated 
 with a white fur. hie is not coughing much. Takes liquid 
 nourishment well. 
 
 September 1st. Since the tank was raised to 95°, his 
 temperature has increased, and when out of the tank for three- 
 quarters of an hour this morning it ran up, and at 12 noon 
 102'4° was recorded. Tongue moist. Bowels confined. He 
 took over five pints of milk during the last 24 hours. He is 
 now ordered, in addition, peptonised bi-ead and milk, two ounces 
 of butter, and porridge. 
 
 September 3rd. He was taken out of the tank at 11-30 
 last night, as the hot water pipe had burst, and consequently the 
 temperature of the tank could not be maintained. His tempera- 
 ture rose to 103'6' at 4 a.m. At 8 a.m., it was 102"; at noon, 
 
140 THE TREATMENT OF TYPHOID FEVER. 
 
 102"8°; and at 1-30 p.m. he was replaced in the tank at 90^ 
 Tongue not so moist. Pulse 124. He is rather deaf: no 
 abdominal distension, but there is a sense of resistance, and he 
 complains of pain. No rose spots, no ankle clonus, cannot 
 elicit knee-jerks. His bowels have been moved twice since he 
 was taken out of the tank, motions slightly formed, yellow, and 
 acid. Urine alkaline, sp. gr. 1025, a trace of albumen, a few 
 triple phosphates, and numerous crystals of urate of ammonium : 
 gives purplish red colour with Ehrlich's test. 
 
 September 9th (fifteenth day). Up till to-day he progressed 
 favourably since last note. His bowels have been confined, and 
 only about one motion every alternate day. He had not had 
 a motion for two days, and last night he was ordered two 
 grains of calomel. He had also two doses of chloral and 
 bromide but did not sleep well, and ^vas very fretful. At 7-30 
 this morning he told the nurse that his bowels had moved and 
 he wished the tank cleaned. She found the water very red 
 with blood. His temperature was 99^ Dr. Askin had hiin 
 taken out of the tank at 9-30. The tank was found to contain 
 a large quantity of blood, some of which was clotted, and only 
 a slight amount of faeces. He was ordered 10 minims of 
 turpentine and 5 minims of laudanum every three hours. At 
 11 a.m. his temperature (out of the tank) had reached 101"4^ 
 Pulse 128, small and weak. He is very drowsy ; there is some 
 subconjunctival haemorrhage in both eyes. Tongue dry. After 
 two doses of the medicine it was discontinued as he was 
 sleeping quietly. Iced-compresses to be applied to abdomen. 
 At 1 and 4 p.m. he vomited, t.he matter ejected containing some 
 blood. Temperature 103°. At 5-40 p.m. he was ordered 
 turpentine and ergot, but half -an -hour afterwards there was 
 some more hsematemesis, and the medicine was stopped. Iced- 
 compresses continued. 
 
 September 10th. He slept fairly well, and was not sick. He 
 took about two pints of milk during the night. Tongue rough 
 and dry, slightly furred. Pulse 140, weak and compressible. 
 Heart sounds feeble but clear. His bowels have not acted 
 since . yesterday morning. There has been slight epistaxis. 
 
CASES TREATED IN THE TANK. 
 
 141 
 
 Mucous membranes are very ansemic. There are now numerous 
 petechial spots on chest, back of neck, arms, and a few bright 
 red purpuric spots on legs. Plantar reliexes well marked. No 
 ankle clonus or knee-jerks. Iced-compresses continued to 
 abdomen, ordered ten minims of oil of turpentine with 
 mucilage and water every third hour. 
 
 ^^SSuSSSSmSMSmSmSuSSSSJSnnKSKSn 
 
 II 
 
 E. G., 10-9-90, Pulse 140,- Pressure 2 ozs. 
 September 11th (seventeenth day). His temperature at mid- 
 night was 103 '2°, and he was then placed in the tank at 90°, 
 and at 8 a.m. his temperature had fallen to 99"2°. At 2 a.m. 
 there was considerable haemorrhage from the bowels, the water 
 being quite red, and there were several clots. At 2-15 a.m. he 
 had a starch enema with ten minims of laudanum. He then 
 slept well till 6 a.m. His bowels acted very slightly ; there 
 has not been a good motion since the 5th. He took 2 pints of 
 peptonised milk, and half-a-pint of kolatina during the night. 
 10-45 a.m., he has had a quiet sleep. Pulse 104, rather stronger. 
 Tongue moist, says he feels better, there is slight twitching of 
 facial muscles. 4 p.m., some dark blood clots passed, but no 
 recent hfemorrhaare. 
 
 E. G., 11-9-90, Pulse 118, Pressure 3 ozs, 
 
 September 12th. He had a very good night, sleeping soundly. 
 
 Tongue is quite moist. Temperature has fallen steadily, from 
 
 102 last night to 99"8'' this morning. Pulse 132, rather 
 
 stronger ; there has been slight cough. Bowels acted at 7 a.m.. 
 
142 THE TREATMEXT OF TYPHOID FEVER. 
 
 motion brownish red, some very dark blood clots. He took 2 
 pints of peptonised milic and some kolatina. 
 
 E. G., 12-9-90, Pulse 132, Pressure 4 ozs. 
 
 September 15tli. He slept very well. Tongue moist. 
 Pulse 124. Temperature 98-8° to 100-2°. Last night there was 
 a small, dark motion, about the size of a walnut. He had two 
 drachms of castor oil, but there has been no further motion 
 yet. He complained several times of griping pains in the 
 abdomen. He is taking liquid nourishment well. 
 
 September 16th. Slept well. Tongue clean and moist. He 
 had an enema this morning, which brought away a lot of hard 
 scybalse. 
 
 September 18th. 1^ Ammonia Carb., gr. v. Caffeinse, gr. ii. 
 Tinct. Chinchonge Flav , il^^xx. Aq. Chloroformi, ad §i. Every 
 four hours. 
 
 September 23rd (twenty-ninth day). His temperature has 
 been practically normal for four days, the evening rise not 
 exceeding a degree or a degree and-a-half, and the morning 
 temperature usually about 98^ Net weight 69 lb., show- 
 ing a loss of only 4 lb. in 24 days. Taken out of tank at 
 3-45 p.m. Bowels confined ; he had an enema which acted 
 
 well. 
 
 September 24th. At midnight his temperature reached 
 101 '8", but with the use of iced compresses to abdomen it fell 
 to normal at 8 a.m. Tongue clean. Pulse 128. Heart sounds 
 clear. Lungs healthy. Knee-jerks present. No ankle clonus. 
 He feels all right. No abdominal distension. Continue iced- 
 compresses to abdomen. There was an evening exacerbation 
 of about two and-a-half degrees each day till the thirty -fourth 
 day of the disease, after which the temperature did not rise 
 above 99''. 
 
CASES TREATED IN THE TAXK. 14o 
 
 September 30th, net weight, 65 lb. 
 
 October 8th, 66i lb. 
 
 October 10th, he was placed on ordinary diet. 
 
 October 14th, net weight, 65| lb. 
 
 October 22nd, weight, with clothes, 82 lb. 
 
 October 24th, discharged quite well. 
 
 Case 18. Case of Typhoid Fever ; Thirteen days in the 
 tank ; Cure. 
 
 Miles W., age 22, milk-house keeper, admitted to hospital 
 September 4th, 1890. He has always enjoyed fair health, 
 except that during the last four months he has suffered from 
 rheumatic pains. On the 31st ult. he did not feel well, and 
 had headache, which has since continued. On the 1st inst., he 
 had two loose motions, and the same on the 2nd. He was 
 seen by Dr. Wild on the evening of that day, who found his 
 temperature 104°, and yesterday morning 103°. Dr. Wild 
 sent him into hospital to-day. 
 
 On admission he was perspiring freely ; complained of pain 
 in back and headache. Tongue coated with white fur in centre, 
 red and clean at tip and edges. Slight gurgling in right iliac 
 fossa; no distension or tenderness of abdomen; heart and 
 lungs healthy. Pulse 112 ; temperature 101°, rising in the 
 evening to 102°. Ordered 2 grains of calomel ; 4 pints of 
 milk. 
 
 September 5th (fifth day). He did not sleep well last night. 
 Took one and-a-half pints of milk during the night. He now 
 complains of shooting pains in the back, and headache. Face 
 flushed ; pupils dilated. Tongue coated with a brownish fur. 
 Motions loose, greenish yellow, alkaline, and very offensive. 
 Urine alkaline, sp. gr. 1018, no albumen, gives Ehrlich's 
 reaction, deposit of triple phosphates and crystals of urate of 
 ammonium. Stomach somewhat distended ; spleen not 
 apparently enlarged ; not much abdominal distension ; one 
 suspicious typhoid spot ; slight tenderness in right iliac fossa. 
 No ankle clonus. Knee-jerks present. Pulse 104, rather small, 
 moderately full and compressible. Respirations 26. Tern- 
 
144 
 
 THE TREATMENT OF TYPHOID FEVER. 
 
 perature 102°, rising inthe evening to 103"4°. Ordered boiled 
 bread and milk. 
 
 M. W. 5-9-90, Pulse 96, Pressure 2 ozs. 
 
 September 6th. He still complains of pain in back. He 
 had a restless night, though he took 30 grains of bromidia. 
 He was sick this morning. One suspicious spot on chest. 
 Respiratory sounds rather harsh. Pulse 112. Respirations 28. 
 
 September 7th. He had one drachm of bromidia, but did 
 not sleep well. His bowels acted twice yesterday and once this 
 morning. Motions greenish yellow, liquid, alkaline, and offen- 
 sive. He was sick, and had slight epistaxis yesterday evening. 
 Tongue dry and furred ; a few typhoid spots now present on 
 abdomen; no ankle clonus, knee-jerks not well marked. 
 Ordered six grains of /^-naphthol every four hours. 
 
 September 8th. He had 30 grains of sulphonal last night 
 and slept rather better. Some rose spots on abdomen. Urine 
 gave a deep port wine colour with Ehrlich's test. Net weight 
 131 lb. His temperature at 4 p.m. was 104°, and at 4-30 p.m. 
 he was placed in the tank at 90°. At 8 and 12 p.m. his 
 temperature was 101°. 
 
 September 9th. He slept fairly well and felt comfortable. 
 Tongue is still furred and dry. Pulse 92, firmer. He is taking 
 liquid nourishment well. 
 
 September 10th. He had one drachm of bromidia and slept 
 fairly well. He feels comfortable and is taking plenty of 
 milk. Tongue moist, sordes about teeth. Bowels have acted 
 several times, motions slightly formed, greenish yellow, acid, 
 and offensive. Pulse 96. Temperature to-day did not i-ise 
 above 100-2°. 
 
 September 11th. He slept well and took two pints of milk, 
 and some boiled bread and milk during the night. Tongue 
 
CASES TREATED IN THE TANK. 145 
 
 moist, yellow fur in centre. Pulse 102, small and compressible. 
 There was a slight evening exacerbation to 102° but the mean 
 temperatui'B to-day was only 100"3°. 
 
 September 12th. He slept well; bowels acted three times 
 during the night. Tongue moist, centre coated with thick 
 yellowash brown fur. Pulse 108. Mean temperature 100"3°. 
 
 September 13th. Periodate crystals, 5 grains every four 
 hours were substituted for the naphthol. 
 
 September 16th. He has progressed very favourably since 
 last note. Temperature 99° to 101°. Mean of twenty-four 
 observations 100° 
 
 September 22nd. The patient was taken out of the tank at 
 1-30 p.m. yesterday. His mean temperature for the previous 
 four days being 99'15°. At 4 p.m. his temperature was 101°, 
 and at 8 p.m. 1026°. Iced -compresses were then applied to 
 his abdomen. He slept fairly well and his temperature this 
 morning is normal. Pulse 96. Tongue furred and moist. 
 Respiratory sounds on right side of chest are rather feeble, 
 otherwise normal. The abdomen is now rather retracted, no 
 pain or tenderness. Knee-jerks well marked, no ankle clonus. 
 There is a well marked papular rash on back of chest and 
 abdomen. 
 
 September 23rd. Net weight 1281b. I^ Caffeinse, gr. ii. 
 Tinct. Chinchonae Co., iT^xxx. Aq. Chloroformi, ad §i. Every 
 four hours. 
 
 September 30th. Net weight 1151b. Ordered fish diet. 
 
 October 7th. Net weight 118 lb. 
 
 October 14th. Net weight 121 lb. 
 
 October 15th. Discharged quite well, though yet below his 
 usual weight. 
 
 Case 19. Typhoid (J) Fever ; three days in the tank ; Cure. 
 
 William R., age 19, fitter, admitted to hospital October 7th, 1890. 
 He has always been healthy until the present illness, which 
 began on September 26th, with a rigor, headache and pains in 
 the back. He was unfit for work the following day, but did 
 not take to bed till the 30th. He now complains of a dull 
 K 
 
146 THE TREATMENT OF TYPHOID FEVER. 
 
 hea^"A' pain in back, but no headache. Pupils normal. Tongue 
 dry, clean at tip, elsewhere coated with a thick yellowish fur ; 
 sordes on lips and teeth : no rash. Temperature 103°. Bowels 
 have been rather confined throughout, except after a dose of 
 castor oil, which he had about a week ago. Net weight 122 lb. 
 Ordered three grains of calomel. Four pints of milk, soda 
 water, and 12 ozs. of bread daily. 
 
 October 8th. He did not sleep well. Bowels have acted 
 twice, motions loose, yellowish, neutral, and very offensive. 
 Pulse 88, small and compressible. Respirations 36. Heart and 
 lungs normal : hepatic and splenic dulness about normal. No 
 abdominal distension, nor any tenderness. No ankle clonus, 
 knee-jerks well-marked, some muscular tremor. Temperatures 
 4 a.m., 103-2" ; 8 a.m., 102-8° ; 12 noon, 101-4°; 8 and 12 p.m., 
 103°. This evening he presented a slight dusky mottling on 
 abdomen, and he was strictly isolated. 
 
 October 9th (fourteenth day). He had a very restless night, 
 and was very delirious. Tongue dry, and tremulous; lips dry, 
 and coated with sordes. Decubitus on side, and seems to have 
 great difficulty in turning, owing to pains in his back. There 
 is an obscure dusky mottling over chest and abdomen. Dr. Hope, 
 Assistant Medical Officer of Health, saw him with me, and 
 pronounced the case undoubtedly one of typhoid fever. This 
 authoritative judgment relieved my mind somewhat, but it did 
 not entirely satisfy me, and in order to err on the safe side and 
 prevent any risk of infection if the case should turn out to be 
 one of typhus, I had him immersed in the tank, though I did 
 not consider the case a very severe one. His temperature 
 which was 103-2' steadily fell after he was placed in the tank 
 at 92°. 
 
 October 10th (fifteenth day). He was very restless last night, 
 and tried several times to get out of the tank. He had fifteen 
 minims of laudanum. He feels much better to-day. Tongue 
 furred but quite moist, no pain in back. Pupils rather con- 
 tracted. He is drowsy and inclined to sleep. Pulse 76. 
 Temperature has declined from 103-4° at 4 p.m. yesterday, to 
 99-2° at noon to-day ; there was a slight evening rise to 100° 
 
CASES TREATED IN THE TANK. 147 
 
 The dusky mottling is less marked. Splenic dulness four and- 
 a-half by three and three-quarter inches. Ordered 4 grains 
 of calomel. 
 
 October 11th (sixteenth day). He had a quieter night, but 
 did not sleep much. Looks much better this morning. Tongue 
 rather dry. Pulse 72. Bowels have not acted since the morning 
 of the 8th, though he has had two doses of calomel of 4 grains 
 each. He is taking milk freely. Ordered one ounce of castor oil. 
 
 October 12th. He had 10 minims of laudanum, and later 
 10 minims of nepenthe, and he slept pretty well during the 
 night. Tongue moist, slightly furred. Pulse 72. Bowels have 
 acted freely, motions yellow and formed. Temperature 
 normal. He was taken out of the tank this afternoon to make 
 room for his mother. Iced compresses were then applied to 
 his abdomen. 
 
 October 13th. He had no draught last night, and slept 
 well. The iced compresses are continued, and his temperature 
 has not risen. Tongue rather dry and sticky; pulse 80; respira- 
 tions normal. Heart sounds clear. No distension of abdomen. 
 Knee-jerks marked; ankle clonus present on both sides. 
 
 October 14th (nineteenth day). He slept well. His tem- 
 perature rose to 101° at midnight, but by 8 a.m. it had fallen 
 to normal. Iced compresses continued. Heart sounds feeble, 
 rhythm irregular. Pulse slow, infrequent, irregular, and of 
 moderate tension. Tongue dry, and slightly furred, papillae 
 well marked. 
 
 October 15th. Net weight 111 lb., showing a loss of 11 lb. in 
 8 days. Ordinary diet. 
 
 October 24th. Net weight 113 lb. 
 
 October 27th. Weight in clothes, 125 lb. He has been out 
 of doors for several days. Discharged to-day, quite w^ell. 
 
 Case 20. Severe case of Typhoid {?) Fever ; Three days in 
 the wet-pack ; rdne days in the tank ; Cure. 
 
 Mary R., aged 39, housewife, mother of last patient, admitted 
 to hospital October 7th, 1890. She is the only survivor out 
 of twelve children. Her father is alive at tlie age of 63. 
 
148 THE TREATMENT OF TYPHOID FEVER. 
 
 Mother died in parturition. This patient was married at 
 the age of 17, and is the mother of 10 children, and has had 
 three miscarriages. After the birth of her fourth child, 12 
 veal's ago. she was laid up for 19 weeks with "white leg." 
 After the birth of her last child, two years ago, she was ill for 
 5 months with " white leg." 
 
 Her present illness began ten days ago with headache, 
 languor, and a disagi'eeable taste in her mouth. She attended 
 to her household duties to the 5th inst., .since which time she 
 has been confined to bed. She always suffers from constipa- 
 tion, and her bowels have been confined since she took ill, 
 except when .she has had a dose of liquorice powder, or an 
 enema. 
 
 She is a moderately well-developed, fairly nourished woman, 
 dark sallow complexion. She has . an anxious expression, 
 talks in a low dull tone, and moans with every respiration. 
 She is quite intelligent. Skin of a jaundiced hue, hot and 
 dry. Temperatiu'e about 104". Tongue moist, coated in 
 centre with a soft white fui\ Complains of thirst. She 
 vomited twice to-day, the matter consisting of curdled milk 
 and ropy rnucus. Abdomen large, flabby, and distended. She 
 jdelds to pressure in the right iliac fossa. No rash; knee-jerks 
 present : plantar reflexes well marked. Heart and lungs 
 normal. Four pints of milk daily ; ten grains of periodate 
 crystals every four hours. 
 
 October 9th (twelfth day). She slept at intervals during 
 the night. She has not been delirious, but moans constantly. 
 Muscular tremor well marked around the mouth. Abdomen 
 much distended. Xo rash. Tenderness has disappeared. 
 Tongue coated with a thick fur. Ej^es clear ; and she is in- 
 telligent. Pulse 120. Urine acid, sp. gr. 1019, albuminous. In 
 the afternoon there was an obscure, dusky mottling over the 
 abdomen. Dr. Hope saw her with me, and pronounced the 
 case to be a severe attack of t^qjhoid fever ; she was, however, 
 isolated. There has been a continuous febrile temperature 
 since admission of about 104""., only varying a few points. At 
 4 p.m. to-day it reached 104-8'^ and at 4-30 p.m. she was put 
 
CASES TREATED IN THE TANK. 149 
 
 in a wet-pack. She had 4 grains of calomel. Net weight 
 1121b. 
 
 October 10th. Her temperature has fallen about a degree. 
 the mean yesterday being 104-2°, and to-day 103-3°. Pulse 112. 
 She is quite intelligent, and complains of the cold sheet. Tongue 
 dry, coated in centre with white fur, tremulous. There is 
 general muscular tremor, which is especially marked about the 
 mouth. She was sick once during the night, and her bowels 
 were'freely moved; motion formed, brown colour, acid reaction. 
 Spleen large. Other organs appear normal. 
 
 October 11th (fourteenth day). Passed a very restless night 
 and was delirious. Pulse 136. Respirations 40, Mean 
 temperature to-day 103-4°. 
 
 October 12th (fifteenth day). She had ten minims of 
 laudanum, and fifteen minims of nepenthe during the night, 
 but was very restless, and did not sleep at all. She only took 
 one pint of milk and a little soda water. She is now lying on her 
 back, moaning, and complains of the cold. Eyes dull. Pupils 
 not much contracted. Tongue dry and furred, and she cannot 
 protrude it far. Heart sounds dull. Respiratory sounds feeble, 
 but no dulness. Pulse 152, very weak. Respirations 30. She 
 is passing urine and fseces involuntarily. She is hyperaesthetic, 
 and trying to elicit ankle clonus causes her great pain. Knee- 
 jerks present. Subsultus tendinum present in left arm. 
 Temperature 103-2°. At 2-30 p.m. she was placed in the tank 
 at 94°, and would have been placed in it sooner, but we have 
 only one tank room, which was occupied by her son, and we 
 cannot mix the sexes. Her temperature steadily fell, and by 
 midnight it was only 99-2°. 
 
 October 13th (sixteenth day). She had a good night, slept 
 from 12-30 to 6 a.m. Tongue moist, pupils contracted. Pulse 
 144, weak. She appears more at ease, lies quietly with her 
 eyes closed, but moans frequently. Owing to the general 
 tremor it is impossible to take the temperature in her mouth, 
 and so from this time it is directed to be taken in the rectum ; 
 this makes the temperature appear at a higher level than it 
 would if taken in the mouth. This evening it rose to 103°, 
 
150 THE TREATMENT OF TYPHOID FEVER. 
 
 Motion large, partly formed, yellow, and very offensive. Urine 
 acid, sp. gr. 1022, albuminous. 
 
 October 14th. Had ten minims of nepenthe, and slept fairly 
 well, but was restless and moaned frequently. Temperature at 
 8 a.m. in rectum 102"4°. Pulse 144, small and compressible. 
 Tongue moist. She complains of the water being cold, though 
 it is 94°. There is general muscular tremor. Mean rectal 
 temperature 102'2°. Bowels confined, ordered one ounce of 
 castor oil. 
 
 October 15th (eighteenth day). She had a restless sleep, and 
 moaned nearly all night. Puts out her tongue better this 
 morning; it is moist. Pulse 136, small and weak. Bowels 
 acted freely, motion yellow, partly formed, and offensive. She 
 is taking nourishment well. Mean rectal temperature to-day 
 101-2°. 
 
 October 16th (nineteenth day). She had fifteen minims of 
 laudanum, and passed a very good night. Tongue clean and 
 moist. Bowels moved. Pulse 124, stronger. Mean temperature 
 100°. 
 
 October 21st (twenty -fourth day). She has progressed very 
 favourably since last note. Her temperature has been fairly 
 normal, and her pulse has now come down to 104. In addition 
 to her milk she has been taking bread and peptonised gruel. She 
 was taken out of the tank this afternoon. I^. Caffeinae, gr. ii. 
 Tinct. Cinchonse- Co., n^xxx. Aq. Chloroformi, ad §i. Every 
 four hours. 
 
 October 23rd. Ordered fish and ordinary diet. 
 
 October 25th. Net weight 1141b., which shows a gain of 
 2 1 lb., therefore what flesh she lost during the febrile stage has 
 now been more than restored. She was discharged quite well, 
 November 3rd, 1890. 
 
 Case 21. Very Severe Case of Typhoid Fever; Relapse ; Thirty - 
 one days in the tank ; Cold water enemata ; Death ; Post 
 mortem. 
 
 Ann K., age 36, housewife, admitted to hospital, October 27th, 
 1890. She is the mother of nine children, seven of whom are 
 
CASES TREATED IN THE TANK. 151 
 
 alive ; the eldest fifteen years, and the youngest one year. The 
 eldest boy and eldest girl have been recently in this hospital 
 suffering from typhoid fever, and the latter is still here. On 
 the 16th and 17th inst., she was engaged working, and on the 
 latter day she felt chilly ; she did some work on the 18th, but 
 since then she has been confined to bed. On admission she was 
 in a very collapsed condition. Temperature in axilla 103°, 
 extremities cold, pulse small, weak and rapid. Dr. Barr ordered 
 her some brandy, and 3 grains of calomel. 
 
 October 28th (twelfth day). Urine and faeces passed invol- 
 untarily. During the night she had two ounces of brandy, and 
 about 24 ounces of milk. It was with great difficulty that the 
 milk was given — the patient holding it in her mouth, and then 
 spitting it out. She slept the greater part of the night, and 
 is now in a very drowsy, stupid state ; answers questions when 
 loudly spoken to, but quickly relapses into a stupid lethargic 
 condition, with low muttering delirium. Dorsal decubitus. 
 She has some difficulty in putting out her tongue, which is 
 dry ; sordes on lips and teeth. Eyes dull, pupils about normal 
 size. She will not swallow any fluid at present. Temperature 
 at 8 a.m., in axilla, 102'8° ; pulse 128, very small, weak, and 
 irregular ; respirations 36. The first cardiac sound at apex is 
 inaudible, second sound not loud but sharp and clear. 
 Respiratory sounds anteriorly below right clavicle are rough 
 in character and accompanied by some rhonchi ; anteriorly on 
 left side fairly normal ; posteriorly there are many small 
 crepitant rales, with harsh breath sounds ; percussion note 
 fairly resonant. Hepatic dulness increased. Splenic dulness 
 measures 6| by 5 inches. Abdomen full, soft, and flabby. 
 There are a few rose spots which disappear on pressure. 
 Numerous petechial fleabites. No ankle clonus. Knee-jerk 
 on left .side feebly marked, more easily elicited on right side. 
 Her extremities are kept warm by hot bottles. Ordered 2 
 grains of caffeine, and one minim of Liq. Atropini Sulph. 
 every 3 hours ; malted milk as freely as can be administered. 
 She was placed in the tank at 11-30 p.m. ; temperature of 
 of the water 92^. Her temperature to-day fluctuated between 
 
152 THE TREATMENT OF TYPHOID FEVER. 
 
 101° and 103°. Temperature to be taken in the rectum. Net 
 weight 118Hb. 
 
 October 29th (thirteenth day). Drowsy and semi-conscious. 
 Tongue moist, she cannot protrude it much ; no sordes on 
 teeth. Bowels did not act to-day. Temperatures, 4 a.m., 103°; 
 8 a.m., 101-2° ; 12 noon, 102-2° ; 4 p.m., 102-4° : 8 p.m., 103° ; 
 12 midnight 104°. 
 
 October 30th (fourteenth day). She is in a very drowsy 
 apathetic condition, and can scarcely be roused : she only pro- 
 trudes her tongue very slightly, but it is clean and moist. 
 Temperature of tank, 92°. Pulse small and feeble ; face dusky 
 livid hue, u^jacous membrane rather purple. Eyes bright, 
 pupils normal. She takes her nourishment, which consists of 
 milk and malted milk, badly, and had very little during the 
 night. There has been no vomiting. Her bowels were fairly 
 moved this morning, after a dose of calomel and an enema. 
 She had another dose of 3 grains of calomel. Her skin feels 
 cool, but the temperature in rectum is very high, the records 
 to-day being 104-8° ; 105-4° : 105° ; 104-6° ; 104° ; 103-8°. 
 Ordered one minim of 1 per cent, solution of nitro-glycerine to 
 be added to each dose of her mixture. 
 
 October 31st. Slept very well last night, and took nourish- 
 ment better. She had 12 ounces of milk and some bread and 
 milk. Medicine every third hour. At 12 a.m. she had 10 
 grains of /3-naphthol, and 10 grains of salicylic acid suspended 
 in milk. This she spat out. It was repeated at 4 a.m., but 
 she again refused to swallow it. At nine a.m. she took the 
 powder readily. Pulse 132, small, weak and irregular ; she is 
 still drowsy, but more easily aroused, and says she is better. 
 Face flushed, dusky hue. Tongue fairly moist and clean ; she 
 is unable to protrude it far, but makes a much better attempt 
 than yesterday. 
 
 November 1st (sixteenth day). She was very drowsy all 
 nighc. Took very little nourishment, six ounces of milk and 
 some bread and milk. Spat out the powders, but took caffeine 
 mixture. Temperature at 8 a.m. 103.2°. Respirations 22. Pulse 
 small, weak, irregular, compressible, and very frequent, 137; 
 
CASES TREATED IN THE TANK. 153 
 
 Heart sounds dull ; the first barely appreciable. Respirations 
 quiet. There are some rhonchi heard all over chest. She 
 is exceedingly stupid, and it is with great difficulty that she 
 can be roused up to comply with such directions as putting out 
 her tongue. Her face is not quite so dusky, and the tongue 
 and mucous membranes are not so livid as yesterday. Her 
 temperature has been over 103° until noon to-day, when 102*2° 
 was recorded. At 1-30 she had an enema of one and-a-quarter 
 pints of cold water, at a temperature of 54°. Her temperature 
 is now (2-30 p.m.) 103° in rectum. Ordered an enema of iced 
 water containing Condy's fluid. 
 
 November 2nd (seventeenth day). Temperature at 12 a.m. 
 and 4 a.m. 100° ; at 8 a.m. 101-2°. Slept very well. Took 
 nourishment better ; 24 ounces of milk and some bread and 
 milk. This morning, she has been induced with great difficulty 
 to take about 5 ounces of milk. She is quite conscious, but 
 seems obstinate. Puts her tongue out better to-day ; it is 
 moist. Face flushed ; not so livid. Pulse 140, fuller and 
 stronger, but still very weak and compressible. Respirations 
 28. She had 4 grains of calomel last night. Bowels have not 
 acted. ■ 
 
 November 3rd. Yesterday afternoon had an enema of one 
 and-a-quarter pints of iced water with 5 ounces of peroxide of 
 hydrogen (10 vols.) Bowels acted freely before enema was 
 given. Motion loose, yellow, and offensive. Slept very well 
 last night. Took about 30 ounces of milk during the night, 
 and a little bread and milk this morning. Temperature at 8 
 a.m. 99°. Pulse 128, fuller, not so compressible or irregular ; 
 there are occasional intermissions. She is very drowsy still, 
 but can be more easily roused. Tongue is clean, but rather dry. 
 
 November 4th (nineteenth day). She slept very well, and 
 took nourishment well, about 30 ounces of milk and some bread 
 and milk. Seems more sensible this morning ; not so drowsy 
 or stupid. Tank has been cleaned. Bowels acted slightly. 
 Motion loose, yellow, and oflensive. Temperature dunng night 
 100° ; at 8 a.m. normal. Pulse still very frequent, 136, but is 
 somewhat increased in volume, and is not so compressible, 
 
154 THE TREATMENT OF TYPHOID FEVER. 
 
 Respirations 24. Tongue is moist, of a purplish colour. Sali- 
 cylic acid and naphthol powders continued ; also caffeine and 
 Liq. atropini sulph. Nurse says she seemed much more sensible 
 this morning. She wanted to know how long she was going 
 to remain in the tank. She also missed Mrs. Roberts, who was 
 discharged yesterday. 
 
 November 5th (twentieth day). Slept well. Took nourish- 
 ment well. Temperature at 8 a.m. normal. Pulse 128. Bowels 
 acted this morning, motion loose, brown, and offensive. Seems 
 much more conscious this morning. Puts out her tongue when 
 told to do so ; it is clean but very dry. 
 
 November 6th. Not much change. Slept well and took 
 nourishment well. Tongue clean but rather dry. Temperature 
 at 8 a.m. 99-4°. Pulse 128. Still very drowsy. When asleep 
 left eye is partially open. Bowels acted slightly ; motion loose, 
 yellow, but not so offensive. 
 
 November 7th (twenty-second day). Slept well. Tongue 
 moist but purple. Temperature at 8 a.m. 100°. Pulse is very 
 frequent (136), small, weak and compressible. Is taking 
 nourishment well. Bowels acted this morning; stool loose. 
 When asleep both eyes are partially open, especially left one. 
 
 November 10th. Seems very much better this morning. 
 Says she feels quite well and is very anxious to have some fish. 
 Slept well, tongue moist and fairly clean. Temperature at 
 8 a.m. 99'6°. Pulse 128, still small, weak, compressible, 
 and somewhat irregular in rhythm and force. Bowels acted 
 this morning, motion partially formed, yellow, and offensive. 
 Face flushed, eyes bright, pupils normal. There is slight 
 conjunctivitis in left eye. 
 
 November 11th (second day of relapse). Yesterday evening 
 at 8 p.m. temperature ran up to 102°. At 12 a.m., was 100° ; 
 at 4 a.m., 99-8° : and at 8 a.m., 102-4°. She slept well, and is 
 taking nourishment all right. Says she feels all right. Is not 
 coughing. Tongue is furred, but moist. She is at present 
 sleeping with eyes half open. Had 4 grains of calomel yester- 
 day. Bowels have not acted since. Pulse at the wrist is not 
 so frequent this morning, but is very difficult to count as it is 
 
CASES TREATED IN THE TANK. 155 
 
 very irregular in force. Heart sounds almost inaudible. 
 Ordered fish and Benger's food. At 5-30 p.m. she had an iced 
 enema, temperature of water 48" (Oiss). At 4 p.m. tempera- 
 ture was 101-4° ; at 12 midnight it fell to 100°. 
 
 November 13th (fourth day of relapse). Yesterday morning 
 at 8 a.m. temperature was 102 6° ; at 10-45 another iced enema 
 was given, temperature of water 38° (Oiss) ; it was retained 
 some time. On the 11th had some fish (fried flat fish) in the 
 evening, and yesterday had some boiled flat fish. Bowels have 
 not acted since yesterday morning after enema. Slept well 
 last night, and took nourishment well. Tongue moist. Pulse 
 136, still very weak and irregular. Heart sounds are very 
 irregular. Temperature at 8 a.m. 101-6°. At 11-45 a.m. had 
 iced enema (Oiss), with peroxide of hydrogen (5 oz). At 12 
 p.m. temperature was 99-9°. At 8 p.m. iced enema was repeated 
 as temperature was 101-6°. 
 
 November 14th. At 12 a.m., temperature was 100° ; at 4 a.m., 
 100° ; at 8 a.m., 98-2°. Tongue moist. Bowels acted to-day ; 
 motion formed and yellow. Naphthol and salicylic powders 
 discontinued. 
 
 November 15th (sixth day of relapse). During the night 
 some discharge was noticed from the right ear. This morning 
 the discharge is purulent and very foetid. Cannot obtain a good 
 view of the membrane, but there is perforation, as air can be 
 heard passing through it. Ear to be syringed twice daily with 
 boracic acid solution, boracic powder blown in, and then to be 
 packed with cotton wool. 
 
 November 16th (seventh day of relapse). Last night, 8 p.m., 
 temperature was 102-4°. Iced enema was given, and at 12 a.m., 
 temperature was 100° ; at 4 a.m., 100° ; and at 8 a.m., 102-8°. 
 Iced enema was given at 10 o'clock and was well retained ; at 
 11 a.m. temperature 101°. Patient did not sleep well last night, 
 and was very fretful. Bowels acted this morning ; stool loose, 
 yellow, and offensive. Had 4 grains of calomel last night. 
 Tongue is rather dry this morning. Pulse at wrist can hardly 
 be felt and cannot be counted. Heart sounds very feeble and 
 irregular. There is no appreciable dulness on percussion over 
 
156 THE TREATMENT OF TYPHOID FEVER. 
 
 lungs ; some moist r^les and rhonchi can be heard. Cough is 
 not accompanied by any crepitation. Ears have been syringed 
 this morning ; very slight discharge from right ear which was 
 sweet. Abdomen is not distended, no pain or tenderness. 
 Knee-jerks present, no ankle clonus. Naphthol powders 
 renewed without salicylic acid. 
 
 November 20th (eleventh day of relapse). On the right hip 
 there is a bed sore just forming, about the size of half-a-crown. 
 Has not had any fish for the last four days. Ordered mutton 
 broth and two ounces of butter. 
 
 November 21st (twelfth day of relapse). Slept very well 
 last night. Had iced enema at 8 p.m. Temperature at 12 a.m., 
 100^ ; at 4 a.m., 101-2° ; at 8 a.m., 102-6°. Pulse is very small, 
 weak and compressible, difiicult to count, about 136. Tongue 
 fairly moist. Bowels acted this morning very slightly, motion 
 yellow, and loose. No discharge from right ear. A few 
 rhonchi and some crepitant rales can be heard over back of 
 chest, but are not numerous. Knee-j erks present , no ankle clonus. 
 She says she feels better, and she looks brighter and more 
 cheerful. Heart sounds are still very irregular. On right hip 
 there is a bed sore just forming, and on right side, quite close 
 to fold of nates, there is a large red abraded surface which bled 
 slightly this morning. She is at present taking only milk ; 
 she does not like Benger's food. 
 
 November 23rd (fourteenth day of relapse). Has had about 
 three pints of milk during last 24 hours, exact quantity not 
 measured. Had one feeder of mutton broth. Did not sleep 
 very well. Had iced injection last night at 10-45 which was 
 only retained for about five minutes. Bowels acted soon after 
 it was given. Had another iced enema this morning at 9-30. 
 Bowels acted soon after receiving it, and she complained of 
 pain in abdomen. Tongue is dry. Pulse 140, regular and more 
 easily counted. Temperature at 8 a.m. 102°. Right heel is 
 rather sore ; there is a raw surface about size of a crown piece. 
 Nourishment for last 24 hours, viz., milk, 38 oz. ; Benger's food 
 with milk, 30 oz. ; gruel, 10 oz. ; mutton broth, 15 oz. ; butter, 
 2 oz. November 24th. Net weight 96 lb. 
 
CASES TREATED IN THE TANK. 157 
 
 November 28th (nineteenth day of relapse). About 11 p.m. 
 I saw the patient, who was then in a very collapsed condition. 
 Temperature at 10.30 in rectum 96° ; temperature of tank 93°. 
 Respirations 24, laboured and sighing. Pulse very weak and 
 compressible. Patient is in a drowsy, stupid semi-conscious 
 condition. At 11-30 temperature in rectum 97 '8° ; temperature 
 of tank 95°, raised to 100°. 
 
 November 29th. 1 a.m., rectal temperature 99'4°. She was 
 taken out of tank as her breathing had become much 
 worse. She was quite unconscious, conjunctivfe completely 
 insensible to touch, pupils normal. She appeared to be dying. 
 Atropine /„ grains, (two injections with interval of quarter-of- 
 an-hour). Aether (n^xxx.) hypodermically. Caffeine, 3 grains, 
 hypodermically. Strychnine liquor, TT]^x., repeated in about 20 
 minutes. Hot tins applied to feet and legs. Hot stupes 
 applied to heart. She rallied wonderfully after this ; pulse 
 became stronger ; conjunctivae responded to touch. Tem- 
 perature at 1.45 a.m., 98-2° in axilla; at 2.15 a.m., 98*8 ; at 
 2.45 a.m. she became suddenly worse and died. 
 
 November 30th ; Noon. Post Mortem. 
 
 Rigidity present ; slight lividity of posterior surface. The 
 body is spare, but there is no extreme emaciation, and there 
 is slight oedema of subcutaneous tissue of lower extremities. 
 There is an abrasion of the skin over sacrum, and right 
 heel. On laying chest and abdomen open there is a layer 
 of subcutaneous fat varying from a quarter to half-inch 
 in thickness, and there is also a considerable amount of 
 fat in omentum and mesentery. Left lung weighs l^lb., slightly 
 oedematous ; structure healthy, save some emphysema along 
 anterior margin. Right lung weighs 17| ounces, is slightly 
 oedematous ; marked emphysema of upper lobe ; no pleuritic 
 adhesions. Kidneys : right weighs 7^ ounces, capsule strips 
 easily, section pale and slight fatty infiltration. Left weighs 
 5| ounces, and is similiar in appearance to right. Heart 
 weighs nine ounces ; right side contains small quantity of 
 rather light coloured fluid blood, and a small decolourized clot, 
 extending from right auricle into pulmonary artery. The 
 
158 THE TREATMENT OF TYPHOID FEVER. 
 
 walls of right auricle and ventricle are thin and infiltrated 
 with fat; the musculi papillares are pale, and contain some 
 fatty striation ; the tricuspid orifice admits five fingers ; 
 tricuspid, and pulmonic semi-lunar valves are healthy. Left 
 vent, contracted and empty ; muscular structure pale, otherwise 
 healthy ; mitral orifice admits three fingers ; mitral and aortic 
 semi-lunar valves normal. Liver weighs 5 lb., section pale, 
 and feels greasy to touch. Spleen weighs 16^ ounces; soft, 
 friable, and almost diffluent, of a deep chocolate colour. There 
 is no distension of the bowel. At sigmoid flexure the bowel 
 is much contracted, but lumen not closed, and on laying open 
 this portion it was found quite healthy, could be readily 
 stretched, and showed no sign of stricture. At lower part of 
 jejunum, and upper part of ileum, Peyer's patches were 
 distinctly marked, but were smooth and not elevated above 
 surface, and were evidently in an advanced stage of resolution. 
 Lower down the ileum, and especially towards lowest part, 
 Peyer's patches and solitary glands were distinctly ulcerated ; 
 many of them were in various stages of advanced resolution, 
 while others presented a punched out appearance, with 
 thickened margins. The peritoneal surface over these latter 
 ulcers were markedly injected, but not thickened. There were 
 several small ulcers in the caecum and ascending colon. The 
 rest of the colon was healthy. 
 
 Case 22. Very severe case of Typhoid Fever; Double Pneu- 
 monia; Leiter's tubes applied for four days; In the tank 
 for nineteen days; Cold water enemata ; Cure. 
 
 Joseph L, Dean, aged 22, fireman, admitted to hospital, 
 November 24th, 1890. The exact date of the commencement 
 of his present illness is rather difficult to fix, but as reckoned 
 from the commencement of headache this would be the twelfth 
 day. About three weeks ago he suffered from a severe cold in 
 the head which he treated with rum and milk ; this was 
 followed by pains across the top of his chest and the headache 
 above alluded to. For the last six days he has been confined 
 to bed. He is a well nourished, well developed man, of dark 
 
CASES TREATED IN THE TANK. 159 
 
 complexion, with flushed face and anxious expression. Skin 
 hot and dry. Temperature in axilla at 4 p.m. 105°. Eyes 
 glistening. Tongue moist and very tremulous, coated with a 
 white fur, and papillse rather prominent. The abdomen is 
 much distended ; there are a few rose spots. After 4 grains of 
 calomel the stool was loose, offensive, and acid in reaction. He 
 has a frequent cough with viscid mucous expectoration. There 
 are numerous bronchitic rales heard all over chest. Net weight 
 1511b. 
 
 November 25th (thirteenth day). Vomited twice during 
 the night. Pulse 100, markedly dicrotic. He is very thirsty 
 and drinks large quantities of milk. His diet consists of four 
 pints of milk, eight ounces of bread, and two ounces of butter. 
 Y^. /3-naphthol, gr. x., every four hours. His temperature to-day 
 remained about 103°, except at noon, when it fell to 100° for a 
 a very short time. Urine alkaline, sp. gr. 1027 ; no albumen ; 
 gives a deep purplish colour with Ehrlich's test. 
 
 J. L. D., 25-11-90 ; Pulse 102 ; Pressure 2^ ozs. 
 
 November 26th. Pulse 96 to 108, markedly dicrotic. Respira- 
 tions 30. Knee-jerks present, no ankle clonus. Temperature 
 to-day 102"2° to 104'2°; mean 103'3°. Ordered one pint of mutton 
 broth, and three table spoonfuls of extract of malt daily. 
 
 November 27th (fifteenth day). He had 10 minims of 
 nepenthe, and slept fairly well. Tongue dry ; abdomen distended. 
 Dull percussion at base of right lung, numerous bronchitic 
 rales over chest. Mean temperature 104'2°. 
 
 November 28th. About 9 p.m. last night his abdomen was 
 covered with 24 yards of india-rubber tubing, through which 
 a constant stream of water at a temperature of 40° has since 
 flowed. His temperature at midnight was 104"6° ; at 8 a.m. it 
 was 101°, and during the day remained rather below that 
 
160 THE TREATMENT OF TYPHOID FEVER. 
 
 level. Pulse 116, soft and dicrotic. Tongue dry, sordes on 
 lips and teeth. The dull percussion at right base is extending, 
 and there is now also dulness at left base ; at both bases E. M. 
 is feeble, and there are small crepitant rales. Abdomen 
 distended and tympanitic. Calomel, 3 grains. 
 
 November 29th (seventeenth day). He had 15 minims of 
 nepenthe and slept fairly well. Vomited twice curdled milk 
 mixed with blood. Tongue dry, furred, and fissured, sordes on 
 lips and teeth. There are considerable dyspnoea, and general 
 uneasiness. Alee nasi are dilated in inspiration. There is now 
 dull percussion over the whole of the lower lobes of both lungs ; 
 over this area the R. M. is defective, expiration prolonged, 
 numerous crepitant rales in inspiration, and loud snoring 
 rhonchi both in inspiration and expiration. In front of chest 
 there are some rhonchi, expectoration streaked with blood. 
 Abdomen is still much distended and tympanitic. Motions 
 loose, yellow, and offensive. Knee-jerks are well-marked, no 
 ankle clonus ; ordered mustard poultice to back of chest. One 
 table-spoonful of charcoal three tipies a day. 
 
 November 30th. He had a fairly good night after getting 
 
 15 minims of nepenthe. His temperature fluctuated a little 
 
 •yesterday, and at midnight ran up to 104°. To-day it ranged 
 
 between 102° and 104°. Pulse 128. Respirations 40. Dorsal 
 
 decubitus. 
 
 J. L. D., 30-11-90 ; Pulse 128 ; Pressure 2^ ozs. 
 December 1st (nineteenth day). He had a very restless 
 night. Urine and f^ces passed involuntarily; motion loose, 
 yellow, and alkaline. Dorsal decubitus. He is in a drowsy 
 stupid condition. Over both lower lobes percussion very dull, 
 crepitant rales and rhonchi. In front there are coarse rhonchi 
 and a few crepitant rales. Respirations 44. Pulse 132, very 
 
CASES TREATED IN THE TANK. 
 
 161 
 
 dicrotic. Tongue dry and fissured. Sordes on lips and teeth. 
 Cheeks flushed. Abdomen distended. Splenic dulness measures 
 5f by 4f inches. Temperature, 4 a.m., 103°; 8 a.m., 104-8°; 12 
 noon, 103-8°: 4 p.m., 103-2°: 8 p.m., 104°. Net weight 139 lb. 
 
 J. L. D., 1-12-90 ; Pulse 124 ; Pressure 2 ozs. 
 December 2nd. He was placed in the tank at 7-30 yesterday 
 evening at 90°, and would have been immersed much sooner 
 only the tank room was occupied by the last patient till the 
 29th ult., and afterwards required some alterations. He is 
 comfortable in the water. Tongue still dry and rough. Pupils 
 contracted. Face flushed. Pulse not so dicrotic. Temperature 
 steadily fell throughout the day, and by midnight it was normal. 
 
 J. L. D., 2-12-90 ; Pulse 114 ; Pressure 3 ozs. 
 December 3rd (twenty-first day). He had a good night. 
 Tongue moist. Pupils rather contracted. Pulse more frequent 
 and dicrotic. Tank 94°. His temperature fluctuated to-day, the 
 records being, 99-8°, 99-2°, 98-6°, 97-8°, 100°, 101-2°. Ordered 
 3 grains of caflTeine, and 2 grains of quinine every four hours. 
 
 J. L. D., 3-12-90 ; Pulse 136 ; Pressure 4 ozs. 
 December 4th (twenty-second day). The condition of this 
 patient has not materially altered since yesterday. He 
 
162 
 
 THE TREATMENT OF TYPHOID FEVER. 
 
 a restless night, and was occasionally delirious. His face is 
 now much flushed, and of a slightly purplish hue. Tongue 
 clean and moist, but of a dark livid colour. He is taking 
 nouiishment well. Bowels have been slightly opened. There 
 is considerable muscular tremor, but very little shivering to- 
 day. His respirations are quieter, and he is only occasionally 
 troubled with cough. Pulse rapid and very hyper-dicrotic. 
 Abdominal distension less. Splenic dulness measures 5j by 4 
 inches. Over lower lobe of right lung the percussion is abso- 
 lutely dull: breathing tubular and coarse crepitant rales in 
 inspiration. There are the same phenomena over the left 
 lower ^obe as high as the sixth dorsal spine. Heart's action 
 rapid : first sound double, but moderately clear : the second is 
 accentuated at the pulmonic cartilage. Urine alkaline, sp. gT. 
 1017, albuminous, and gives Ehrlich's reaction. Add half-a- 
 grain of pulv. dig-italis to each powder of quinine and caffeine. 
 
 J. L. D., 4-12-90 ; Pulse 120 ; Pressure 3 ozs. 
 December oth. His temperature ran up last night, and at 
 10-45 it was 108' in rectum. Pulse 140. Respirations 48. 
 He then received an enema of a pint and-a-half of iced water 
 and half-a-pint of peroxide of hydrogen. At 12-30, temperature 
 in rectum, 101'2' : at 4 a.m., 101'": and at 8 a.m., 99"6"'. He 
 was very restless and delirious during the night. He tried to 
 get out of the tank. Pupils are contracted. Bowels acted 
 last night and this morning. Tongue moist, but rather livid. 
 Cheeks flushed, of a purple colour. Pulse 128, stronger. 
 Respirations 82. He takes his nourishment well, and says 
 he feels better to-dav. Muscular tremor well marked. 
 
 J. L. D,, 5-12-90 ; Pulse 132. 
 
CASES TREATED IN THE TANK. 163 
 
 December 6th. The condition of this patient has consider- 
 ably improved during the past two days, though he is still in 
 a very dangerous condition. His face is flushed, but is not so 
 purplish as before. He is still restless, and rambles a good deal. 
 Pupils contracted There is a general muscular tremor, but not 
 much shivering. Pulse 126, quick, and markedly dicrotic. 
 Respirations 32, shallow, but less laboured than previouslj". 
 Heart's action quick, sounds moderately clear, first double, 
 second accentuated at pulmonic cartilage. He is not disturbed 
 for examination of lungs. Abdomen still distended, though 
 less than before. Splenic dulness oi by 4 inches. Knee-jerks 
 exaggerated. Marked ankle clonus in both feet. There is also 
 ready reaction of triceps at elbow joint. His temperature 
 at midnight was 102°. The tank was then lowered to 90°, and 
 by noon to-dav his temperature was 98"8°. 
 
 g 
 
 imii 
 
 
 JtMisBs^aii^jaiBg EniiM ii IB 
 
 SB 
 
 J. L. D., 6-12-90 ; Pulse 126 ; Pressure 4 ozs. 
 
 December 7th (twenty-fifth day). At ten last night patient 
 was in a very bad, anxious condition. Temperature 103'2°. 
 Pulse 140. Respirations 36. I gave him an enema of iced water 
 and peroxide of hydrogen, which however he did not retain 
 for many minutes. The tank was 94° ; I had it emj)tied and 
 refilled with a stream of water at 90° running over the patient. 
 Patient's temperature at 12-20 a.m., 1021°; 2-20 a.m., 102-3°. 
 He had another iced enema, and the tank was emptied and 
 refilled with a stream of water over the patient, at 90°. At 5 a.m., 
 patient's temperature 101 '8°; tank 90°. At 7-40, temperature 
 101-8°: tank 90°. Pulse 120. Respirations 38. Taking nourish- 
 ment well. In a drowsy condition all night, spoke sensibly 
 when roused, but muttered in his sleep. Ten grains of salicylic 
 acid every four hours are now substituted for the naphthol. 
 
164 
 
 THE TREATMENT OF TYPHOID FEVER. 
 
 nHMHl^B^lVnMIHHin 
 
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 IMI^I^BIBlMBIMWTgMWBiaWiaWWIBWMi 
 
 vm 
 
 J. L. D., 7-12-90 ; Pulse 132 ; Pressure 3 ozs. 
 
 December 8th. He rambled a good deal during the night, 
 but this morning is in much the same condition as yesterday. 
 Temperature to-day 99-8" to 101 •8". 
 
 J. L. D., 8-12-90 ; Pulse 126 ; Pressure 4 ozs. 
 
 December 9th (twenty-seventh day). He does not seem so well 
 this morning. Breathing more laboured. Face flushed. Tongue 
 moist, coated with a thin semi-viscid layer of mucus. He is 
 languid and arowsy, and doses with eyelids only partially closed. 
 There is frequent lateral movements of the lower jaw, and he 
 seems to roll his tongue towards the left buccal cavity. Mean 
 temperature to-day 100-2'. Pulse 124-132. Respirations 32-38. 
 
 J. L. D., 9-12-90 ; Pulse 124 ; Pressure 3^ ozs. 
 December 10th (twenty-eighth day). He had a good night, 
 and took nourishment well. Bowels have acted freel}^ ; 
 motions loose, yellow, and offensive. Tongue quite moist : face 
 flushed ; pulse 116 : respirations 32 : temperature to-day, 996°- 
 101 "6°. The percussion is still impaired, but not so absolute as 
 formerly over the right lower lobe and the lower half of the 
 left lower lobe. Over these areas the breathing is markedly 
 
CASES TREATED IN THE TANK. 
 
 165 
 
 tubular ; inspiration, accompanied by coarse crepitant rales, 
 and the V.R. and V.F. are increased. Butter is, to-day, 
 increased to 4 ounces. Ordered ten grains of salol every four 
 hours, in place of salicylic acid. 
 
 J. L. D., 10-12-90 ; Pulse 126 ; Pressure 3i ozs. 
 
 December 11th. He slept well, no delirium, and is decidely 
 better this morning. Tongue moist ; pulse 126 : respirations 
 26 ; temperature 99° to 100°. 
 
 J. L. D., 11-12-90 ; Pulse 130 ; Pressure 4 ozs. 
 
 December 12th. Rather better to-day. 
 
 December 13th. He had a good night, and has not 
 been delirious for two days. Bowels acted freely this 
 morning. Heart's sounds dull, second sound accentuated. No 
 enlargement of cardiac area. Percussion over lower lobes 
 impaired, though much less dull than it was : respirations less 
 frequent. Still numerous crepitant rales over both lungs, 
 especially the right. Digitalis, quinine, and caffeine powders 
 stopped. 
 
 J. L. D., 13-12-90 ; Pulse 144 ; Pressure ,3^ ozs. 
 
166 
 
 THE TREATMENT OF TYPHOID FEVER. 
 
 December 15th. The powders of qumine, caffeine, and digi- 
 talis are]_to be resumed every six hours. 
 
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 J. L. D., 15-12-90 ; Pulse 120 ; Pressure 3^ ozs. 
 December 16th (thirty -fourth day). He had an excellent 
 night, and seems quite easy this morning. Respirations 20, 
 quiet. Pulse 120, soft and dicrotic. Bowels well moved 
 yesterday, and slightly this morning : motions loose, yellow, 
 and offensive. Knee-jerks and ankle clonus present. 
 
 
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 Mur 
 
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 J. L. D., 16-12-90 ; Pulse 116 ; Pressure 4 ozs. 
 
 December 20th. He seems very quiet and comfortable this 
 morning. Tongue moist ; face flushed. Eyes clear, pupils 
 moderately contracted. Pulse 124. Temperature normal. 
 
 December 21st. He was taken out of the tank at 7-30 last 
 night. Net weight 119 lb., showing a loss of 20 lb. in the tank, 
 and 321b. since his admission to hospital. He was rather 
 restless last night. Respiratory sounds in front of chest are 
 normal. Posteriorly there is some dulness at right base, and 
 at left base the percussion note is impaired : over rest of lungs 
 percussion resonant. There are no rales. Respiratory 
 murmur at right base is feeble, but otherwise fairly normal. 
 Heart's first sound is double. Knee-jerks present ; slight 
 ankle clonus on right side, but not on left. 
 
 December 23rd. This patient having lost 20 lb. during the 
 twenty days in the tank, and 12 lb. during the preceding seven 
 days in hospital, and having passed through such a serious 
 illness, is now in a very weak but not entirely helpless 
 
CASES TREATED IN THE TANK. 
 
 167 
 
 condition. His eyes are bright, countenance clear with pinkish 
 flush on cheeks. His colour has remained good during his 
 illness and there is now no evidence of anasmia. He sleeps 
 very well, and is taking his liquid nourishment well. He 
 complains of hunger. Tongue clean and moist. Bowels rather 
 constipated, but with enema the motion was semi-solid, alkaline, 
 and rather ofl'ensive. The urine when last examined contained 
 a little albumen, and only gave a slight rosy tint with Ehrlich's 
 test. His body is much emaciated, there is now no distension 
 of abdomen. Knee-jerks are lively, but there is only slight 
 ankle clonus. Pulse quite regular, moderately full, and reveals 
 both to finger and sphygmograph full dicrotism. Heart : apex 
 beat in fifth interspace, in nipple line ; deep transverse dulness 
 measures 6 inches, and vertically reaches to the upper border 
 of third rib. The impulse is moderately strong, and in second 
 left interspace, close to the sternum, a distinct snap can be felt 
 synchronous with the closure of the pulmonic valves. The first 
 sound is dull and duplicated, the first element of which is 
 loudest over the right ventricle ; the second pulmonic sound is 
 clear and accentuated ; at the aortic cartilage the second sound 
 is duller but still very distinct. Lungs : respirations are quiet, 
 and he is not now troubled with any cough. Over lower half 
 of back there is still marked evidence of the mustard plaster 
 which was applied in the earlier part of illness. The percussion 
 is fairly clear over the whole back, the breathing is loud and 
 harsh, and of a vesicular character, but otherwise free from any 
 accompaniments. Splenic dulness measures 4 by 3^ inches. 
 Hepatic dulness measures 5 inches in lines of nipple and 
 axilla, and 4 inches in line of sternum. There is considerable 
 maceration of the skin of palms and soles. Fish diet. 
 
 ■roSMA^BMIilMt^BBSIWiii 
 
 J. L. D., 23-12-90 ; Pulse 106 ; Pressure 3 ozs. 
 Jan. 1st, 1891, first sound of heart still double. Ordinary 
 
168 THE TREATMENT OF TYPHOID FEVER. 
 
 diet. Jan. 3rd, Caffeine and digitalis powders stopped as 
 heart's action is now only 68. Jan. 5th, net weight 130 lb. 
 First cardiac sound still double. Jan. 15th, net weight 131| lb. 
 Jan. 23rd, net weight 1401b. Feb. 3rd, net weight 1541 lb. 
 Feb. 4th, discliarged quite well. 
 
 DESCRIPTION OF THE TEMPERATURE 
 CHARTS. 
 
 In illustration of the effects of the tank on the temperature 
 two charts are here published. Cases 4 and 22 have been 
 selected, as they were very severe and complicated. The 
 temperatures daily recorded were taken at 4 a.m., 8 a.m., 12 
 noon, 4 p.m., 8 p.m., and 12 midnight. 
 
 Case 4 was put in the tank on the afternoon of the twelfth 
 day of the disease ; she was taken out on the twenty-fourth 
 day, and left out for three days. She became much worse, and 
 she was replaced in the tank on the twenty-seventh day. She 
 was then kept in the tank till the thirty-first day, after which 
 convalescence was quickly re-established. The daily exacerba- 
 tions of temperature during the periods of immersion, chiefly 
 occurred when she was out of the tank while it was being 
 cleaned. 
 
 Case 22 had Leiter's tubing with a stream of iced- water 
 appHed to his abdomen, from the evening of the fifteenth to 
 the evening of the nineteenth day. During the first two days 
 there was a great fall in the temperature, but it then rose to 
 its former level. On the evening of the nineteenth day he 
 was placed in the tank, and kept in it till the afternoon of the 
 thirty-eighth day. In the tank period the daily exacerbations 
 frequently occurred when he was out of the tank while it 
 was being cleaned : but at other times the tank had not a 
 sufficiently controlling influence over his temperature, and then 
 he received enemata of iced-water, and j)eroxide of hydrogen. 
 

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CASES TREATED WITH WET-PACKS, ICE- 
 BAGS, COLD COMPRESSES, &c. 
 
 Case 23. Severe case of Typhoid Fever ; Hcemorrhage ; Iced 
 Compresses to Abdomen ; Cure. 
 
 Genaro E., aged 18, sailor, admitted July 19th, 1890. He is a 
 Spaniard, unable to speak English. He was brought from a 
 Spanish vessel in the ambulance, with the history that he had 
 been ill for a week. He is weak and apathetic. Tongue fairly 
 clean and moist." He has no appetite, and is very thirsty. 
 Motions loose, yellow, neutral, and offensive. Temperature, 
 101° to 102°. Pulse 96. Respirations 26. Heart and lungs 
 healthy. There are a few rose spots on abdomen which 
 disappear on pressure. Splenic dulness enlarged. No ankle 
 clonus, and knee-jerks not elicited. Ordered four pints of milk 
 daily. Net weight, 106 lb. 
 
 July 21st. Urine acid, sp. gr. 1025, albuminous. Ordered 
 boiled bread and milk ; 6 grains of /3-naphthol, every four 
 hours. 
 
 July 26th. Progressing favourably. Urine acid, sp. gr. 
 1024, no albumen. Temperature ranges from 99° to 102°. 
 
 August 2nd (twenty-second day). His temperature has been 
 rarely over 102°, and there is a prolonged daily remission to 
 normal. Urine acid, sp. gr. 1024, no albumen. Bowels rather 
 constipated throughout illness, and had frequent enemata. 
 
 August 11th (thirty-first day). This morning there was a 
 severe attack of epistasas. Pulse, which has only been 60 to 
 72 for nine days, is now 88. Temperature normal. Urine 
 acid, sp. gr. 1020, no albumen. 
 
 August 12th. There has been another severe attack of 
 epistaxis to-day. Pulse 108. Temperature 97°-100°. Ordered 
 ten minims of turpentine, and two grains of caffeine every three 
 hours. 
 
 August 13th (thirty-third day). There has been another 
 sharp attack of epistaxis, and severe hsemoi-rhage from the 
 
172 THE TREATMENT OF TYPHOID FEVER. 
 
 bowels. The total loss of blood must have been very consider- 
 able, as the patient is now blanched, and there are numerous 
 petechial and small subcutaneous haemorrhages over the 
 abdomen. Pulse 116, quieter, small, and dicrotic. Temperature 
 99°-100"6°. Tongue slightly furred and rather dry. He is 
 taking liquid nourishment well. Motions very loose, but not 
 very offensive. Abdomen not distended. Hepatic dulness 
 normal. Splenic dulness 5 by 3f inches. Heart sounds dull 
 and feeble. No ankle clonus. Knee-jerks can be easily elicited. 
 Ordered iced compresses to abdomen. 
 
 G. E., 13-8-90 ; Pulse 124 ; Pressure 2h and 3 ozs. 
 
 August 14th. He slept fairly well after 15 minims of 
 laudanum. Bowels acted freely, motions dark coloured, but no 
 fresh hemorrhage. Pulse stronger. Purpuric spots more 
 numerous. 
 
 August 15th. Bowels acted five times yesterday afternoon 
 and eveninc, motions dark with blood. He had a starch and 
 laudanum enema : there have been two motions this morning, 
 streaked with blood. Tongue dry. Pulse 96, stronger. No 
 more epistaxis : continue iced compresses. 
 
 August 16th. He slept well, and is taking nourishment 
 better. Bowels have not acted for last 24 hours. Tongue dry 
 and furred. Temperature subnormal. Pulse 76. 
 
 August 19th. He is much better. No blood in motion since 
 the 15th, and his temperature has been normal since the 14th. 
 Pulse 72. Purpuric spots fading. No ankle clonus, cannot 
 elicit knee-jerks. His temperature ran up to a 100'4° this 
 morning, but afterwards remained normal or subnormal. His 
 bowels have usually been constipated, and he required frequent 
 enemata. 
 
 August 26th. Net weight 107 1 lb. Ordered fish diet. 
 
CASES TREATED WITH THE WET-PACK, ETC. 173 
 
 August 27th. Up to-day for an hour. 
 
 August 30th. Ordered chicken. 
 
 September 2nd. Net weight 105| lb. 
 
 September 3rd. Placed on ordinary diet. IjL Ferri et Amnion. 
 Cit., gr. X. Potassse Citrat., gr. xv. Sp. Chloroformi, ij\js.. 
 Aq. ad §i. To be taken thrice daily after meals. 
 
 September 7th. Net weight 1101b. 
 
 September 8th. Discharged to-day quite well. 
 
 Case 24. Moderately severe case of Typhoid Fever ; 
 HcBinorrliage ; Iced Compresses to Ahdomien ; Cure. 
 
 John Francis R., aged 19, labourer, admitted to hospital 
 September 8th, 1890. His present illness began about three 
 weeks ago with diarrhoea, but although he felt ill, he continued 
 at work till four days ago, when he took to bed and remained 
 there until to-day, when he walked a short distance to the 
 Stanley Hospital, where he was seen by Dr. Bradshaw, who 
 diagnosed typhoid fever, and sent him here under my care. 
 His temperature on admission was 102'6°, and rose at midnight 
 to 104"4°. Ordered four pints of milk, and peptonised bread 
 and milk. 
 
 September 9th. Tongue furred but moist. There is con- 
 siderable diarrhoea ; motions liquid, alkaline, and brownish. 
 Pulse small and weak. Heart's sounds clear. He has a slight 
 cough, but no expectoration. There are a few cooing rhonchi 
 all over the chest ; spleen enlarged ; abdomen rather tense and 
 distended, and tender over the lower part. Knee-jerks 
 present ; no ankle clonus. Net weight 106 lb. 
 
 September 10th (twenty -third day, approximately). He 
 had a drachm of bromidia, but slept badly, and was very restless. 
 He had ten motions yesterday, and during the night there 
 was very free hfemorrhage from the bowels. He had an 
 enema of starch and laudanum, and was ordered 15 minims of 
 oil of turpentine, every three hours. 1 ongue dry and furred. 
 Pulse 96, small, weak and soft. Ordered iced compresses to 
 abdomen, which is tense and distended. Temperature this 
 morning fell to 99°, but rose in the evening to 102"8''. He 
 
174 THE TREATMENT OF TYPHOID FEVER. 
 
 had fifteen loose motiotis to-day, but after the sixth there was 
 no blood. 
 
 September 11th. At 10.45, last night, he had a starch 
 enema, with 15 minims of laudanum : but he was very restless 
 till 2 a.m., when he had 15 minims of nepenthe. He then 
 slept till 6 a.m. Motions brownish, watery, and alkaline ; 
 Tongue very dry ; abdomen quite flat. Continue iced com- 
 presses. There were marked evening exacerbations of 
 temperature, with remissions in the morning to nearly normal, 
 until September 19th. 
 
 September 23rd. Net weight 96 lb. I^ Caffeinse, gr. ii. 
 Tinct. Cinchonse Co., n]^xxx. Aq. Chloroformi ad §i. To be 
 taken every fourth hour. 
 
 September 27th. Beef tea, fish, and rice. 
 
 October 4th. Chicken. 
 
 Net weights: Setember 30th, 981b.: October 13th, 1091b. 
 Discharged on this day quite well. 
 
 Case 25. Typhoid Fever ; Wet-pack for 5 days ; Cure. 
 
 Annie R., aged 6 years, (child of case 21), admitted to 
 hospital October 1st, 1890. She is a delicate-looking poorly 
 nourished child, suifering from typhoid fever of nine days 
 duration. Temperature 103"^ Ordered 3 pints of milk, and 
 peptonised bread and milk. 
 
 October 2nd (fourth day). Net weight 39^ lb. She had 
 four loose alkaline motions to-day. I^ Bismuthi subnitrat., 
 gr. V. ^-naphthol, gr. v. Fiat pulv. Sig. : One every four 
 hours. 
 
 Her temperature steadily declined from 103", on night of 
 admission, to 96-4°, at 4 and 8 in the morning of the 3rd. Her 
 temperature rose to 101-2° on the eleventh day, and 102-8° on 
 the twelfth day. She was then placed in the wet-pack, which 
 was continued for two days. On the sixteenth day her 
 temperature had again become subnormal, and there was well- 
 marked ankle clonus. On the twenty-first day she weighed 
 401 lb. Her temperature remained normal from the 16th to 
 the 23rd, when there was a rise to 101°, and the febrile move- 
 
CASES TREATED WITH THE WET-PACK, ETC. 175 
 
 merit between 99° and 101° continued for four days. On the 
 twenty-fourth day the w^et-pack was resumed, and continued 
 till the twenty-seventh day. On the thirty-second day she 
 weighed only 37| ] b. From this time the improvement 
 was uninterrupted. On October 26th ( thirty-fourth day ), 
 she got fish diet ; and on October 27th, ordinary diet. On 
 October 31st she weighed 41 lb., and she was discharged quite 
 well on November 4th, 1890. 
 
 Case 26. Prolonged case of Typhoid Fever ; Wet-pack ; Cure. 
 
 Thomas J., aged 22, sailor, admitted to hospital October 7th, 
 1890. His present illness began in Roumania, about a month 
 ago, and he ascribes it to drinking the Danube water. He has 
 suffered from severe diarrhoea, from twelve to fifteen motions 
 each day, since his illness began. He was treated by the 
 Captain of the vessel with diarrhoea mixture. He is a well 
 developed man but now much emaciated, very weak, and 
 anaemic. Temperature on admission 100°, and in the evening 
 101°. Pulse 104. During the first 24 hours he had eleven 
 loose, alkaline, and very offensive motions. Tongue moist and 
 pale ; mucous membranes very anaemic ; pupils dilated. Heart's 
 sounds dull and feeble ; lungs healthy. Splenic dulness 6 by 4 
 inches. Net weight 128^ lb. Ordered milk diet; ten grains 
 of ^-naphthol, every four hours. 
 
 His temperature for the first five days usually ranged from 
 99° to 101°, the highest being 102° in the evening of October 
 11th. From this time it remained normal, and his condition 
 improved until the 21st, when there was a rise of tempera- 
 ture. On the l7th he was placed on ordinary diet, and 
 got a mixture of caffeine and cinchona. On, the 22nd he was 
 ordered ten grains of quinine. On the 23rd, when his tempera- 
 ture reached 101°, he was placed in the wet pack. This was 
 discontinued in three days when his temperature became 
 normal. On November 1st he was ordered two ounces of 
 butter. On November 3rd he had a slight rigor (during which 
 his temperature reached 101°), followed by profuse sweating. 
 He got four grains of quinine every four hours. From this time 
 
176 THE TREATMENT OF TYPHOID FEVER. 
 
 his temperature remained normal. He had several doses of 
 calomel during his illness. His net weight was, on November 
 3rd, 129 lb. ; 7th, 131^ lb. ; 14th, 140i lb. Discharged November 
 I7th, quite well and strong. 
 
 Case 27. Severe case of Typhoid Fever ; Wet-pack for eleven 
 
 rlxiys ; Cure. 
 
 Eobert B., aged 25, packer, admitted October 16th, 1890. 
 This patient was sent in by Dr. G. G. Stopford Taylor, from 
 whom I got a full account of the history of the case, of which 
 the foliowing is a brief abstract. About the middle of August 
 the patient suffered from a severe attack of coryza accompanied 
 by a troublesome cough. A few days after the commencement 
 of his illness he bathed in the Dee : this was followed by 
 suppurative inflammation of left middle ear with rupture of 
 the membrana tympani, and a very free discharge of blood and 
 pus. The right ear was also affected, but there was no suppura- 
 tion. On August 20th he visited St. Paul's Eye and Ear 
 Infirmary, and after a time his ears got gradually better. Once 
 or twice during this illness he passed a quantity of blood per 
 rectum. His temperature, however, was never high, and 
 crenerally about normal. He continued very weak for some 
 time, complaining of indefinite pains, slight headache and 
 earache. About three weeks ago he improved so much that 
 he was advised to go to the convalescent home at Woolton. 
 He did well there for the first ten or twelve days, but the 
 dav before leaving (Thursday) he felt pains in the limbs 
 au'l abdomen, and was very shaky. He ascribed this to 
 having caught cold, as he was unable to keep himself warm 
 in bed. 
 
 On Friday, October 10th, he called on Dr. Taylor, and on 
 the 11th, took to bed. He complained principally of severe 
 headache, pains in the abdomen and limbs. He also passed a 
 little blood per rectum. Temperature 103^ On Sunday and 
 Monday he felt much about the same, headache, pains in all 
 his limbs and back. Sometimes he felt rather chilly, and at 
 others was sweating profusely. Temperature 103° to 104°. 
 
CASES TREATED WITH THE WET-PACK, ETC. 177 
 
 On Tuesday there was severe hgematuria, and he was sent to 
 hospital on Thursday, October 16th. 
 
 On admission he was very prostrate, face dusky, anxious 
 expression. Eyes dull, pupils dilated: skin hot and dry, tempera- 
 ture 103°. Tongue moist, coated with a thick white fur, 
 tremulous. Pulse soft and compressible. Slight cough with 
 scanty expectoration. Bowels constipated ; urine acid, sp. gr. 
 1017, contains albumen and blood. Ordered 4 pints of milk 
 and 12 ozs. of bread. Calomel 4 grains. 
 
 October 18th (tenth day). Temperature 103°-104^ Pulse 
 100-112. Motions loose, yellow, and alkaline. Urine neutral, 
 sp. gr. 1020, albumen and blood, with Ehrlich's test gave a 
 bright red colour. Ordered 10 grains of periodate crystals 
 every four hours. Net weight 124 lb. 
 
 October 21st. Mean temperature since last note 103"2°. Pulse 
 96. Respirations 36. Urine alkaline, sp. gr. 1015, no albumen 
 and no blood. Motion loose. Placed to-day in wet-blanket. 
 
 October 24th. The wet blanket has had very little effect 
 on the temperature, and to-day it is changed for a wet-sheet. 
 
 October 26th. He did not sleep well. Tongue very dry. 
 Pharynx and tonsils dry and glazed, he has almost lost his 
 voice. His temperature has been about a degree lower since 
 wet-sheet was adopted (101°-103"6°). Pulse 96. Dry rhonchi 
 heard all over chest. He ta.kes liquid nourishment well. 
 
 October 31st (twenty-third day). This patient's condition 
 since last note is fairly indicated on the temperature chart. 
 He has been rather listless, but often expresses dislike for the 
 wet-pack. His tongue has been rather dry, brown, and slightly 
 fissured. Bowels moved about once daily. No headache. He 
 does not sleep well. There is no distension of the abdomen. 
 Splenic dulness 6 by 4f inches. Heart sounds dull. Respira- 
 tions 18 ; loud, sonorous rhonchi all over chest. Well marked 
 ankle clonus, and exaggerated knee-jerks. Body much 
 emaciated. 
 
 November 1st. Temperature has fallen to normal. He is 
 much troubled with vomiting. Ordered an alkaline mixture. 
 Discontinue wet-pack, and clothe lightly. 
 
178 THE TREATMENT OF TYPHOID FEVER. 
 
 November 2nd. Sickness less. Temperature normal. Pulse 
 104. Respirations 22. 
 
 November 7th. Temperature has been normal for three 
 days. Pulse 92. Bowels rather constipated, and lately he has 
 had several doses of calomel. Net weight 108 lb. He has lost 
 ] 61b. in 20 days. Ordered fish diet. 1^ Caffeinse, gr. ii. Tincturae 
 Cinchonse Co., ]\xx. Aq. Chloroformi, ad §i. Every four hours. 
 
 November 14th. Net weight 111 lb. 
 
 November 23rd. Net weight 1181b. 
 
 November 26th. Knee-jerks are well marked. Ankle 
 clonus has disappeared. 
 
 December 13th. Discharged quite well. 
 
 Case 28. Severe case of Typhoid Fever ; Basilar Meningitis ; 
 Double Otitis Media ; Nineteen days in Wet-'pa.ck ; Fed 
 by Nostril for twenty -three days ; Cure 
 
 This case was very interesting, not merely on account of its 
 severity, and the recovery of the patient, but also from a 
 diagnostic point of view. The problem presented to my mind, 
 and to the others who saw him, wa.s, is it a case of typhoid fever 
 or of tubercular meningitis ? That basilar meningitis had 
 developed in the course of the illness was fairly established 
 by the irritability and hypersesthetic condition : the retraction 
 of the head ; the gradually increasing difficulty in swallowing, 
 with eventual impossibility to do so : the tonic contraction of 
 the muscles, and the loss of the knee-jerks. The condition of 
 the lungs was such as might be expected in either typhoid 
 fever or tuberculosis, but no tubercle bacilli were found in the 
 vomited matter, part of which was evidently bronchial mucous. 
 The previous history of fourteen days illness with diarrhoea, 
 the character of the motions, the enlargement of the spleen, 
 and the fact that the urine gave a deep purple reaction with 
 Ehrlich's test showed the presence of typhoid fever. The 
 complete recovery of the patient eradicated all tuburcular ideas 
 from our mind, and finally left us with the diagnosis stated 
 above. Whatever difference of opinion there may be ds to the 
 nature of the case, there can be none as to its severity. 
 
CASES TREATED WITH THE WET-PACK, ETC. 179 
 
 James V., aged seven years, admitted to hospital November 
 3rd, 1890. His mother states that he has been ill about a fort- 
 night, and for the last week he has been confined to bed. He 
 has had diarrhoea, and for a few days has been attended by 
 a medical man, who reported the case as one of typhoid fever. 
 
 On admission he was in a very weak, emaciated condition, 
 and following day only weighed 33 lb. Face pale ami shrunken. 
 Pupils dilated. Tongue fairly clean and moist ; he cannot 
 protrude it well, but tries to do so when requested. Sordes on 
 lips and teeth. He is irritable and very fretful ; will not 
 answer questions. Temperature I02'6'. Pulse 148. Ordered 
 4 pints of milk and 6 ounces of bread. 1^ /i-naphthol, gr. iv. 
 Every four hours. 
 
 November 4th (fifteenth day). He slept fairly well. He is 
 passing urine involuntarily. Bowels acted after an enema ; 
 motion loose, bright brown, and offensive. Heart's sounds clear. 
 Respiratory murmur harsh, but it is rather difficult to 
 auscultate, owing to his constant whining. Lung percussion 
 clear. Splenic dulness increased. No abdominal distension, 
 and apparently no pain on pressure, as he does not wince. 
 Knee-jerks present, but not well marked. There is now a malar 
 flush. Pulse 142, small and weak. Temperatures to-day, 4 
 a.m., 102-6' ; 8 a.m., 103' ; noon, 101-8' ; 4 p.m., 103-8' : 8 p.m., 
 1002' ; midnight, 103'. He was put in the wet-pack at 6 p.m.: 
 the efiect on his temperature was soon noticeable, though, as 
 noted, there was a rise at midnight. 
 
 November oth (sixteenth day). He did not sleep at all, but 
 whined all night, and kept the other patients awake. He took 
 his milk freely but would not swallow any boiled bread and 
 milk. He is very fretful and irritable. Commences to cry 
 when anyone goes near him. He will not put out his tongue. 
 Pulse 160, quick, small and weak. He passes urine involun- 
 tarily. Head retracted, and at present legs extended. The 
 nurse says he usually lies on his side with thighs flexed on 
 abdomen, and legs on thighs. Knee-jerks present ; left 
 most marked. Temperature to-day 99-8' to 102'. Bowels 
 not moved. I^ ^-naphthol, gr. iv. Pulv. Ipecac. Co., gr. "iv. 
 
 M 
 
180 THE TREATMENT OF TYPHOID FEVER. 
 
 Fiat Pulv. Sig. : One every four hours. Calomel two 
 grains. 
 
 November 6th. He got three powders, the last at midnight, 
 and he slept well after 1 a.m., so the powders were not repeated 
 during the night. He only took eight ounces of milk during 
 the night, and had great difficulty in swallowing. Bowels 
 moved freely this morning after an enema. Motion loose, 
 yellow, acid, and offensive. He seems quite unable to swallow, 
 and it is now directed that he be fed through a fine tube, 
 passed down through the nostril into the gullet. Pulse 152. 
 Temperature, 4 a.m. to 4 p.m., 100° to 101° ; 8 p.m., 103-4° ; 
 midnight, 102°. Urine and fseces passed involuntarily. 
 
 November 7th. He slept fairly well. It is directed to put 
 the naphthol and pulv. ipecac, co. in separate powders, so that 
 he may have the former every 4 hours, and the latter as often 
 as required. Temperature, to-day, 99*2° to 102°. Pulse 160. 
 He slept from 4 to 10 p.m. 
 
 November 8th (nineteenth day). He was very restless until 
 3 a.m., and afterwards slept quietly. At 10-30 a.m. he vomited. 
 Whenever the pack is changed he flexes his thighs and legs, 
 and the nurse has some trouble in straightening them. His 
 body is very rigid, and head retracted. He is unable to 
 swallow, and is very irritable. Knee-jerks present ; no ankle 
 clonus : pulse 164, small, soft, quick, and weak. He is troubled 
 with cough ; breath sounds very harsh. Expectoration and 
 vomited matters examined for tubercle bacilli, but none found. 
 Tongue moist, coated with whitish fur. Sordes on lips and 
 teeth. Urine passed involuntarily, but a little was saved and 
 examined with the following result : sp. gr. 1010, alkaline, 
 small quantity of albumen, and with Ehrlich's test gave a 
 deep ruby colour. One motion, partly formed, yellow, and 
 very ofi'ensive. Temperatures, 102°, 99-8°, 99-6°, 103-2°, 101-6°, 
 101°. 
 
 November 9th. He was rather better, and not so irritable 
 this morning. Pulse 136. Temperature, 4 a.m., 102°; 8 a.m., 
 98-8°; noon, 98-6°; 4 p.m., 99°. He had a loose, yellow, 
 offensive, and alkaline motion this afternoon. At 8 p.m. his 
 
CASES TREATED WITH THE WET-PACK, ETC. 181 
 
 temperature ran up to 103°, and remained at that level to 
 midnight. Pulse 160. He had the naphthol and Dover's 
 powders regularly. 
 
 November 10th. He slept fairly well, and received 27 
 ounces of milk during the night. No motion to-day. Pulse 
 160. Temperatures, 102°, 99°, 99°, 101-4°, 99°, 100°. 
 
 November IJth (twenty-second day). Two motions, yellow, 
 formed, and alkaline. Pulse 156. Temperatures, 100°, 98-6°, 
 98-6°, 100°, 98-6°, 99-6°. 
 
 November 12th. He had a very good night, and received 
 30 ounces of milk. Temperature 98° to 100°. Pulse 152. 
 No motion. Three grains of calomel. 
 
 November 13th. He was rather restless last night. Received 
 30 ounces of milk through the nostril. Pulse 152. There is 
 a foetid purulent discharge from both ears ; syringed with 
 solution of boracic acid. One loose, light yellow, alkaline 
 motion. Urine neutral, sp. gr. 1016, slightly albuminous. 
 Both faeces and urine passed involuntarily. Temperatures, 
 99-8°, 98-6°, 98°, 98°, 98-8°, 101°. 
 
 November 14th. Slight discharge from both ears ; syringed, 
 and dressed with powdered boric acid. Temperatures, 100°, 
 99-6°, 101-6°, 101-2°, 99-8°, 102°. No motion. 
 
 November 15th. He did not sleep well. Received 30 ounces 
 of milk through nostrils. Knee-jerks absent, no ankle clonus. 
 One greenish motion after an enema. Pulse 160. Tempera- 
 tures, 99-8°, 100°, 98°, 97-6°, 99-4°, 99-6°. Discharge from ears 
 stopped. 
 
 November 16th (twenty-second day). Crepitant rales audible 
 all over back of chest ; expiration prolonged, some dulness in 
 percussion all along vertebral grooves. Ordered two ounces of 
 butter, and malted milk daily. One alkaline, light yellow, 
 offensive motion. Pulse 136. Temperatures, 100°, 100°, 986°, 
 99-8°, 101-2°, 103°. 
 
 November I7th. Knee-jerks present, no ankle clonus, 
 numerous moist rales heard all over chest, and tubular 
 breathing at back, dulness increased. One offensive motion. 
 Pulse 164. Temperatures, 1034°, 100°, 101-4°, 102-4°, 100°, 
 
182 THE TREATMENT OF TYPHOID FEVER. 
 
 99°. I^ ^-naphthol, gr. iv. Pulv. Ipecac. Co., gr. iv. Quininse 
 Sulph., gr. ss. Pulv. Digitalis folise, gr. -J-. Fiat Pulvis. Sig. : 
 One every four hours. 
 
 November 18th. He had four powders and slept very well. 
 He received through nostrils two pints of milk, to which malted 
 milk, and melted butter had been added. He coughs less. No 
 motion. Pulse 140. Temperatures, 99-2°, 99-6°, 101-2", 99°, 
 98°, 99°. Calomel 3 grains. 
 
 November 19th. Received, during night, two pints of liquid 
 nourishment, consisting of milk, Benger's food, malted milk, 
 and butter. Slept well. Two loose, yellow, offensive motions. 
 No discharge from ears. There is a bed sore forming at lower 
 part of back, and one on right heel. He was placed on a 
 water-bed yesterday afternoon. Temperatures, 100°, 98°, 
 97-6°, 976°, 98-8°, 99-2°. Pulse 144. 
 
 November 20th. He had six pints of liquid nourishment 
 during last 24 hours. Temperature 97° to 99°. No motion. 
 Three grains of calomel. 
 
 November 21st. Temperature 97'2° to 99"8°. One motion. 
 
 November 22nd. He passed a restless night. Dr. Askin 
 was called to see him at 4 a.m., and found him very collapsed. 
 Temperature 97'2°. Pulse imperceptible at wrist. He was 
 taken out of wet-pack and hot bottles applied. He soon rallied 
 and at 10 a.m. pulse 160, temperature 101°. The wet-pack 
 was then resumed. He took five pints of liquid nourishment 
 during last 24 hours ; it consisted of milk, Benger's food, malted 
 milk, isinglass, and butter. No motion yesterday or to-day. 
 Temperature 98° to 99'6°. The wet-pack is now discontinued. 
 
 November 24th (thirty-fifth day;. Net weight 29f lb., thus 
 showing a loss of 3j lb. He is very fretful, cries when 
 touched, but does not speak. He has not spoken since his 
 admission to hospital. Tongue dry and coated with a brownish 
 fur. He has still to be fed by nostril. Pupils dilated, the 
 retraction of the head has disappeared. The muscles of the 
 extremities are in a state of tonic contraction ; the arms are 
 drawn close to the sides, and the forearms flexed on the arms ; 
 his lower limbs are extended and much wasted, and muscles 
 
CASES TREATED WITH THE WET-PACK, ETC. 183 
 
 rigidly contracted. Any attempt to test for knee-jerks or 
 ankle clonus causes great pain. Temperature 97'^ to 99^. 
 
 November 26th. Knee-jerks present on left side, absent on 
 right. His forearms are acutely flexed on arms and difficult to 
 extend. Tongue moist. He takes a fair amount of nourish- 
 ment through the nostril. Pupils dilated, face flushed. The 
 sores on the back are healing, a large sore on right heel is 
 sloughing; there is slight discharge from right ear. Temperature 
 98*^. Urine alkaline, slightly albuminous. 
 
 November 27th. Butter is now increased to four ounces 
 daily. 
 
 November 29th. He took a feeder of milk by the mouth 
 this morning for the flrst time. 
 
 November 30th. Weight 32f lb. Temperature normal 
 
 December 2nd. He is more intelligent. Put out his tongue 
 to-day for the first time when told to do so. Ordered one 
 ounce of malt extract. 
 
 December 6th. Net weight 36 j lb. He began yesterday at 
 noon to eat bread and butter, and now takes it with avidity. 
 He is quite intelligent, and does what he is told, but he has 
 not yet spoken. The discharge from the ears has ceased, and 
 the sores on the sacrum and right heel are healing. Tongue 
 clean and moist, appetite fair, bowels constipate 1 except when 
 moved by aperients. The flexor muscles of the forearms and 
 legs are still contracted. 
 
 December 10th. He has spoken to-day for the first time. 
 
 December 12th. One egg. 
 
 December 15th. Net weight 40 lb. 
 
 December 26th. Net weight 421b. Knee-jerks still absent. 
 
 January 2nd. Net weight 46 lb. Ordered fish diet. 
 
 January 7th. Net weight 49 lb. 
 
 January 14th. He has considerable difiiculty in walking, 
 and his gait is characteristic of paresis of the extensor and 
 peroneal muscles, but all the muscles respond to the Faradic 
 current. Ordered massage and the Faradic current. 
 
 February 9th, 1891. Net weight 50 lb. He was discharged 
 to-day quite well, fat, and strong. 
 
184 THE TREATMENT OF TYPHOID FEVER. 
 
 Case 29. Severe case of Typhoid Fever ; Ice-hag to Abdomen 
 for six days ; Leiter's tubing for six days ; Gold Water 
 enemata ; Cure. 
 
 William S., age 10, admitted to hospital November 6th, 1890. 
 Illness began two weeks ago with headache, and for the last 
 week he has been confined to bed= He is a bright, intelligent 
 lad, but rather fretful. He is emaciated, eyes bright, pupils 
 dilated. Temperature 102°. Pulse 128, soft, weak, and 
 dicrotic. Respirations 18. Numerous dry rhonchi heard all 
 over chest. Cardiac sounds normal. Tongue moist, but rather 
 glazed. Sordes on lips and gums. No abdominal distension. 
 Spleen enlarged. Pain in right iliac fossa on firm pressure. 
 No typhoid spots visible. Knee-jerks well-marked ; ankle 
 clonus present on both sides. 
 
 November 7th (fifteenth day). Bowels acted this morning 
 after an enema ; motion loose, yellow, and acid. Urine acid, 
 slight albumen. Net weight 52| lb. Ordered 4 pints of 
 milk and 8 ounces of bread daily. Temperature, 100° to 103°. 
 
 November 8th. One loose, yellow, alkaline motion. Urine 
 alkaline, sp. gr. 1020, no albumen, deposit of triple phosphates 
 and urates, with Ehrlich's test gave a very characteristic deep 
 ruby-coloured reaction. Pulse 124. Temperature, 100° to 
 103° ; mean 101 "75°. Ordered 6 grains of /3-naphthol, every 
 four hours. 
 
 November 9th, He slept very well. He does not like the 
 boiled bread and milk, so Benger's food is substituted. Pulse 
 120. Temperature, 10r-103° ; mean 102-2°. No motion. 
 
 November 10th. He slept well. Pulse 128. Temperature, 
 101°-103'4° ; mean 102°. After an enema, motion loose, bright 
 yellow, ofiensive, and acid. Ordered 2 grains of calomel. 
 
 November 11th (nineteenth day). He sleeps very well. 
 Pulse 124. Cough easier ; there are still some bronchitic rales. 
 Tongue clean and moist. Knee-jerks and ankle clonus well 
 marked on both sides. Temperature, 101''-103"6° ; mean, 
 102'5°. No motion. 2 grains of calomel. 
 
 November 12th. After an enema, motion loose, bright 
 yellow, alkaline, and very offensive. Pulse 116. Temperature, 
 
CASES TREATED WITH THE WET-PACK, ETC. 185 
 
 100^-103'4° ; mean 101 •5'. Spleen can be felt underneath the 
 ribs. 
 
 November I3th. Urine acid, sp. gr. 1025, no albumen. 
 Pulse 128. Temperature, 101'-103-6' ; mean 1027". No 
 motion. He received 3 grains of calomel, and afterwards 2 
 grains. 
 
 November 14th. After an enema, two loose motions, bright 
 3^ellow, acid, and offensive. Pulse 120. Mean temperature, 
 102-3". 
 
 November 15th (twenty-third day). One motion partly 
 formed, yellow, and alkaline. Temperature, lOl'-lOi' ; mean 
 102'5^. Two grains of calomel. Ice-bag applied to abdomen. 
 
 November 16th. After enema, one loose alkaline motion. 
 Temperature, 99-8"^-104\: mean 101-7'-. Pulse 120. 
 
 November 17th. Slept well. Temperature, 99-2' to 103" ; 
 mean 10 1 '3''. No motion. 
 
 November 18th. Loose alkaline motion after enema. Pulse 
 128. Temperature, 101'--103-8'- : mean 102-5''. 
 
 November 19th (twenty-seventh day). Two motions, after 
 3 grains of calomel. Pulse 128. Temperature, 101-8''-104-2° ; 
 mean lOo'l'. When the temperature reached its maximum 
 he received an enema of 15 ounces of iced water, and 5 ounces 
 of peroxide of hydrogen (10 vols, strength). Knee-jerks and 
 ankle clonus pronounced. Spleen much enlarged. 
 
 November 20th. EQs temperature steadily fell after the 
 iced-enema last night, and by midnight it was 102°, and at 
 noon, to-day, it was only 100'. At 4 p.m. it rose to 102"", and 
 he had then another iced-enema, and at 8 a.m. it was lOO'G^ 
 Two loose motions. Abdomen rather retracted. 
 
 November 21st. One loose light yellow, acid, oftensive 
 motion. Pulse 112. Temperature, 99-8'-10r. Leiter's tubing 
 with iced-water, substituted for ice-bag. 
 
 November 22ud. He slept well, and is taking nourishment 
 well. Temperature, 100''-101-8'; mean 100-4'. Pulse 120. One 
 motion. 
 
 November 23rd. Palse 112. Temperature, 98-6^-100-. No 
 motion. 
 
186 THE TREATMENT OF TYPHOID FEVER. 
 
 November 24th (thirty-second day). Temperature, 97°-99-8° 
 mean 98-2°. One motion. Net weight 55 lb. Knee-jerks and 
 ankle clonus well-marked. 
 
 November 27th (thirty-fifth day). Pulse 112. Temperature 
 normal for last three days, with a slight evening rise. Leiter's 
 tubing discontinued. Pulse 112. No motion to-day. 
 
 November 29th. Knee-jerks and ankle clonus still well- 
 marked. Pupils widely dilated. Tongue fairly moist and 
 slightly furred. Stop naphthol. 1^ Ammon. Garb., gr. iii. 
 Tinct. Cinchonse Co., n\xx. Caffeinse, gr. ii. Aq. Chloroformi, 
 ad §i. Every four hours. 
 
 December 1st. Net weight 50^ lb. Temperature normal. 
 Bowels usually confined, and he has had an occasional dose of 
 calomel. Pulse 92. 
 
 December 3rd. Pulse 76. Knee-jerks and ankle clonus 
 still well-marked. Spleen cannot be felt, but it is still enlarged. 
 
 December llth. Net weight 57|- lb. Fish diet. 
 
 December 19th. Net weight 64 lb. 
 
 December 26th. Net weight 66^ lb. 
 
 January 1st, 1891. Net weight 71 lb. 
 
 January 4th. Discharged quite well and strong. 
 
 Case 30. Severe case of Typhoid Fever ; Wet-pack for twenty 
 days; Ice-bag to Abdomen; and cold water enemata ; 
 Cure. 
 
 Maud G., aged 6 years, admitted to hospital November 6th, 
 1890, on the seventh day of illness. She is a fairly healthy 
 looking child, with flushed face, bright eyes, and dilated pupils. 
 Tongue moist, furred and transversely fissured. Pulse 128. 
 Respirations 36. Temperature, 104'2°. Abdomen distended 
 and tympanitic ; splenic dulness increased. There are a few 
 lenticular rose spots on chest and abdomen, and on the back 
 there are numerous rose spots which disappear on pressure. 
 Knee-jerks present, no ankle clonus. Heart and lungs healthy. 
 Ordered two pints of milk and six ounces of bread. 
 
 November 7th (eighth day). She slept well. Temperature, 
 4 and 8 a.m., 102'6'^ ; noon 103"2'^ ; she was now placed in a wet- 
 
CASES TREATED WITH THE WET-PACK, ETC. 187 
 
 sheet, and at 4 p.m. her temperature had fallen to 101'2° ; but 
 at 8 p.m. it was 103-4° ; and at midnight, 103°. She took 
 nourishment badly. Two loose yellow alkaline motions. 
 
 November 8th. She slept fairly well last night and took 
 nourishment better — about 28 ounces of milk. Two loose 
 yellow alkaline offensive motions. Pulse 156, small and weak. 
 Tongue clear and fairly moist. Temperature, 4 a.m., 102-8° ; 
 8 a.m., 103-6° in rectum. (From this time till December 3rd, 
 all the temperatures recorded were taken in the rectum) ; 
 noon, 103-8°; 4 p.m., 102-8°; 8 p.m., 103-2°; 12 a.m., 103-6°. 
 Net weight, 31 J lb. 
 
 November 10th. She did not sleep well, and only took one 
 pint of milk, and that with reluctance, during the night. Pulse 
 160. Tongue fairly moist and clean. Temperature keeps high, 
 103°-104°. Two loose yellow alkaline motions daily. Ordered 
 4 grains of /3-naphthol, every four hours. 
 
 November 11th. Temperature, 4 a.m., 101-2° ; 8 a.m., 104-8°; 
 noon, 104-2°, In addition to the wet-pack an ice-bag was now 
 applied to her abdomen, and by 8 p.m. her temperature had 
 fallen to 101°. Pulse 154. She had 2 grains of calomel, and 
 she passed three loose, yellow, very offensive, alkaline motions. 
 
 November 12th. Temperature to-day, 102°-104-2° ; mean, 
 103°. Pulse 136. Two motions. 
 
 November 13th. She slept fairlj^ well last night, and during 
 last 24 hours took 55 fluid ounces of milk. Tongue clean and 
 moist. Pulse 132-140. Knee-jerks present. No ankle clonus. 
 One motion. Abdomen is not now distended. Many rose 
 spots still visible. Temperature 102-2°-104-8° : mean, 103°. 
 Two grains of calomel. Ordered Benger's food and milk in 
 place of bread. 
 
 November 14th. Tongue clean and moist. Eyes bright. 
 Pupils dilated. Cheeks flushed. Her temperature dropped 
 this morning to 99-4°, and the ice-bag was discontinued. Her 
 temperature rose at 4 p.m. to 103-2°,but fell at midnight to 100-4°. 
 
 November 15tb. Temperatures, 4 a.m., 105-4" ; 8 a.m., 
 102-2°; noon, 103°; 4 p.m., 102°; 8 p.m., 1022°; 12 a.m., 1036°. 
 Two motions. Pulse 148. 
 
188 THE TREATMENT OF TYPHOID FEVER. 
 
 November 16th. Takes her milk with great reluctance. 
 There are nuaierous moist rales all over back of chest. Pulse 
 128. Respirations 50. Temperatures, 4 a.m., 100"4° ; 8 and 12, 
 102° ; 4 p.m., 104-2° ; 8 p.m., 104°. Ice-bag to abdomen 
 resumed; midnight, 101'4°. Two alkaline motions. 
 
 November 1 7th. Temperature, 4 a.m., 98'4° (ice-bag 
 removed) ; 8 a.m., 994^ ; noon, 108° (ice-bag renewed) ; 4 p.m , 
 104-8° (vomited) ; 8 p.m., 103-2° ; midnight, 101-2°. Four 
 motions, loose, yellow, and acid reaction. Pulse 156. 
 
 November 18th Temperature 4 a.m., 99-2° (ice-bag removed); 
 8 a.m., 102-2° (ice-bag repeated); noon, 101-4° ; 4 p.m., 101-2°; 
 8 p.m., 104° ; midnight. 101-6°. Pulse 144. Two loose yellow 
 acid motions. 
 
 November 19th. Temperature, 4 a.m., 100° ; 8 a.m., 99-2° 
 (ice-bag removed); noon, 102-2° (ice-bag repeated); 4 p.m., 
 100-8° ; 8 p.m., 103° (iced-enema, which was only retained 
 a short time). Three loose motions, second acid, and third 
 alkaline. Vomited to-day. 
 
 November 20th. Temperature, 4 a.m., 99-6°; 8 a.m., 99-2°; 
 (ice-bag removed); noon, 104°; (ice-bag renewed); 4 p.m., 
 100-4° ; 8 p.m., 99° ; midnight, 100-2°. Pulse 168. Respirations 
 60. Four loose, dark, offensive motions, third and fourth tested 
 and found acid. Vomited this afternoon. 
 
 November 21st. Temperature, 97-8°-100°. Pulse 124; one 
 loose, light yellow, acid motion. 
 
 November 22nd. Temperature, 98-4° to 100-6°. Pulse ] 24. 
 Three pale yellow, alkaline motions. 
 
 November 23rd. Temperature, 98-8° to 102°; mean 100°. 
 Pulse 144. Respirations 34. Vomited twice. Two yellow 
 formed motions, first acid, second alkaline. 
 
 November 24th. Temperature, 97-8° ( ice-bag removed ) ; 
 8 a.m., 99-6° (ice-bag repeated); noon, 992°; 4 p.m., 99-6°; 
 8 p.m., 100-2° ; midnight 99-8°. Pulse 128. Two acid motions. 
 
 November 26th. Temperature 98-8° to 99-6°. Ice-bag finally 
 stopped. Pulse 128. One acid motion yesterday, and to-day. 
 Net weight 29| lb. ; loss in eighteen days 2^ lb. 
 
 November 27th. Pulse 128. Temperature normal, wet-pack 
 
CASES TREATED WITH THE WET-PACK, ETC. 189 
 
 finally discontinued, and her temperature afterwards ran up to 
 100-2°, but again soon declined. Ordered 2 ounces of butter 
 daily. The breath sounds are fairly normal, a few rhonchi 
 can be heard at back of chest. Knee-jerks well marked, no 
 ankle clonus. 
 
 December 1st. There has been an evening rise of temperature 
 of a degree and-a-half, since last note. Breath sounds on front 
 of chest are harsh, and there are a few rhonchi ; and at base of 
 right lung there are a few crepitant rales. Naphthol stopped. 
 1^ Quinines Sulph., gr. i. Caifeinas, ^r. i. Acidi Hydrobrom. 
 dil., Tl\^v. Syrupi, 5ss. Aq. Chloroformi, ad §ss. Thrice daily. 
 
 December 3rd. Temperature normal, now taken in the axilla. 
 Pulse 116. 
 
 December 5th. Net weight 29 lb. Mutton broth. 
 
 December 12th. Net weight 321b. Fish diet, and buttered 
 toast 
 
 December 16th. Allowed up on couch for the firet time 
 
 December 19th, Net weight 32 lb. 
 
 December 26th. Net weight 35^ lb. 
 
 January 1st. 1891. Discharged quite well. 
 
 Case 31. Severe case of Typhoid Fever; Ice-hag to tJte 
 Abdomen ; Cure. 
 
 Isabella B., aged 10, admitted to hospital December 8th, 
 1890. This patient was very prostrate on admission, and 
 apparently unconscious. She lay curled up in bed with her 
 knees drawn up nearly to her chin. She could not be got to 
 answer any questions, but lay in a somnolent condition, 
 occasionally waking up with a low moan, and then quietly 
 lapsing into an apathetic drowsy condition. Her mother 
 stated that she had been ill fifteen days prior to admission. 
 
 She is a poorly nourished child, with a pale, emaciated 
 appearance. Skin hot and dry. Tongue dry. Lips and teeth 
 covered with sordes. She passes urine and faeces involuntarily. 
 Motions loose, pale yellow and alkaline. The breath sounds 
 are harsh, and there is a good deal of hacking cough. 
 Respirations 38. Pulse 148, small and feeble. Spleen enlarged. 
 
190 THE TREATMENT OF TYPHOID FEVER. 
 
 Knee-jerks not elicited. Ankle clonus slightly marked on 
 right side. Net weight, 35 lb. Ordered 3 pints of milk, 8 
 ounces of bread, and 2 ounces of butter. Six grains of naphtha- 
 line every four hours. Her temperature was 102° on admission, 
 and steadily rose, till the following evening it was 104*4°. An 
 ice-bag was applied to the abdomen, which in 12 hours brought 
 down the temperature to 98°. She then became more conscious. 
 Put out her tongue, which was very dry and fissured. The 
 percussion at the bases of both lungs was impaired, and there 
 were rhonchi. 
 
 December 11th. Bowels acted freely and involuntarily. 
 Motions alkaline and offensive. Pupils dilated. Tongue very 
 dry and fissured. Knee-jerks, present. No ankle clonus. 
 Pulse 144. Respirations 42. Temperature 100° to 102-4°. Ice- 
 bag continued. Benger's food and extract of malt. 
 
 December 13th (twenty-first day). She had a good night. 
 Bowels acted twice involuntarily. Tongue hot and dry. She 
 is coughing less. There are numerous small crepitant rales" 
 over lower lobes of both lungs. Percussion note impaired, 
 especially over right lower lobe. Respirations 36. Pulse 158, 
 small, but moderately firm. Knee-jerks well marked. No 
 ankle clonus. Temperature fell this morning to normal and 
 afterwards remained so. Ice-bag stopped on the 14th. Her 
 urine was saved on December 15th, and it then gave Ehrlich's 
 reaction, well marked. 
 
 On December l7th, she weighed 40 lb. 
 
 December 23rd, fish diet. Naphthaline stopped, and given 
 a mixture of caffeine and cinchona. December 27th ; net 
 weio-ht, 42 lb. January 2nd ; net weight, 42 lb. ; 9th, 46 lb. ; 
 14th, ordinary diet and one egg ; 16th, net weight, 48 lb. 
 Discharged January 20th, 1891, quite well. 
 
 Case 32. Typhoid Fever ; Ice-bag applied to the Abdomen 
 
 for thirteen days ; Cure. 
 
 Mary E. J., aged eleven, admitted January 27th, 1 891, on 
 
 the sixth day of illness. She has at present two brothers and 
 
 one sister in this hospital suffering from typhoid fever. She 
 
CASES TREATED WITH THE WET-PACK, ETC. 191 
 
 has always been a delicate girl. She took ill on the 22nd 
 instant with pain in the back and abdomen. 
 
 She is a spare delicate looking child, net weight 54 lb. Face 
 pale, with malar flush, eyes bright, pupils dilated. Tongue 
 moist, coated in the centre with a greyish white fur, tip and 
 edges clean, papillae prominent, sordes on lips and teeth. 
 Appetite bad ; bowels confined. Lungs healthy. Heart's sounds 
 clear, second sound accentuated at pulmonic cartilage. Splenic 
 dulness increased, abdomen not distended nor tender on pressure 
 No typhoid spots. Knee-jerks present, no ankle clonus. 
 Temperature 103°. Pulse 108. Urine acid, sp. gr. 1028, no 
 albumen, urea 3'5 per cent, deposit of urates, and gives Ehrlich's 
 reaction. Ordered 4 pints of milk, and 6 ounces of bread 
 daily ; 10 grains of salol every 4 hours. 
 
 There were marked fluctuations of temperature in this case 
 throughout, the daily range being about four degrees. On the 
 thirteenth day the ice-bag was applied to the abdomen and 
 continued to the twenty-fifth day. She was also frequently 
 sponged with cold water when the temperature rose to 104°. 
 Her bowels were rather confined throughout, and she had 
 several doses of calomel, and enemata. On nineteenth day 
 ordered 2 ounces of butter daily. Her temperature became 
 normal on the twenty-fourth day. Twenty-sixth day, net weight 
 49 lb., showing a loss of 51b. during twenty days in hospital. 
 
 Febiuary 17th. Stopped salol, and put on a mixture of 
 bark and caflfeine. 
 
 February 21st. Ordered fish diet. 
 
 February 26th. Net weight 54 lb. Put on ordinary diet, 
 one pint of milk, and an egg. 
 
 March 3rd. Net weight 56 lb. 
 
 March 5th. Discharged quite well. 
 
 Case 33. Severe and prolonged case of Typhoid Fever ; Ice- 
 bag applied to the Abdomen for twenty -two days; 
 '\^ et-pack for seven days; Cure. 
 Jane M, aged 18 years, admitted to hospital January 10th, 
 1891. She has been married two years, and about 7 months 
 
192 THE TREATMENT OF TYPHOID FEVER. 
 
 ago she was prematurely confined of a child, who lived 8 
 weeks. At the end of last month she had an abortion of nine 
 weeks sfestation, from which she had not recovered when the 
 present illness began on New Year's Eve. Since then she has 
 felt miserable and weak, but did not take to bed until the day 
 before admission. For the last two days she has suffered from 
 diarrhoea, though previous to that her bowels were confined. 
 There is still some discharge of blood from uterus. She is 
 now very deaf and stupid, but answers questions intelligently, 
 and there is no delirium. Her face is flushed, eyes bright, 
 pupils dilated ; tongue dry and fissured ; lips and teeth coated 
 with sordes : motions acid, loose, light yellow, and offensive. 
 Heart's sounds clear. Pulse 128, soft and dicrotic. She lies 
 chiefly on her right side, and there is impaired percussion at 
 base of right lung. Eespirations 44, shallow. Hepatic dulness 
 normal ; splenic dulness increased. Her abdomen is not 
 distended. . There is tenderness, but no gurgling in right iliac 
 fossa. Over chest and abdomen there are several distinct 
 elevated rose spots, which disappear on pressure. Knee-jerks 
 present, but not much marked : no ankle clonus. Tempera- 
 ture, 102-6'' to 103-6'. Ordered 4 pints of milk and 8 ounces 
 of bread daily ; 10 grains of /i-naphthol every four hours. 
 
 January 12th (thirteenth day). She had a fair night, after 
 a dose of nepenthe. The diarrhoea is less : tongue very dry 
 and fissured ; there are dry rhonchi over posterior aspect of 
 right lung. She has passed no urine since 7 p.m. yesterday, 
 and there is no distension of bladder. Net weight 88| lb. 
 
 Fifteenth day. She slept fairly well after a dose of nepenthe. 
 One motion daily for last three days, loose, greenish yellow, 
 acid reaction. She has only passed 10 ounces of urine during 
 the last 24 hours, sp. gr. 1019, acid, albuminous, gives 
 Ehrlich's reaction, and contains 2-2 per cent, of urea. Tongue 
 very dry. There are a few crepitant rales audible over lower 
 lobe of right lung. Pulse 120; respirations 32-36. Her 
 temperature reached 104-8' at midnight. She was sponged, 
 and had one grain of calomel. 
 
 Seventeenth day. For the last two days her temperature 
 
CASES TREATED WITH THE WET-PACK, ETC. 193 
 
 has been mostly above 104^ except when brought down by 
 sponging with cold water and vinegar. There is very little 
 cough, but coarse rhonchi are now heard over both lungs. 
 Pulse 116 ; respirations 36. She has been sick. Motions loose, 
 yellow, and alkaline. Urine scanty, sp. gr. 1024, albuminous, 
 3*25 per cent, of urea. No ankle clonus ; cannot elicit knee- 
 jerk on right side ; it is present on left. She is taking 
 nourishment well. Abdomen full, and tympanitic. Ordered 
 ice-bag to be kept constantly applied to abdomen. 
 
 Twentieth day. Her temperature has been kept at a lower 
 level, and since the ice-bag was applied has only once risen 
 above 103°. Tongue still very dry and fissured, but not so 
 thickly crusted ; no sordes on lips and teeth. Abdomen is 
 less distended. Motions loose, yellow, alkaline, and very 
 offensive. No sickness for last two days, and is now taking- 
 lime water with her milk. She complains of pain and stiffness 
 in left arm. 
 
 Twenty-third day. Tongue very dry. She complains of 
 pain and stiffness in both legs : no ankle clonus; knee-jerks 
 present ; plantar reflexes well marked. Crepitant rales audible 
 over lower lobes of both lungs, and at right base the percussion 
 is impaired. Substitute ten grains of salol for /?-naphthol, 
 every four hours. 
 
 Thirtieth day. Her temperature has ranged between 100° 
 and 103°, for the last ten days. Her urine has been much more 
 abundant, but is still slightly albuminous ; the percentage of 
 urea has ranged from 2 to 2'5 ; it still gives Ehrlich's reaction 
 well marked. Pulse 120-136 ; respirations 30-38. The motions 
 are still very offensive. Ordered one drachm of charcoal to 
 to be added to each salol powder. 
 
 Thirty-second day. She did not sleep well, complains of pain 
 in right foot and right axilla : in the latter situation there is a 
 glandular swelling. At the junction of the third left costal 
 cartilage with the rib there is considerable inflammatory 
 thickening with tenderness on pressure. Temperature 100°- 
 102°. Pulse 128. Respirations 26. Urine contains a trace of 
 albumen. Motions loose, alkaline, and not so offensive. 
 
194 THE TREATMENT OF TYPHOID FEVER. 
 
 Thirty-fourth day. Ordered five grains of quinine each 
 afternoon. 
 
 Thirty-sixth day. There has been a decided fall in her 
 temperature, but it still runs up each evening to 101°. Net 
 weight 85 lb., showing a loss of only 3^ lb. in twenty-three 
 days. 
 
 Thirty-ninth day. As her temperature still keeps above 
 normal (99° to 101 '4°), she was to-day placed in the wet-sheet 
 and ice-bag to abdomen discontinued. Ordered one and-a-half 
 pints of mutton broth daily. A small abscess in right axilla 
 was opened this morning. The periosteal thickening at junction 
 of third left rib with costal cartilage has now almost completely 
 disappeared. 
 
 Forty-sixth day. Her temperature has been normal, and 
 wet-sheet is discontinued. 
 
 Forty-eighth day. Stop salol, charcoal, and quinine, and give 
 the following mixture : — ^ Ammon. Garb., gr. v. Tinct. 
 Cinchonse Flav., ii]^xxx. Caffeinse, gr. ii. Aq. Chloroformi, 
 ad §i. Every four hours. To have bread and butter, and two 
 eggs daily. Net weight 78 lb. 
 
 Fifty-lifth day. For last four days she has had slight 
 rheumatism with effusion in knee-joints, but she is now much 
 better. She is placed to-day on ordinary hospital diet. 
 
 March 3rd (sixty -third day). Net w^eight 83 lb. March 1:3th, 
 87 lb. She has been moving about the wards for some time. 
 There was paresis of the extensor muscles of both legs for 
 some time, but that has now disappeared. 
 
 March 15th. Discharged quite well. 
 
CASES SYMPTOMATICALLY TREATED. 
 
 Case 34. Mild case of Typhoid Fever ; Cure. 
 
 Evan Jones, aged 18 years, sailor, admitted to hospital January 
 17th, 1889, with well-marked symptoms o£ typhoid fever, on 
 the seventh day of illness. Two to five loose motions daily ; 
 urine, acid, sp. gr. 1018, albuminous. Temperature 101° to 
 104°. Ordered milk, lime water, and ice; five grains of naph- 
 thaline every four hours. January 26th, two grains of calomel. 
 
 February 11th, boiled rice. February 14th, minced meat. 
 18th, chicken. 25th, porridge. On March 4th he was sent 
 to the convalescent home at Woolton for two weeks. He was 
 then quite well, but had not fully regained his strength ; 
 Weight 112^ lb. On his return from Woolton he was quite 
 well and strong. 
 
 Case 35. Aborted Typhoid Fever ; Ulcerated Sore Throat ; 
 
 Cure. 
 
 Marquis E., aged 38, Spaniard, sailor, admitted to hospital 
 November 17th, 1889, suffering from haemoptysis. He has had 
 a cough for three days, and has brought up a little clotted 
 blood. He has had a severe headache since the commencement 
 of his illness. There is tenderness in the epigastrium and in the 
 right side. Tongue dry and coated with a brown fur in the 
 centre, appetite bad, bowels confined. There is tenderness and 
 gurgling in right iliac fossa. Spleen enlarged. Temperature 
 103"4°, Ordered six pints of milk. For four days his tempera- 
 ture ranged between 101° and 104°, the mean of twenty-three 
 observations being 102'2°. The fever aborted on the ninth 
 day. In the beginning of December he had a badly ulcerated 
 sore throat, and was feverish for seven days. He was discharged 
 quite well on December 9th, 1889. 
 
 Case 36. Typhoid Fever ; Cure. 
 
 Margaret A. D., aged 14, admitted to hospital December* 
 23rd, 1889, on the twentieth day of an attack of typhoid fever. 
 
196 THE TREATMENT OF TYPHOID FEVER. 
 
 She has had slight diarrhoea from the commencement, the 
 motions being watery and yellow. She is a spare girl, cheeks 
 flushed, pupils dilated, tongue dry in centre. She has a slight 
 cough. Respirations 21. Pulse 84, small and feeble. Tem- 
 perature 99° to 101°. There are about a dozen rose spots on 
 the abdomen ; spleen enlarged. Patellar reflexes normal, ankle 
 clonus well-marked on both sides. Ordered three grains of 
 naphthaline every four hours. Diet ; milk and peptonised 
 gruel. Her temperature became normal on the twenty-fifth 
 day (December 28th). 
 
 January 7th, 1890. Ordered bread and butter, and milk diet. 
 
 January 9th. Two eggs ; 15th, ordinary diet. Her weight 
 was not taken on admission, but the following are the records 
 during convalescence. January 3rd, 62| lb. ; 9th, 681b. ; 18th, 
 76 lb. ; 24th, 76^ lb. Discharged quite well January 28th, 1890. 
 
 Case 37. Mild case of Typhoid Fever ; Cure. 
 
 Ellen B., aged 20, admitted March 11th, 1890. Illness began 
 on 3rd instant with shivering and pain in back, followed by 
 severe headache, which has since continued. Bowels have been 
 confined since the 5th. She is a well developed, well nourished 
 girl. Pupils dilated. Tongue furred and dry in the centre. 
 Sordes on teeth. Appetite poor. Bowels confined. Slight 
 tenderness in right iliac fossa. There are a few well marked 
 typhoid spots. Knee-jerks slight. No ankle clonus. Tempera- 
 ture 101° on admission, but afterwards did not rise above 100°. 
 Ordered six pints of milk. No medicine except two grains of 
 calomel. 
 
 March 23rd. One egg ; 27th, fish ; 28th, two eggs. 
 
 April 2nd. Chicken diet. 
 
 April 14th. Discharged quite well. 
 
 Case 38. Mild cam of Typhoid Fever ; Heart Disease ; Cure. 
 
 John K, aged 26, cattleman, admitted March 31st, 1890. He 
 has always enjoyed good health, except for an attack of 
 rheumatism three years ago, with which he was laid up in 
 New York for two months. His present illness began eight 
 
CASES SYMPTOMATIC ALLY TREATED. 197 
 
 days ago on his way from New York, with headache, diarrhoea 
 and sickness. Bowels have been moved two or three times 
 daily. Motions loose, yellow, and veiy offensive. Abdomen 
 distended and tympanitic, and tender in umbilical region. 
 Spleen enlarged ; can be felt below the ribs. Hepatic dulness 
 increased. There is pericardial friction, and at the aortic 
 cartilage first sound prolonged, at pulmonic cartilage second 
 sound accentuated. Ordered milk diet. 
 
 April 1st.' Slept badly. Tongue furred but moist. Rose 
 spots on abdomen. Pulse Si, soft and dicrotic. Respirations 
 16. 
 
 April 2nd. Motions very loose, oflfensive and greenish colour, 
 acid reaction. Xo fresh spots. Hepatic dulness, 5| inches in 
 line of axilla ; 6 inches in line of nipple, and 5^ inches in 
 mesial line. Splenic dulness 8 by 6 inches. Respiratory 
 phenomena normal, except a few crepitant rales at margins of 
 luno-s. Xet weio'ht 1841b. Pulse 112. Three motions. 
 
 April 3rd. Slept badly. Tongue dry and furred : motions 
 loose, greenish, very offensive, and acid. Temperature 99' to 
 101'-. Pulse 96. 
 
 April 4th. ^ Quininfe Sulph., gr. ii. Caffeine, gr. ii. 
 Fiat pulv. Sig. : one every four hours. 
 
 April 8th. Slept well ; says he feels better : tongue furred. 
 Pulse 80 ; splenic dulness rather less ; knee-jerks present, 
 tendency to ankle clonus on right side, none on left. 
 Temperature about normal. 
 
 April 18th. Ordinavy diet. 
 
 April 22nd. This patient has greatly improved and is now 
 anxious to get up. Temperature is and has been normal for 
 some time, and digestive functions are in good order. Liver and 
 spleen continue very large. Hepatic dulness 6^ inches in line 
 of axilla and nipple, and 5| inches in mesial line. Splenic 
 dulness is an irregular oval in shape, measuring 9i by 6 inches. 
 Cardiac dulness is enlarged, and extends If inches to the right, 
 and 5 inches to the left of the mesial line: deep transverse 
 dulness 6f inches, vertical 4i inches. Apex beat rather diffused 
 and can be felt in four or five interspaces, outside nipple line. 
 
198 THE TREATMENT OF TYPHOID FEVER. 
 
 There is rlistinct retraction of third, fourth, and fifth intercostal 
 spaces during systole. Over the greater part of the heart there 
 is a loud grating systolic friction sound, which is especially 
 marked at base and apex, and at the latter situation it is rather 
 high pitched ; at the apex the first sound is soft and prolonged 
 but there is no distinct systolic murmur ; in the tricuspid area 
 the first sound is dull and accompanied by soft blowing systolic 
 murmur ; at the aortic cartilage and propagated into the 
 vessels of the neck there is a short rough somewhat rasping 
 systolic murmur : at the pulmonic cartilage the second sound 
 is accentuated. The veins of the neck are full and pulsate 
 during systole. Pulse 78, soft, and feeble. ^ Tinct. Digitalis, 
 iT^x. Acidi Nitro-mur. dii., VI\jk. Ammonii, Chloridi gr. x. 
 Syrupi, 5i- -^-q- Chloroformi, ad §i. Thrice daily after meals. 
 
 May 8rd, chop. 14th, net weight 122 lb. 
 
 May 15th. Discharged in goud condition. 
 
 Case 39. Moderately severe case of Typhoid Fever ; Cure. 
 
 Sarah E. W., aged 15, dressmaker, admitted to hospital July 
 9th, 1890. She has always been a delicate girl and has suffered 
 from rheumatism. She menstruated about four weeks ago for 
 the first time. Her present illness began on Monday, June 
 30th., with pains in the head and neck ; on Tuesday she felt 
 worse, but went to work : she had several shivering fits and 
 pains all over her body. Since Wednesday she has been confined 
 to bed. She has had three or four loose motions daily. 
 
 She is a delicate-looking, small, but well formed, girl. She 
 complains of headache, and pains in her legs and body. Lips 
 very dry and covered with sordes. Tongue very dry and 
 furred. There are numerous typhoid spots on chest and 
 abdomen. Splenic dulness, 4f by 4i inches. Hepatic dulness 
 increased. Heart healthy. There are a few crepitant rales 
 over right lung, but otherwise respiratory phenomena normal. 
 Knee-jerks feeble ; no ankle clonus. Temperature, 103°. 
 Ordered 4 pints of milk, boiled rice and tapioca, and two 
 lemons. Naphthaline, gr. v., every four hours. 
 
 July 10th (eleventh day). She passed a restless night. 
 
CASES SYMPTOMATIC ALLY TREATED. 199 
 
 Pulse 116 ; respirations 26. Temperature, lOT' to 103'' ; 
 mean 102' She had, to-day, eight loose, greenish, motions ; 
 urine acid, sp. gr. 1017, albuminous. 
 
 July 11th. She did not sleep well, but is rather better this 
 morning. Tongue not so dry. Pulse 112; respirations 84. 
 Temperature, 100' to 103' ; mean 10 1 "3". Four loose, greenish, 
 offensive motions. 
 
 July 12th. Slept fairly well, after a dose of nepenthe. 
 Pulse 116 ; respirations 32. Temperature, 102^ Three loose 
 offensive motions. Net weight, 73 lb. 
 
 July 13th. Temperature, 102" to 103-6\: mean 1024'. 
 Pulse 124. Urine acid, sp. gr. 1015, a trace of albumen. One 
 formed yellow motion. 
 
 July 14th. She had a better night. There are a few 
 bronehitic rales over chest. Knee-jerks better marked. She 
 had an enema this morning, and it was followed during the 
 day by six loose motions. 
 
 July I7th. Dry rhonchi heard over chest : she is coughing 
 a little, but there is no expectoration. Tongue clean and 
 moist, and she is taking nourishment well. Pulse 116 ; 
 respirations 38. Temperature, 1006' to 102-6\ Two charac- 
 teristic typhoid stools. Knee-jerks present ; ankle clonus on 
 right side. 
 
 July 21st. She was delirious yesterday afternoon, and tried 
 to get out of bed. Her bowels were confined, but she has had 
 an enema this morning, followed by a free evacuation. She 
 slept well last night, and feels better to-day. Tongue clean. 
 Her temperature became practically normal on the 23rd, but a 
 slight evening rise continued till the thirtieth day of the 
 disease. 
 
 On July 2oth her net weight was 64 lb., showing a loss of 
 9 lb. in 13 days. The progress of the case from this time was 
 uninterrupted, but .she continued to lose weight until August 8th, 
 when 58 lb. were recorded. 
 
 On August 5th, she was ordered a pint of strong beef tea, 
 and on the 7th, fish diet. 
 
 On August 15th, she weighed 64 lb., on 21st, 681b., and on 
 
200 THE TREATMENT OF TYPHOID FEVER. 
 
 27th, 75 lb. On the 18th, she was ordered a lightly boiled egg 
 daily. During this month her bowels were confined, seldom 
 opened except by enemata. Motions alkaline in reaction. 
 
 On the 27th the urine was noted as free from albumen. 
 
 On September 5th her net weight was 77^ lb., and on the 
 8th she was discharged quite well. 
 
 Case 40. Typhoid Fever ; Cure. 
 
 Hans H., aged 21, Norwegian sailor, admitted to hospital 
 July 15th, 1890. He was unable to speak English, and no 
 history of his illness was obtained, but judging from the 
 condition of the patient and the after progress of the case, the 
 stage of his disease may be fixed as the end of the second week 
 when admitted. His tongue was dry. Motions loose, yellow, 
 and alkaline. Over the chest and abdomen there were 
 numerous lenticular spots which disappeared on pressure. 
 Pulse dicrotic. Heart sounds normal; apex beat in fourth inter- 
 space, and there was retraction of the intercostal spaces during 
 systole. Bronchitic rales over chest. iSpleen enlarged. Knee- 
 jerks and ankle clonus present. Temperature 102"" to 103'. 
 Pulse 88. Respirations 28. Urine alkaline sp. gr. 1027, a 
 trace of albumen. 
 
 H. H., 15-7-90 ; Pulse 88 ; Pre.ssure 1 oz. 
 
 He was ordered four pints of milk, and boiled bread and 
 milk. ^-naphthol, gr. vi, every four hours. He was 
 occasionally delirious for the first week in hospital. His 
 temperature was practically normal from July 23rd, though 
 there was an evening exacerbation till the 26th. 
 
 On August 4th, he was ordered fish diet, and on the 6th, 
 chicken. He was not weighed till the 12th, when he was 
 136 lb., and on the 28rd 138 lb. He was discharged quite well 
 on August 27th. 
 
CASES SYMPTOMATICALLY TREATED. 201 
 
 Case 41. Typhoid Fever ; Cure. 
 
 Antonio P., aged 25, fireman, admitted to hospital, July 19th, 
 1890. He is a Spaniard, and unable to speak English, but a 
 history was obtained of twelve previous days illness. He is 
 now very weak. Tongue dry and furred in centre, clean at 
 tip and edges. False 96. Respirations 30. Motions offensive, 
 liquid, brownish, and alkaline in reaction. On chest and 
 abdomen there are a few well marked typhoid spots. Abdomen 
 not distended nor tender. Spleen 6 by 4 inches. Knee-jerks 
 not well marked. There is a tendency to ankle clonus. Urine 
 slightly albuminous. Heart sounds very feeble at apex. There 
 are a few crepitant rales over back of chest. Net weight 
 137 lb. Ordered four pints of milk and boiled bread and milk, 
 ^-naphthol, gr. vi, every four hours. 
 
 After the second day in hospital his temperature did not rise 
 above 101°, and on the twentieth day of his illness it became 
 normal. 
 
 On August 6th (thirty -first day), he was ordered fish, and on 
 the 9th, chicken. On the 12th his net weight was 134 lb. He 
 was discharged, quite well, on August 18th. 
 
 Case 42. Severe case of Typhoid Fever ; Relapse ; Cure. 
 
 Elizabeth Anne S., aged 8, admitted to hospital July 19th, 
 1890. She has had measles, scarlatina, and chicken pox. Her 
 present illness began on the 13th instant, with sickness, and 
 since then she has vomited after all the food she has taken. 
 Her bowels have been rather confined, but after an aperient 
 the motions were liquid, and of a brownish colour. 
 
 Present condition. Temperature 104"2°. Pulse 126. Respira- 
 tions 28. She complains of frontal headache, and thirst. Tongue 
 dry, and furred, Heart and lungs healthy. Spleen enlarged. 
 No abdominal pain or tenderness. Feet rather cold. Knee-jerks 
 present, no ankle clonus. Ordered three pints of milk daily, 
 and one drachm of Liq. Ammonite Acetatis, every three hours. 
 
 July 20th (eighth day). She slept fairly well. Temperature 
 at 8 a.m. 103". After an enema she had a liquid, yellow, 
 alkaline motion. 
 
202 THE TREATMENT OF TYPHOID FEVER. 
 
 July 22nd. She has been rather restless and delirious. She 
 has been sick. Motion after enema, loose, yellow, alkaline, and 
 offensive. One or two rose spots found on upper part of right 
 thigh. Ordered 2 grains of naphthaline every four hours ; and 
 1 grain of calomel at once. 
 
 July 23rd. Temperature 101' to 102-8'. Pulse 124. 
 Respirations 30. Tongue very dry. Respiratory murmur over 
 right lung is very feeble, especially at base where the percus- 
 sion note is impaired. The abdomen is distended and tympanitic. 
 Ordered a turpentine stupe. She presented a continuous febrile 
 temperature, ranging from 101' to 103', till the fifteenth day 
 of the illness, after which there was a considerable morning 
 remission, and on the twentieth day it became normal. Her 
 bowels were usually confined, and she had frequently enemata, 
 and small doses of calomel. Her pulse fell to 100', and 
 her temperature remained normal to the twenty-fourth day, 
 when there was an evening exacerbation, which continued to 
 increase till the twenty-seventh day (fourth day of relapse), 
 when it reached 104"4'. The relapse lasted fourteen days. On 
 the eighth day of the relapse she was ordered peptonised gruel, 
 and the following mixture in place of naphthaline. I^ Caffeinas, 
 gr. i. Sodse Sulpho-Carbolat., gr. xv. Tinct. Cinchonse Flav., 
 5ss. Syrupi, 5i- ■^^.^ ^d §ss. To be taken every four hours. 
 During last few days of relapse iced compresses were applied 
 to abdomen. 
 
 On August 26th, after her temperature had been normal for 
 eight "days, she was placed on fish diet ; on September 4th, 
 ordered chicken : and on 7th, two eggs. She was not weighed 
 on admission, but the following are the net weights during 
 convalescence : — August 24th, 35^ lb. ; 29th, 38 lb. ; September 
 5th, 44i lb. ; 12th, 43i lb. ; 19th, 46^ lb. Discharged quite well 
 on September 24th, 1890. 
 
 Case 43. Mild case of Typhoid Fever ; Cure. 
 
 Mabel W., aged 10, admitted to hospital July 19th. The 
 present illness began on the 7th inst. with headache. She is 
 now weak and much emaciated. Her bowels have been rather 
 
CASES SYMPTOMATICALLY TREATED. 203 
 
 confined, but after an enema the motion was liquid, brown, 
 alkaline, and ofiensive. One rose spot on abdomen disappearing 
 on pressure. Knee-jerks present, no ankle clonus. Heart 
 sounds normal. Lungs healthy, except for a few dry rhonchi, 
 and there is slight cough. The fever abated on the fourteenth 
 day (July 21st). She then weighed 331b. On August 15th, 
 42 lb. ; 22nd, m lb. ; 29th, 46 lb. ; September 5th, 46 lb. 
 
 Her diet at first consisted of milk, boiled bread and milk, 
 and butter. Afterwards of arrowroot, lightly boiled eggs, fish, 
 and chicken. She was discharged quite well oa September 
 8th. 
 
 Case 44. Mild case of Typhoid Fever ; Cure. 
 Agnes T., aged 42, housewife, admitted to hospital July 24th, 
 1890. She is a married woman and the mother of four children, 
 the eldest, a boy of eight, is at present in Netherfield Road 
 fever hospital with typhoid fever, the youngest is 18 months 
 old, and has just been weaned. Her present illness began four- 
 teen days previously with headache, pains in her body, vomiting 
 and diarrhoea. For the last week she has been under the care 
 of Dr. Permewan, who sent her to hospital. She is now sufiering 
 from headache, sleeplessness. Tongue furred ; motion liquid, 
 yellow, and alkaline. Spleen enlarged; no abdominal distension, 
 but there is much tenderness, no rose spots found. Knee-jerks 
 present, no ankle clonus. Temperature 100'^ to 102". She was 
 placed on bread and milk diet, and ordered six grains of naph-' 
 thaline every four hours. During convalescence she was 
 ordered fish and chicken. On August 21st she was ordered a 
 mixture of nux vomica and hydrochloric acid. She was not 
 weighed on admission, but the following records were made : — 
 August 22nd, 1121b.; 29th, 1171b.; September 5th, 1171b. 
 Discharged this day quite well. 
 
 Case 45. Typltoid Fever ; Cure. 
 
 Mary G., aged 13, admitted to hospital September Sth, 1890. 
 She is a bright, intelligent child. Says she took ill on the 1st 
 instant, with headache. She has been in bed since the 2nd, 
 
204 THE TREATMENT OF TYPHOID FEVER. 
 
 and has suffered from sickness, headache and diarrhcsa. She 
 has been under the care of Dr. Swift, of the North Dispensary, 
 who sent her to hospital. She now complains of slight head- 
 ache and weakness. Her face is flushed, eyes bright, pupils 
 dilated. She is thirsty, and has no appetite. Tongue dry, red, 
 and glazed. Motions loose, yellow, and alkaline. Pulse 104, 
 soft and compressible. Heart and lungs healthy. Splenic 
 dulness increased. Abdomen distended and tympanitic. Knee- 
 jerks well marked. No ankle clonus. Ordered four pints of 
 milk and peptonised bread and milk. 
 
 September 9th (ninth day). She slept well, but has a slight 
 headache this morning. Motions pale yellow, loose, offensive, 
 and alkaline. There are a few rose spots on abdomen. Pulse 
 108. Temperature 99'2^ to 103°. Tongue dry and glazed. Urine 
 gives a deep red colour with Ehrlich's te.st. Net weight 51 lb. 
 
 On the 11th, she was ordered five grains of naphthaline 
 every four hours. She progressed very favourably, and her 
 temperature remained normal after the twenty-first day. 
 
 On the 19th, she weighed 54 lb., showing a gain of 3 lb. 
 during the first eleven days in hospital, i.e. during the second 
 half of the fever. September 26th : net weight 54 lb. 
 September 29th ; fish diet. October 3rd ; weight 54i lb.; 6th, 
 chicken ; 10th, weight 61 lb ; 14th, net weight 66 lb. 
 
 Discharged well and strong on this last day. 
 
 Case 46. Typhoid Fever ; Cure. 
 
 Sarah D., aged 19, housewife. She and two of her brother's 
 children, who live two doors from her residence, were admitted 
 to hospital, October 1st, all suffering from well marked 
 •symptoms of typhoid fever. It is rather difiicult to fix the 
 commencement of her illness, as she has been ailing for some 
 time. Five weeks ago she got badly crushed in a crowd, and 
 afterwards suffered from diarrhoea for a fortnight. About 
 thirteen days ago she took to bed with what was supposed to be 
 inflammation of the lungs, for which her chest was poulticed. 
 About a week ago a rash appeared on her abdomen, and about 
 that time the diarrhoea ceased. 
 
CASES SYMPTOMATICALLY TREATED. 205 
 
 We received her temperature record as taken by the District 
 Nurse, from September 24th. From the 24th to the 28th it 
 ranged from 1 03° to 105° ; on the latter day she was sponged, 
 and had a dose of antipyrim, and it did not afterwards rise 
 above 102'6° ; mean 10 L "8". 
 
 She has been married seven months, and is a well-developed 
 woman ; dark complexion ; flushed face ; bright eyes, pupils 
 dilated ; and expression anxious. Tongue dry and furred. 
 She has a troublesome cough, and scanty expectoration. 
 Pulse 112, soft, weak, and small. Heart's sounds clear. There 
 are numerous cooing rales all over the chest. There are 
 numerous lenticular rose spots over the abdomen, which is 
 distended. There has been very little diarrhoea since she 
 took to bed. After an enema she had three loose, yellow, 
 alkaline, motions. She was ordered 4 pints of milk, 12 ounces 
 of bread, and a cough mixture. 
 
 October 2nd. Yesterday evening her temperature reached 
 102"6°, but has fallen this morning to 99°. There is marked 
 muscular tremor about the mouth, and in the lower limbs. 
 Knee-jerks present ; ankle clonus well marked on left side. 
 Urine alkaline, sp. gr. 1019, slightly albuminous, and with 
 Ehrlich's test gives a deep port wine colour. Net weight 
 109 lb. On October 4th her temperature became normal : 
 14th, net weight. 111 lb. She was discharged quite well on 
 October 22nd. 
 
 Case 47. Typhoid Fever ; Cure. 
 
 Thomas K., aged 13, nephew of the last patient, and son of 
 the woman who was afterwards received and died (Case 21). 
 Admitted October 1st., about the end of the second week of 
 illness. He is a poorly nourished boy with a languid listless 
 appearance. Tongue moist but furred. Pulse quick and feeble. 
 Skin hot and dry. Pupils dilated. Heart's sounds clear. 
 There are numerous rhonchi all over chest. Knee-jerks 
 present ; marked ankle clonus, especially on left side. 
 Temperature, 101' to 102-4°. Urine gives a deep purple 
 colour with Ehrlich's test. Net weight 53^ lb. Milk 4 pints, 
 
206 THE TREATMENT OF TYPHOID FEVER. 
 
 and 8 ounces of bread. Six grains of periodate crystals every 
 four hours. 
 
 His temperature became normal on October 7th. 10th, IJL 
 CafFeinse, gr. i. Tinct. Cinchonae Co., ]\x. Aq. Chloroformi, ad §i. 
 Every four hours. 14th, net weight 52 lb. 20th, fish diet. 
 24th, weight 56 lb. Discharged quite well on October 27th. 
 
 Case 48. Heart Disease ; TypJioid Fever ; Cure. 
 
 Edward M., aged 6, admitted October 4th, 1890. About 
 nine months ago he got a severe attack of rheumatic fever, 
 with which he was confined to bed for seventeen weeks, and has 
 not been well since. His present illness began about ten days 
 ago, with headache and pains in the abdomen. He has been 
 confined tq bed since September 28th, and on the 29th he had a 
 severe attack of epistaxis. He has had about three loose, yellow 
 motions each day. He is a well nourished child, but rather 
 ansemic. Tongue furred in centre, papillae enlarged. Motion 
 yellow, acid, and offensive. Temperature 100° to 102°. Pulse 
 104, visible pulsation in vessels of neck, veins full. There are 
 well marked mitral systolic, and aortic systolic and diastolic 
 murmurs. At the bases of lungs there is impaired percussion 
 with feeble breath sounds. Urine gives Ehrlich's reaction. Net 
 weight 37i lb. Ordered 3 pints of milk, and boiled bread and 
 milk, with extract of malt ; 5 grains of /3-naphthol, every four 
 hours. 
 
 October 6th. Heart's sounds almost inaudible, there are 
 double aortic murmurs, and a systolic murraur at the apex, 
 
 October 14th. Weight 36^ lb. ; 24th, 37 lb. 
 
 October 25th. Discharged, quite well from the typhoid 
 fever, and in fair general health. 
 
 Case 49. Mild case of Tyijhoid Fever ; Cure. 
 
 Mary Ellen T., aged 23, worker in belt factory. She says 
 about five years ago she was in Netherfield Road Hospital with 
 fever. Since that time she has suffered from constipation, her 
 bowels being only moved every three or four days. Her 
 present illness began eleven days ago with headache, and 
 
CASES SYMPTOMATICALLY TREATED. 207 
 
 vomiting, the latter sympton lasted for three days, and the head- 
 ache still continues. She also felt pains in her back and legs, 
 and has had about three watery motions each day. She has 
 been confined to bed for the last eight days, and attended by Dr. 
 Permewan, who sent her in here. Temperature 104". Pulse 
 92. 
 
 October 9th (twelfth day). She passed a restless night, and 
 did not sleep at all, she is languid and heavy this morning. 
 Face rather pale and relieved by malar flush. Eyes heavy, but 
 glistening, complains of headache. Tongue moist, coated with 
 white fur. Sordes on teeth and lips. She is very thirsty. 
 She speaks in a dull apathetic tone, and is very deaf. Skin 
 hot and dry. Abdomen rather distended. Splenic dulness, 5f 
 by 4^ inches. There is no rash. There are well marked linae 
 gravidarum, she gave birth to a child five years ago. Net 
 weight 107 lb. Ordered 4 pints of milk, and 12 ounces of bread, 
 and 2 ounces of butter. Six grains of /3-naphthol every 4 hours. 
 She passed through an uneventful attack of typhoid fever, and 
 her temperature became normal on the twentieth day. x\fter 
 this her bowels became confined, and she required frequent doses 
 of calomel, and enemata. On the twenty-third day the 
 naphthol was stopped, and she was ordered a mixture of 
 caffeine, and cinchona. 
 
 Twenty-eighth day, Net weight 104 lb. Thirtieth day, she 
 was placed on fish diet. 
 
 October 31st. Weight 1051b.; November 7th, 1081b. 
 Ordinary diet. Discharged November 10th quite well. 
 
 Case 50. Mild case of Typhoid Fever ; Cure. 
 
 Margaret McM., aged 13, domestic servant, admitted to 
 hospital October 9th, 1890. Her illness began on the 2nd inst. 
 with headache and drowsiness. Since the 4th she has had 
 diarrhoea, about eight motions daily, and on the 5th pain began 
 in the back and abdomen. Her appetite is bad ; tongue large, 
 flabby, coated with a white fur, moist, and tremulous. Over 
 the trunk there are about a dozen elevated rose spots disap- 
 pearing on pressure. Respirations 16. Pulse 116, fair tension. 
 
208 THE TREATMENT OF TYPHOID FEVER. 
 
 Face pale, eyes suffused. Net weight 641b. Ordered six pints 
 of milk. 
 
 October 11th. She is rather better, the headache and pain 
 in the back have disappeared. Pupils large, tongue moist. 
 There are ten more rose spots to-day. Respirations 13. Pulse 
 112. Temperature 99' to 10 1-6 \ 
 
 October 12th. Four or five fresh spots on the trunk : bowels 
 moved twice after three grains of calomel. Respirations 17. 
 Pulse 108. 
 
 October 14th. Boiled bread and milk. 
 
 October 17th. Net weight 641b. 19th, patient steadily 
 improving. She sleeps well and takes her food well. Tongue 
 much furred. The epigastric and abdominal reflexes are very 
 active. Knee-jerks not exaggerated, slight ankle clonus. 
 Plantar reflexes almost absent. 25th, weight 641b. 29th, 
 one egg. 
 
 November 8th. Net weight 721b. 11th, ordered Blaud's 
 pills, loth, 74^ lb. 18th, discharged in good condition. 
 
 Case 51. Mild case of Typhoid Fever ; Cure. 
 Michael B., aged 19, painter, admitted to hospital November 
 3rd, 1890, with typhoid fever of about ten days duration. He 
 has been confined to bed for last nine days, and has been 
 attended by Dr. Price. On admission the fever was mild, but 
 there was ankle clonus on both sides. Net weight 1041b. His 
 treatment in hospital consisted of four grains of /3-naphthol 
 everv four hours, and during convalescence a mixture of 
 caffeine, cinchona and strychnine. He was put on fish diet 
 on November 11th, and on ordinary diet November 19th. He 
 was discharged quite well November 26th. 
 
 Case 52. Typhoid. Fever ; Salivation ; Cure. 
 Mary B., aged 29, married, admitted to hospital November 
 5th, 1890, on her arrival from New York. She aborted in 
 August, and since then has been in bad health, and was 
 returning to England for the benefit of her health. About 
 five weeks ago she had an attack of diarrhoea, which lasted 
 
CASES SYMPTOMATICALLY TREATED. 209 
 
 ten days. Her present illness began three clays after leaving 
 New York with diarrhoea, which has since continued, so that 
 we reckoned the day of admission as the sixth day of illness. 
 Her temperature on admission was 99-6" ; on the seventh day 
 day it reached 102-6' ; and on the eighth day 103-6 ; the mean 
 temperature of 18 records on the eighth, ninth, and tenth days 
 was 102-6°. Pulse 120, small, and compressible. Tongue dry 
 but clean ; breath offensive. Bowels acted three times on the 
 seventh day after a dose of castor oil. Motions liquid, alkaline, 
 and offensive. Abdomen distended. Hepatic dulness extends 
 one inch below margin of ribs. Splenic dulness increased, no 
 pain or tenderness. Heart and lungs healthy. No ankle 
 clonus. Net weight 92 lb. Urine acid, sp. gr. 1012, a trace 
 of albumen, and Ehrlich's test gives a deep ruby colour. She 
 was ordered bread and milk diet, and ten grains of naphthaline 
 every four hours. 
 
 November 10th (eleventh day). She complains of severe 
 pains in feet and ankles. Tongue dry, furred in the centre, 
 and clean at the tip and edges. There was considerable 
 abdominal distension yesterday, and she received two orains 
 of calomel. Bowels acted well this morning : motion formed, 
 yellow, acid, and very offensive. Pulse 112. Temperature 
 101'^ to 102-6'- 
 
 From the fifteenth day there were marked mornino- 
 remissions, but her temperature did not become normal till 
 the twenty-sixth day. 
 
 On the twenty-ninth day the naphthaline was stopped, and 
 she was ordered a mixture of caffeine and cinchona. Her net 
 weight was then 871b., showing a loss of 5 1b. in 21 days. 
 Her bowels were rather constipated throughout, and she had 
 frequent doses of calomel : the total quantity given up to 
 December 2nd was 37 grains. It was then noticed that she 
 was presenting distinct signs of salivation. A gargle of 
 peroxide of hydrogen was ordered, and, afterwards, one 
 containing chlorinated soda. 
 
 December 4th. There is marked ulceration along the gums 
 of both upper and lower jaws, and of the cheeks opposite the 
 
210 THE TREATMENT OF TYPHOID FEVER. 
 
 teeth. On the internal surface of the lower lip, and on the 
 mucous membrane of the buccal cavities, there is a very 
 extensive exudation of a tough leathery membrane of a 
 distinctly diphtheritic appearance. Breath very offensive. ^ 
 caffeinaB, gr. ii. Tinct. Cinchonse flav. ri^xxx. Potassii 
 Chloratis, gr. xv. Potassii lodidi, gr. v. Aq. ad §i. Draught to 
 be taken every four hours. Ordered gruel and green 
 vegetables. 
 
 The ulcers soon showed signs of healing. On December 27th, 
 she was placed on fish diet, and on ordinary diet, January 12th, 
 189 1. January 2nd, net weight 91^ lb. ; 9th, 97 lb. Discharged 
 quite well on January loth, 1891. 
 
 Case 53. Typhoid Fever ', Cure. 
 
 Thomas J., aged 9 years, admitted to hospital, January 5th, 
 1891. His mother says that he took ill a fortnight ago with 
 headache and chilliness, and for the past week he has been 
 confined to bed. He has been very thirsty and has had two 
 loose, yellow motions daily. Temperature to-day 103° to 104°. 
 Net weight 45 lb. 
 
 January 6th (fifteenth day). He passed a very restless night, 
 was delirious and got out of bed several times, and slept very 
 little. He is now quite conscious. Face flushed. Eyes bright. 
 Pupils medium size. Tongue dry, coated with a thick brownish 
 fur in centre, and transversely Assured. Lips and teeth covered 
 with sordes. There has been slight epistaxis. He had one 
 grain of calomel last night and an enema this morning, and 
 during the day he had three loose, yellow, alkaline very 
 offensive motions. Urine passed involuntarily. Heart's sounds 
 clear. Pulse 112, small and soft. There are dry bronchitic 
 rales all over chest, and at bases the percussion is impaired and 
 there are crepitant rales. He is much troubled with cough, 
 but no expectoration. Abdomen is distended, tympanitic, and 
 tender on pressure. Splenic dulness increased. There are 
 numerous elevated rose spots on chest and abdomen. Cannot 
 elicit knee-jerk on left side, present but not well marked on 
 right side. No ankle clonus. Ordered three pints of milk 
 
CASES SYMPTOMATIC ALLY TREATED. 211 
 
 and six ounces of bread. /^-naphthol, gv. vi., every four 
 hours. 
 
 January 7th. He had a much better night. Pulse 124, not 
 so compressible. Motions of a pea-soup character. Ankle 
 clonus present on left side. Temperature 102° to 103". Urine 
 gives a light ruby colour with Ehrlich's test. 
 
 After the Hfteenth day the temperature did not at any time 
 exceed 101°, and it became normal on the twenty -fifth day, 
 and afterwards remained so. He had usually about one loose 
 alkaline motion each day. 
 
 On January 23rd (twenty- eighth day), net weight 421b. 
 The naphthol was stopped, and the following mixture ordered. 
 li Tinct. Cinchonfe Co, 3i. Tinct. Belladonna? ]\y. Aq. 
 Chloroformi, ad §i. Draught thrice daily. 
 
 January 26th. Fish diet ; 30th, net weight 44 lb. February 
 6th, net weight 48 lb. ; 7th, ordinary diet ; 14th, net weight 
 531b.; 20th, 561b.: 23rd., 56 lb. Discharged this day quite 
 well. 
 
 Case 54. Typhoid Fever ; Cure. 
 
 Alice J., aged 5, sister of the last patient, admitted Januar}^ 
 23rd, on the 9th day of illness. She is a fairly well nourished, 
 and apparently healthy child. She is very apathetic. There 
 is a pink flush on both cheeks. Pupils dilated. Lips dry, 
 brown and cracked. Sordes on teeth. Tongae dry, glazed und 
 red, with epithelium slightly denuded. She is troubled with 
 a slight cough, and there are a few dry bronchitic rales over 
 chest. Pulse 144. Abdomen distended and tympanitic. Spleen 
 large. There are a few rose spots on chest and abdomen. 
 Motions loose, yellow, alkaline, and offensive. Knee-jerks 
 present. No ankle clonus. Net weight 40 lb. Diet: three 
 pints of milk and three ounces of bread. \\ Salol, gr. v, every 
 four hours. 
 
 There were considerable daily fluctuations of temperature, 
 the range being usually from 100" to 103", and on the twenty- 
 tirst day it became normal. There was a considerable amount 
 of diarrhoea, and the urine gave Ehrlich's reaction. On tin 
 
212 THE TREATMENT OF TYPHOID FEVER. 
 
 twenty-fourth day, the salol was stopped, and she was ordered 
 a grain of caffeine and 15 minims of tincture of cinchona 
 every four hours. On the twenty-sixth day, she weighed 
 38 lb. On the twenty-seventh day (Fehruary 10th), placed on 
 fish diet. 
 
 February 19th, ordinary diet, one egg-^ and one pint of 
 milk. 
 
 February 20th, weight 40J lb. ; 23rd, discharged quite well. 
 
 Case 55. Typhoid Fever ; Cure. 
 
 Arthur J., aged 20 months, admitted to hospital January 
 27th, 1891. This is one of four children of the same family at 
 present in this hospital with typhoid fever. His illness began 
 four days previously, and he is now very drowsy and apathetic. 
 Heart and lungs healthy. Pulse 132, moderately strong. 
 Temperature 103-8°. A few suspicious typhoid spots on chest 
 and abdomen. Abdomen distended. He has not been weaned. 
 Net weight 29 lb. Knee-jerks present, but not easilj'- elicited. 
 No ankle clonus. Ordered two pints of milk ; salol, three 
 grains every four hours. There were considerable daily 
 fluctuations of temperature, and after the eighth day it seldom 
 rose above 101°, and it became normal on the fourteenth day. 
 Discharged quite well, February 5th, 1891. Net weight 30 lb. 
 
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