(ENTERIC FEVER)
In writing of these acute diseases which are self-limiting, it is
understood that osteopathy aborts, overcomes symptoms and otherwise
changes conditions frequently. When this occurs the case is not typical
and it is a typical case which is here described.
=Definition.=—An acute, infectious disease caused by the bacillus
typhosus. It is characterized anatomically by hyperplasia and definite
lesions of Peyer’s patches and mesenteric glands, and enlargement of
the spleen, and clinically by its slow onset, often diarrhea, abdominal
tenderness, tympanites, fever, headache, and rose colored spots on the
abdomen.
=Osteopathic Etiology and Pathology.=—Lesions to the lower dorsal and
lumbar regions are always found, which impair the innervation and
vascular supply of the intestines and cause defective nutrition. This
is the most important predisposing cause, although general lowered
vitality from overwork, improper food, unhygienic environment, and
insanitary surroundings, are also of great importance. It is possible
that one’s vitality may be so lowered that the bacillus of Eberth,
if of sufficient numbers or virulency, will find a suitable medium
wherein to multiply and grow, and thus the spinal lesions found in
these cases are the result of reflex irritation. But the most probable
underlying cause is the spinal lesion, and given two individuals with
equal likelihood to infection, one with the spinal lesions and the
other not, the former within all probability will be the more likely
to suffer an attack. The severity and extent of the osteopathic lesion
undoubtedly bears a direct ratio to the probability of attack from
an infectious disease. Typhoid fever usually occurs between the ages
of fifteen and thirty years. Some families are more susceptible than
others. The autumn months, especially after a dry, hot summer, favor
the disease. One may be reasonably certain that whenever there is a
case of typhoid the individual has not been careful as to diet, or
drinking water, or some rule of health, and wherever there is an
epidemic it can always be traced to insanitary surroundings, the water
supply, contaminated garden truck or other food, sewage, etc.; although
this does not preclude the probability that the osteopathic lesion or
lowered vitality of Peyer’s patches and mesenteric glands from other
causes are important and many times primal etiological factors. The
specific poison may be so virulent that practically no one escapes and
again those of lowered vitality only will succumb to an attack.
The =exciting cause= is a special micro-organism, the bacillus of
Eberth. The contagion may be carried through the air from one person
to another, but this is rarely the case. Though the water is the most
common mode of conveyance, the bacillus has been found during epidemics
in both water and milk. The water may be contaminated by the intestinal
discharges which have not been properly disinfected. Extreme cold does
not destroy the typhoid germs. Milk may be infected from the milk-can
being washed with the contaminated water or the unclean hands of the
milker. In fresh milk the germs multiply rapidly. Salads, celery, ice
and fruits may be contaminated. Oysters have become infected while
being fattened or freshened. It is thought by some that the poison is
not eliminated from the sick in a condition capable of transferring
disease to a healthy person, but must undergo changes in the soil
before it is able to cause the disease in another. Typhoid fever may be
caused, however, by direct contact with the stools. Filth, sewers, or
cesspools do not directly cause the disease, but they form a suitable
medium for the preservation of the typhoid germs.
=Pathologically=, the characteristic lesions in typhoid fever consist
of changes in the lymphoid elements of the bowels. These changes
are most striking in the solitary glands and Peyer’s patches. The
alterations which occur may be divided into four well defined stages:
(1) =Infiltration=—the glands are enlarged from infiltration and there
is marked cell proliferation, particularly Peyer’s glands in the
jejunum and ileum and to a lesser extent those in the large intestine.
The glands become pale and prominent. Occasionally the solitary glands,
which are usually deeply imbedded in the submucosa, become prominent
also.
=Microscopically=, the capillary blood-vessels are at first
considerably dilated, but later become more or less contracted,
giving an anemic appearance to the follicles. The adjacent mucosa and
muscularis may become infiltrated. The cells have the character of
lymph corpuscles, some of which are larger, epithelioid in character,
containing several nuclei. From the eighth to the tenth day this
medullary infiltration reaches its height and then undergoes either
resolution or necrosis.
(1) =Resolution= takes place by a granular or fatty infiltration of the
cells. This produces pitting of the swollen follicles, which may cause
small hemorrhages.
(2) =Necrosis.=—With all the severe cases of cell infiltration,
hyperplasia of lymph follicles reaches a stage where resolution is
impossible and necrosis occurs. The necrosis is partly due to the
choking of the blood-vessels and partly to the direct action of the
bacilli. The necrosis may involve only the superficial layers of the
mucosa or it may extend deep into the muscular coat and even perforate
the outer or serous coat. Usually, however, this does not extend
below the submucosa, mucosa, or muscularis. Not all of the patches
necessarily slough, but as a rule it is always more intense toward the
ilio-cecal valve.
(3) =Ulceration.=—The extent and depth of the ulcers depend upon the
amount of the necrosis. Large ulcers are sometimes formed, especially
in the lower end of the bowel, by the union of several. The edges
are swollen and undermined. The base is usually smooth and formed of
submucosa. Perforation of the bowel occurs in a small percentage of
cases; more commonly the ulcers heal. The perforations may be multiple,
but rarely exceed two in number.
(4) =Healing.=—Cicatrization begins about the fourth week. This
granulation tissue covers the floor. It is sometimes formed with
connective tissue and a new growth of epithelium results. The gland
is ultimately replaced by a depressed scar with a smooth, pigmented
surface. The majority of deaths occur before this stage is reached. The
gland structure is never regenerated.
The =mesenteric glands= show intense hyperemia and later become
enlarged and softened, but rarely ruptured. The glands at the lower end
of the ileum are markedly involved.
The =spleen= is enlarged, softened, and diffluent. Occasionally rupture
occurs. Infarction is not a rare occurrence.
The =liver= shows parenchymatous and granular degeneration, and the
cells are found to contain much fat. Infarction abscesses and acute
yellow atrophy occur in rare instances. Diphtheritic inflammation of
the gall-bladder sometimes occurs and the bile is thinner and paler
than normal.
The =kidneys= also show parenchymatous degeneration. They are pale in
appearance, with slight cloudy swelling. Microscopically, there are
seen granular and fatty infiltration of the cells of the convoluted
tubules. Rarely, there is acute nephritis which may be hemorrhagic.
There may be miliary abscesses in which typhoid bacilli have been
found by some observers. Diphtheritic, but more frequently catarrhal,
inflammation of the pelvis of the kidney may occur. Catarrh of
the =bladder= is not infrequent and even sometimes diphtheritic
inflammation is present. Rarely orchitis is encountered.
=Hypostatic= congestion of the =lungs= is not uncommon. Gangrene and
hemorrhagic infarction are sometimes present. Lobar pneumonia may be a
complication.
In the =larynx= ulceration is sometimes met with bacilli, however, have
not yet been found in these ulcers. Diphtheritis of the pharynx and
larynx may occur. Catarrhal or croupous pharyngitis may occur; while
swelling of the follicles of the pharynx and base of the tongue is
frequently noticed.
=Peritonitis= is always present in fatal cases in which perforation
of the bowel has taken place. The perforation may occur in ulcers
from which the sloughs have already separated, or it may be caused by
a necrosis of all the coats. Extensive peritonitis may occur without
perforation, and is probably due to extension of the inflammation to
the peritoneum.
The =heart= may be affected. Endocarditis is rare, while pericarditis
is much more frequent. Myocarditis is frequently met with, the cardiac
muscles presenting parenchymatous and rarely hyaline degeneration.
The =arteries= are frequently found to be involved. These conditions
(obliterating arteritis and partial arteritis) may affect the smaller
vessels, especially those of the heart, but more commonly affect the
arteries of the lower extremities. Thrombosis of the veins, especially
of the femoral, and more rarely of the cerebral veins and sinuses,
occurs.
Granular and hyaline changes in the voluntary =muscles= may occur. This
degeneration does not affect the whole muscle but involves only certain
fibres. Regeneration takes place during convalescence.
With the nervous system meningitis is rare. The peripheral =nerves=
are frequently the seat of parenchymatous changes. The ganglia of the
trunks of the vagi present an inflammatory change.
The =blood= presents little change. During the first two weeks the
red corpuscles gradually decrease in number until the first week of
convalescence, after which they gradually increase in number. There is
often a marked decrease in the number of leucocytes. Leucocytosis is
absent. The hemoglobin is always reduced.
=Symptoms and Course.=—The incubation period varies from a few days to
two weeks or longer. During this time the patient may feel in his usual
health, but more often there is a feeling of languor and indisposition
to exertion, loss of appetite, slight coating of the tongue, nausea,
headache, chilliness, but seldom a decided rigor, pains in the back or
legs and nose-bleeding. Any of these symptoms may be present and last
usually from a few days to a week or more. These symptoms increase in
severity and the patient takes to his bed. The invasion as a rule is
gradual.
The =first week= dates from the onset of the fever which generally (but
by no means in all cases) rises steadily during the first week a degree
or a degree and one-half each day, reaching 103 or 104 degrees F. The
pulse is quickened to 90 to 110 per minute and is full, of low tension
and sometimes dicrotic. There is great thirst, also a coated tongue.
The skin is hot and dry and there is rather intense headache. Unless
the fever is high there is no delirium. The sleep is disturbed and
there may be mental confusion and wandering. Cough with some thoracic
oppression is not uncommon at the onset. The abdomen is slightly
distended and tender. There may be either constipation or diarrhea. The
spleen is somewhat swollen and a rose colored rash appears on the skin
of the abdomen and chest.
During the =second week= the fever remains high and exhibits the
continued type, the morning remission being slight. The pulse is
accelerated. The headache disappears, but there is marked mental
dullness and slowness and there may be a mild delirium at night. The
tongue is coated and the lips are dry. The abdomen is tympanitic and
tender. Diarrhea replaces constipation. The case may prove fatal during
this week from the result of nervous or pulmonary symptoms, hemorrhage,
or perforation.
The fever changes in the =third week= from a continuous to a remittent
type. The pulse ranges from 110 to 130. The patient is very weak.
Complications may arise, as pulmonary symptoms, feebleness of heart,
intestinal hemorrhage, perforation, and peritonitis.
In favorable cases during the =fourth week= the fever begins to decline
and the general and local symptoms gradually disappear. In protracted
cases the =fourth= and =fifth= weeks may present the symptoms of
the third week. Frequently the following aggravated symptoms are
added: stupor, delirium, increased weakness, rapid, feeble pulse,
and distended abdomen. Heart failure and inflammatory complications
increase the danger.
During the =fifth= and =sixth weeks= a few cases will show irregular
fever. Great care should be taken that complications do not occur.
The =fever= is the most important and characteristic symptom and from
the temperature alone a diagnosis may be made. During these stages of
development, which is the first four or five days, the temperature
rises steadily; the evening temperature being about a degree or a
degree and one-half higher than the morning remissions, reaching 104
or 105 degrees F. at the end of the first week. When the =fastigium=
is reached the fever persists with slight morning remissions. At the
end of the second and throughout the third week the temperature becomes
more remittent and there may be a difference of three or four degrees
between the morning and evening temperature. During the last stage the
fever falls by =lysis=, forming a more or less regular step-like line
of descent. The stage lasts from one week to ten days.
When the disease sets in with a severe rigor the fever frequently rises
at once to 103 or 104 degrees F. In the lightest forms the fastigium
may be almost absent; defervescence setting in upon the first day of
the fastigium and in many cases defervescence occurs at the end of
the second week and the temperature may fall rapidly, becoming normal
in ten or twenty hours. This fall in the temperature may take place
without any apparent cause or it may follow an intestinal hemorrhage.
The temperature often falls many hours before the blood appears in the
evacuations. The occurrence of peritonitis is also marked by a sudden
fall in the temperature. =Hyperpyrexia= in typhoid fever is not very
common except just before death.
After the temperature has been normal for several days there may be
a sudden rise of the temperature to 102 or 103 degrees F. This may
persist for a couple of days and then return rapidly to the normal.
These =recrudescences=, as they are called, are quite common and are
caused most frequently by errors in the diet, constipation, excitement
or mental emotion. These elevations in the temperature are found most
frequently in children and persons of a nervous temperament.
=Afebrile Typhoid= is of very rare occurrence. The patient has all the
characteristic symptoms of typhoid fever with the exception of a fever.
The =rash= is highly characteristic. It appears about the eighth or
tenth day, usually upon the skin of the abdomen or chest, rarely
found elsewhere on the body. It consists of a variable number of rose
colored spots distinctly elevated, and disappear on pressure. These
spots last three or four days and appear in successive crops. Vivid red
erythematous eruptions upon the chest and abdomen are commonly seen
during the first week of typhoid fever. Urticaria is rarely seen.
Sweating characterizes some cases of typhoid fever, but generally the
skin is dry. This may occur with or without chilly sensations or actual
rigors. In some cases there may be recurring paroxysms of chills,
fever, and sweats and they may be mistaken for intermittent fever.
Edema of the skin may occur and is usually due to anemia or cachexia
and sometimes to nephritis. Local edema may occur as the result of
vascular obstruction, particularly thrombosis of the femoral vein.
There is a peculiar musty odor exhaled from the skin in typhoid fever,
particularly if the skin has been neglected. In all protracted cases
=bed-sores= are likely to develop. The =hair= is apt to fall out but
is generally renewed. The nails also suffer and ridges can usually be
observed upon them.
=Intestinal symptoms= are very inconstant. Usually there is
constipation at the onset and this may persist throughout the disease
although a moderate diarrhea may occur throughout the disease. The
severity of the diarrhea is due most probably to the degree of the
catarrh rather than to the extent of the ulcers. It is probable that
the discharges are more frequent when the catarrh involves the large
intestine. The number of discharges average, as a rule, from two to
four or more daily. The stools are either fluid or of the consistency
of jelly, of a grayish-yellow color, alkaline in reaction and are very
offensive.
=Hemorrhage= is a serious symptom, but by no means always fatal. This
usually occurs in cases of considerable severity and it generally
occurs at the time of the separation of the sloughs during the third
week. When it occurs quite early in the disease it is generally the
result of hyperemia. It may be so slight as not to be noticed by the
eye or it may be from one to three pints. Intestinal hemorrhage,
however slight, is always a grave symptom. There may be symptoms of
collapse and fall of temperature, or it may occur without any symptoms.
=Meteorism= is an almost constant symptom, and when excessive adds to
the seriousness of the case and corresponds generally with the extent
of local lesions. Abdominal tenderness and gurgling upon pressure in
the right iliac fossa may be present; pain is generally absent, and
when present is usually slight.
=Perforation= almost invariably causes fatal diffuse peritonitis and
is the most serious complication. It may occur at any time but is most
common between the second and fourth weeks. It is usually indicated
by sudden acute pains in the abdomen and symptoms of collapse. As
a rule symptoms of =peritonitis= appear at once; distension of the
abdomen, great tenderness, and rigid abdominal walls. Vomiting, pinched
features, and rapid, small pulse shows general collapse of the
circulatory system.
=Bronchitis= is almost invariably present as an initial symptom. It is
indicated by the existence of sibilant rales. The cough is generally
slight.
Hypostatic congestion of the =lungs= and edema, due to enfeeblement of
the cardio-pulmonary circulation, in the latter part of the disease are
not infrequent.
The =pulse= as a rule is not very frequent and is generally not in
proportion to the fever until late in the disease; 90 to 120 is
the usual range. During the first week it is about 100, full, and
frequently dicrotic; later it becomes more rapid, feeble and small.
In severe cases during the extreme debility of the third week the
pulse may reach 150 or more (the so-called running pulse). During
convalescence the pulse occasionally becomes subnormal and bradycardia
is met with more frequently than after any other acute fever.
The =blood= presents definite changes, some of which are important.
In cases where there is profuse sweating or copious diarrhea, the
red corpuscles may be relatively increased; this is due to the loss
of water. In most cases there is little change until the end of the
second week. During the third week there is generally a decrease in the
number of corpuscles and of the hemoglobin, which is always reduced.
=Leucocytosis= is always absent. The white corpuscles are slightly
diminished especially toward the end of convalescence.
During the first week there is generally persistent headache, sometimes
neuralgia. There are a few cases in which the effects of the typhoid
bacilli or their poison is manifested in the =nervous system= from
the very onset. There are violent headaches, retraction of the head,
rigidity, photophobia, twitching of the muscles, rarely convulsions,
all indicating meningitis as which it is occasionally diagnosed.
It must be remembered however, that all nervous symptoms may occur
independently of a lesion of the nervous system.
=Delirium= may exist from the onset, but it usually is not present
until the second or third week and only in the severer cases. As a rule
it is most marked at night. It is generally of the low, muttering type,
very seldom maniacal. When the patient picks at the bed clothes or
grasps at imaginary objects there is indication of danger, as it is a
serious symptom. Convulsions are rare.
The =urine= is diminished in quantity, high specific gravity, and of
dark hue. Both urea and uric acid are increased and the chlorids are
diminished during the first stages. About the stage of decline the
urine becomes light in color and greater in quantity than normal. The
specific gravity is lowered, urea and uric acid are diminished, and the
chlorids are increased. Febrile albuminuria is very common but of no
special significance. Acute nephritis may develop as a complication.
Pyuria is not an uncommon complication and post-typhoid pyelitis may
also develop.
=Malarial fever= may be associated with typhoid, especially in malarial
districts. Persons with tuberculosis, epilepsy, chorea, and other forms
of chronic nervous diseases are liable to typhoid fever. In epilepsy
and chorea the movements and fits usually cease during the attack of
typhoid fever.
=Varieties of Typhoid= are numerous and are named with reference to
the degree of severity which varies from extreme mildness to extreme
severity.
The =mild= or =abortive= form is of frequent occurrence. The onset is
usually sudden. The symptoms are similar to those of a typical case but
much milder and appear earlier than in the usual type. This form runs
its course in about two weeks. The fever usually reaches 104 degrees F.
In the =severe= or =grave= form there is high fever and the nervous
symptoms show a profound intoxication of the system. The grave types
are those associated with serious complications or those cases which
set in with pneumonia, Bright’s disease, or cerebrospinal symptoms.
In the =latent= or =ambulatory= form (walking typhoid) the symptoms
are very slight, the patient being hardly sick enough to go to bed.
The symptoms may be of this character throughout the attack, and the
patient may be able to be up and about. In other cases the first
symptoms are very mild, but later they may develop symptoms of the
severest type.
The =Afebrile= form is rare. =Hemorrhagic= typhoid is a very fatal but
rare form. In this type there are cutaneous and mucous hemorrhages.
=Diagnosis.=—As a general rule typhoid fever is easily recognized.
The Widal test should be made. At times the diagnosis may have to
be delayed until the distinctive signs appear, especially in those
cases which come on with severe headache, delirium, twitching of the
muscles, and retraction of the head. In these cases the diagnosis of
cerebrospinal meningitis is invariably made, until the appearance of
the colored spots on the abdomen, which must decide the diagnosis;
cerebrospinal meningitis being a rare disease and typhoid fever with
severe nervous symptoms quite frequent, it is more probable that it is
typhoid. At least one-half of the cases termed brain fever belong to
this class of nervous typhoid.
=Prognosis.=—A positive prognosis can not be made, as even the mildest
cases are liable to have severe complications develop at any stage of
the disease. Under osteopathic treatment the prognosis is undoubtedly
more favorable than with the treatment of the older schools. If the
osteopath can see the case early, the first week, there is always a
chance to abort the attack. In all cases there is the probability that
the attack will be shortened; this is a common experience. Price of
Mississippi, has treated many cases, and invariably when the patient
is seen early the attack has been shortened to thirteen or fourteen
days, whereas under other treatment the disease runs the usual course.
Adsit of Kentucky, White of New York, and the staff of the American
School of Osteopathy (Kirksville), as well as many others, have had
the same experience. And if the attack cannot be aborted or shortened
there is the further probability that the severity will be lessened
and complications prevented. The prognosis is always more favorable in
winter than in summer, and especially favorable in children. More women
die than men, and fat persons stand the disease badly.
=Treatment.=—Typhoid fever is one of the diseases that practitioners
of all the schools are agreed that drug therapeutics avail but little
in its treatment. The treatment of the older schools consists of
prophylaxis, good nursing, attention to hygienic principles, dieting,
and hydrotherapy. All of these have their places and are recognized
by the osteopathic school. But the above methods are of the defensive
only—allowing the disease to run its usual course and reducing the
likelihood of complications. On the other hand the above treatment
coupled with osteopathy, not only attacks the ravages of the disease
defensively, but of more importance, the disorder is attacked
offensively. Herein is where attacks are aborted, or shortened,
or severity lessened, or complications prevented. The efficacy of
osteopathy is due to the ability of the osteopath to treat disease,
not only prophylactically and palliatively, but of more consequence,
aggressively.
The correction of the spinal lesions in typhoid fever is of first
importance. This treatment effects a tendency toward equalized
circulation of the intestines. The vasomotor nerves are disturbed by
the above lesions which in turn produces stasis in Peyer’s patches and
the mesenteric glands. Reversely some of the spinal lesions may be due
to reflex stimuli, for “Kirk ... states that muscular contractions
produced by reflex activity are often more sustained than those
produced by direct stimulation of the motor nerves themselves.”[51]
=Prophylactic= treatment is very essential, for typhoid fever as a rule
is a preventable affection. Modern hygienic and sanitary resources
enable a community to reduce the number of cases to a minimum. The
number of cases in a locality depends almost directly upon the
condition of the water supply and drainage. Care should always be
taken in regard to the source of drinking water and milk. During an
epidemic the water should be boiled for half an hour before being used.
The patient should be isolated. In hospitals they should have special
wards; in families a special apartment should be given them. Hygienic
principles should be followed as in other infectious diseases.
The methods of disinfection must be rigid to prevent the spread of an
infection. The excreta (stools, urine, vomitus, and sputum) are to
be received into a bed-pan or any appropriate receptacle containing
half a pint of carbolic acid (one to twenty). Three or four pints of
the carbolic acid (one to twenty) should then be added to the bed-pan
and the contents mixed carefully before emptying. All utensils used
in handling the excreta are to be carefully disinfected by the same
material, and dried. After every stool the nates of the patient should
be cleansed by a cloth compress, wet with a solution of carbolic acid
(one to forty) and the cloth burned. The sick room should be thoroughly
ventilated each day. All utensils used about the patient in feeding
should be boiled in water immediately after using. The bed and body
linen is to be changed as soon as soiled and these, with all changed
bath towels, blankets and rubber sheets, should be received in a sheet
rinsed in carbolic acid (one to forty) and placed where they may be
soaked in the solution for four or five hours. The clothes are to be
boiled for half an hour. The rubber blanket is to be washed in the
solution, dried and aired.
The =General Management=, careful nursing and a regulated diet, is of
paramount importance in the treatment of typhoid fever. The patient
should be placed in bed as soon as the disease is determined and there
remain until the end of the attack. The room should be well ventilated
and have a sunny exposure if possible. The single woven wire bed with
soft hair mattress and two folds of blankets is best. A rubber cloth
should be placed smoothly under the sheet. When a good nurse cannot
be had, the attending osteopath should write out directions regarding
diet, bed linen, and utensils, and the disinfection of the excreta.
A liquid =diet= should be administered. Milk is most commonly used;
care being taken that it is thoroughly digested. If milk is not borne
well by the patient, other foods, as whey, sour milk, buttermilk, and
broths may be substituted. Give food that is easily digested and which
leaves but little residue. When milk is used alone, three pints at
least may be given to an adult in the course of twenty-four hours; and
it should always be diluted, preferably with plain water. Beef juice,
mutton or chicken broth may also be used when milk is not agreeable.
Albumin water, prepared by straining the white of eggs through a
cloth and adding an equal amount of water, is an excellent food. Well
strained, thin barley gruel is considered by many an excellent food
for typhoid fever patients. Cases not able to take nourishment into
the stomach, on account of vomiting and other causes, should be fed
rectally to support life. Do not force feeding to an unwarranted degree.
Recently a number of new diets have received commendation. These
include the “high calory” diet, which includes three pints of milk
with one of cream, two to eight ounces of milk sugar, eggs, butter;
sometimes cereals, toast, potato, and other soft foods are given.
A full sugar diet, as of candy alone, is based upon the immediate
absorption of sugar, its value as a source of energy, and the fact that
a plentiful carbohydrate supply lessens the danger of acidosis.[52]
The best drink for fever patients is pure, cold water and they should
be encouraged to drink freely of it. Barley water, ice tea, lemonade,
or even moderate quantities of coffee or cocoa, may be given.
By =Osteopathic Treatment= many cases of typhoid fever may be aborted,
if treated correctly, during the first week. If the stage of necrosis
of Peyer’s patches has set in, one can either lessen the severity of
the attack or, at least, shorten the usual course. During the stage of
infiltration, treatment to the intestinal splanchnics (chiefly from the
ninth to twelfth dorsal, the innervation to the jejunum and ileum) and
careful treatment over the abdomen is indicated. This treatment will
tend to lessen the intestinal catarrh and diminish the infiltration and
cell proliferation of the lymphoid elements of the intestines, and thus
produce unfavorable the conditions for the bacillus of Eberth. In other
words, increase the tone and activity of the intestines so that the
micro-organisms of typhoid fever will not find the proper tissue-soil
in order to grow and multiply.
All cases of typhoid fever present lesions in the dorsal or lumbar
spine and this is really the great predisposing cause of typhoid
fever. Correcting these lesions is absolutely necessary in order to
abort the disease. Some patients may have such a lowered vitality
to begin with that the recuperative powers of the body cannot be
rendered forceful enough in a short time to combat the effects of the
micro-organism. Carefully raising the cecum is very effective (A.
T. Still), but this must be done with the greatest of caution and
judgment. Dr. Still considers a posterior condition of the third,
fourth and fifth lumbars as typical in typhoid and that it inhibits the
lymphatics to the intestines.
R. L. Price has had excellent success in shortening the usual typhoid
course. His first treatment is to thoroughly empty the bowels by
enemata. This is followed by spinal, liver and splenic treatment, and a
liquid diet.
E. C. White has also treated a large number of typhoid cases with
marked success. He prefers to employ the Brand method (and it must be
properly used) from the start. He is, also, a thorough advocate of the
spinal treatment. In cases of constipation give a very light treatment
over the left iliac fossa. With all patients observe careful dieting.
White believes that many lesions of the spine arise from reflex
irritations during acute attacks. Careful, frequent attention to the
spine is demanded.
Hildreth, relative to abdominal and spinal treatment, writes as
follows: “In the abdominal treatment of typhoid fever, too much care
cannot be exercised; or in the spinal treatment, too much judgment
used in giving just the right kind of manipulation. There can be no
question relative to the seat of the disease, and consequently there
should be no trouble in knowing where or how to affect the nerves to
control the same. That Peyer’s patches or the right iliac region is
always involved, we all know. The spinal treatment should be applied
from the eighth dorsal to the first lumbar inclusive; this affects all
the lesser splanchnics and thus controls the circulation of the entire
bowel. And this treatment should be given, according to the symptoms
indicated, in each and every case. If the patient is constipated,
then the treatment should be more of a stimulative character, but if
diarrhea is present, as is commonly the case, the treatment should be
an inhibitory one. In the above I always finish with a very careful
treatment of the floating ribs on the left side; this affects the
lesser splanchnic nerves. In all cases I always carefully treat
the lower two or three lumbar vertebræ, which directly affects the
hypogastric plexus of nerves, and thus controls the circulation to the
lower bowel.
“In all cases I always treat the bowels directly, more or less, but
this treatment =must= be given with the very greatest =care= and the
best judgment, always governed by the condition of the bowel. By
no means manipulate the bowel, but just lay your hands flat on the
abdomen, and with the most gentle pressure inhibit the peripheral
nerves, thus either quieting an excited peristalsis or equalizing a
disturbed circulation. And with this treatment remember that the two
specific points in typhoid fever are the lower dorsal and lower lumbar
nerves.
“The above treatment is used, of course, in connection with all the
other necessary treatments, such as dieting, nursing, sponging,
relieving the headaches, etc. I am unalterably opposed to ice-packs for
the bowels in typhoid, for the reason it is too much of a shock. Cold
cloths are good and much better than ice, and should always be used
instead of ice.”
After the disease has become thoroughly established always make it a
point during each visit to examine the entire length of the spinal
column carefully and readjust any tissue, whether it be vertebra, rib,
or muscle, that may be found disordered. The bowels are to be watched
carefully and if constipated, they should be moved with a light enema.
Great care must be taken not to treat the abdomen roughly, if at all,
after the first week. The treatment might be very injurious to the
structures diseased. A light treatment over the liver and kidneys
each time is a wise precaution. The heart’s action, should be watched
carefully. In addition to the hydrotherapeutic treatment, the general
fever treatment should be employed. The patient should usually be seen
twice a day.
=Abdominal pain= is best relieved by light treatment over the abdomen
and by thorough treatment of the lower dorsal or lumbar region.
Applications of hot water will be helpful.
=Meteorism= can be relieved by raising the lower ribs and by direct
treatment to the abdomen. A change of diet may be beneficial. When gas
is in the large bowel an enema may be given to remove it.
=Diarrhea= and =constipation= are best controlled by the usual
treatment given the spine in such cases, and over the abdomen and the
liver. Light enemata may be given for constipation. The stools should
be examined when diarrhea occurs, as the presence of curds may cause
the aggravation.
=Hemorrhage= from the bowels demands absolute rest. It is probably
better to have the patient use the draw sheet for the evacuation.
Immediate and thorough treatment must be given to the spinal column
in the region of the intestinal nerves to the diseased area, so
that existing lesions may be corrected and the vascular area of the
mesentery equalized. Ice should be given freely and an ice pack placed
over the abdomen. Food should be restricted for ten or twelve hours.
If the peristalsis of the intestines is increased, an effort should be
made to control it through the vagi and splanchnic nerves.
In =perforation= hot applications, rest and thorough treatment of the
innervation to the peritoneum are of value, but immediate operation is
usually advisable.
=Insomnia= is best relieved by attention to the cervical region.
Relaxation of the muscles in this region and a quieting treatment to
the posterior occipital nerves, coupled with cold sponge baths, will
usually induce sleep.
In =delirium= attention to the circulation of the brain, by careful
treatment of the vasomotor system, and the Brand method of baths will
relieve this distressing symptom.
During =convalescence= the patient should be restricted from any mental
or physical exercise for a week or ten days and then should move about
with care. Solid food should not be given for ten days or two weeks. If
the temperature has been normal for ten days, it is then safe to allow
such food as eggs, milk puddings, and milk toast. If diarrhea should
persist, being due to ulceration, the diet should be restricted and the
patient confined to the bed. If constipation is troublesome relieve it
by enemata.
There are several beneficial effects obtained by =hydrotherapeutic
measures= that should receive careful consideration. Probably it is
of the least significance to lower the temperature; other beneficial
effects being of greater importance. When the baths are systematically
carried out, (1) there is obtained a general improvement of the
nervous system, the mind is rendered clear, muscular twitchings are
lessened, sleep is induced and the heart’s action strengthened; (2)
the respiration is stimulated, thus diminishing the liability of lung
complications; (3) the activity of the renal function is increased,
consequently allowing more rapid elimination of toxic matter; (4)
reduction of the temperature, and overcoming ill effects of high fever.
A cold water bath, or what is generally termed the Brand method, is
commonly employed. The following plan is usually followed. When the
temperature is above 102.5 degrees F., rectally, a bath of 70 degrees
F. is wheeled to the patient’s bedside and he is placed into it for
ten or fifteen minutes. The patient should be lowered into the bath by
means of a sheet. Enough water is used to cover the body and neck of
the patient. The head is sponged and the limbs and trunk are rubbed
=thoroughly= during the entire procedure. When the patient is taken
out he is wrapped in a dry sheet and covered with a blanket. This
procedure is gone through with every three hours if the case is severe,
otherwise once every seven or eight hours will be sufficient.
The luke-warm bath is occasionally used in private practice when one is
unable to use the Brand method. A bath of 90 degrees F. is employed,
which is gradually cooled ten or twelve degrees, after the patient has
been placed in it, by pouring cold water on the patient. This bath is
found very helpful. Also in private practice the cold pack is found
satisfactory. The patient is wrapped in a sheet wrung out of water at
65 degrees F. and cold water is sprinkled over him. Whenever there is
objection to any of these methods the body may be sponged off with
tepid or cold water when the temperature rises above 102.5 degrees
F., rectally. One limb should be taken at a time and then the trunk,
occupying altogether some twenty or thirty minutes.
The Great War brought the subject of typhoid vaccination before the
world with emphasis but its results are not, as yet, in shape so an
unbiased opinion can be formed. The army medical department will tell
us that it was an unqualified success but we do know that there were
serious outbreaks among inoculated troops who were living under most
hygienic surroundings in America. There were, also, outbreaks among
protected troops in France to the extent that the medical authorities
felt called upon to warn all medical officers that vaccination should
not be considered as protecting against unsanitary surroundings
and that great precaution must be observed, the same as under
non-vaccination conditions. This does not imply implicit confidence.
It is, also, a historical fact that the Japanese army, during the
Russo-Japanese war had as low a rate of typhoid without vaccination as
can, probably, be shown with it in this war. At that time they depended
entirely upon pure water and sanitation.
See reports of typhoid fever in A. O. A. Case Reports as follows: C. M.
T. Hulett, Series I, p. 7, J. H. Wilson, Series III, p. 3, F. E. and H.
P. Moore, and F. A. and E. S. Cave, Series IV, pp. 4 and 5.
In =paratyphoid fever=, an acute infectious disease caused by the
paratyphoid bacillus, the treatment is the same as for typhoid fever.
It is milder and similar to typhoid fever.