the rule of absolute quiet and rest laid down above, and that is when
called upon to treat typhoid fever in the built-up portion of our
large cities during the summer season. If the patient were still in
the first week of the disease, if his circumstances were sufficiently
affluent to enable him to surround himself with every comfort, and if
it did not involve a journey of more than a few hours, I should
unhesitatingly send him to the sea-coast. I have so often seen cases
prove fatal in summer in consequence of the great heat of the city--a
heat, too, which is sometimes almost as great at night as in the
day-time--that I should feel that I was giving him an additional
chance of life by sending him where the heat was, at least
occasionally, tempered by cool breezes from the ocean. During the late
war numbers of soldiers were frequently sent in the early stages of
{323} typhoid fever from the camps in the South to their homes or
hospitals in the North, and it is fair to say that they did at least
as well as those who remained behind. But when the journey may be
accomplished by means of Pullman cars and the other appliances of
modern travel the risk, and even discomfort, it involves to the
patient is reduced to the minimum.
As the disease is usually one of long duration, the patient being
rarely able to leave his bed under four weeks, and more frequently
being obliged to keep it for a much longer time, the sick room should,
wherever practicable, be large, airy, and provided with an open
fireplace, which is a much more efficient means of securing thorough
ventilation than an open window, while it is not liable to the
objection sometimes applicable to the latter of causing a direct
draught upon the patient. It is well, however, for the physician to
remember that the danger from this source is very much exaggerated by
the laity, and that patients in the febrile stage of typhoid fever do
not readily take cold. Still, the same end may generally be attained
without the least risk to the patient by opening a window in an
adjoining room. The temperature of the sick room should be steadily
maintained at between 65° and 68° F.
The careful regulation of the diet is also a point of great importance
in the management of typhoid fever; for in this disease there are not
merely the high fever and other exhausting symptoms, speedily inducing
excessive prostration, loss of strength, and emaciation, common to
many fevers, but there is also the peculiar ulceration of the bowels,
which gives rise to danger of its own and demands special
consideration in treatment. The food must therefore be not only
nourishing, but also readily digestible, and not likely to create
irritation in its passage through the intestines. All solid food
should therefore be excluded from the dietary of the patient as long
as the fever lasts. Indeed, it is better to continue this prohibition
even after the subsidence of the fever if rose-colored spots are still
to be seen on the abdomen or elsewhere, or if there exists a tendency
to diarrhoea or any other symptom indicating that the disease has not
fully run its course. Having myself seen some rather disastrous
results from a too early return to solid food, I have been accustomed
in my own practice to interdict its use until at least two weeks after
the beginning of convalescence. Jaccoud also lays much stress upon
this point, saying that the early administration of meat always gives
rise to fever, to which, from its cause, he gives the name of febris
carnis. On the other hand, Flint[97] and Peabody have recently
advocated the giving of solid food immediately after the cessation of
fever, in the belief that recovery is thereby promoted. Milk as an
article of diet is unquestionably to be preferred to all others in
typhoid fever. It is open, it is true, to the objection of
occasionally forming tough curds in the stomach, but this may
generally be prevented by giving the milk in small quantities at a
time, diluted with lime-water or barley-water or mixed with some
farinaceous substance. No positive general rule can be laid down as to
the amount to be given. This will be found to vary not only in
different cases, but also in the same case at different times. Indeed,
in those cases which begin abruptly with symptoms of gastro-intestinal
irritation, if it is forced upon the patient in large quantities it is
not only usually rejected, but also causes an aggravation of the
symptoms, while after {324} this irritation is allayed it will be
digested without difficulty. As a general rule, most adult patients
will be able to take from a quart and a half to two quarts of milk
daily, given in quantities of from four to six ounces every two or
three hours. It should be remembered, however, that if more is taken
than can be assimilated it will act as an irritant and increase the
diarrhoea. If, therefore, the stools contain undigested milk, the
quantity should be diminished. Patients are occasionally met with, but
not in as great number as is often asserted, with whom milk habitually
disagrees. In these cases it must of course be replaced in whole or in
part by some other article of food. Under these circumstances some one
of the liquid preparations of beef may be given with advantage,
although it may be objected to them also that they sometimes occasion
an increase of diarrhoea. Beef-tea or beef-essence, made from the
fresh meat whenever this can be obtained, is to be preferred to all
others; but when it cannot, that made from the preparations of
Johnston or Brand is the best substitute. When the stomach is very
irritable, Valentine's meat-juice, in consequence of the smaller bulk
in which it is given, often answers an admirable purpose.
[Footnote 97: _Medical News_, Mch. 29 and Apl. 5, 1884.]
Various farinaceous substances, such as farina, corn-starch, and
arrowroot, are also occasionally given in typhoid fever, and, although
the last named would seem to be indicated in cases in which diarrhoea
is a prominent symptom, their tendency to cause flatulence is so great
that their use in the acute stage of the fever has not found favor
among physicians generally. In convalescence, on the other hand, they
are generally perfectly well borne.
The subject of the administration of alcoholic stimulants in typhoid
fever may be conveniently considered in this connection. Some
difference of opinion exists in regard to the quantity in which they
should be given, and indeed in regard to the necessity for their use
at all in many cases, as, for instance, in those of young persons
whose health and habits had been good previously to the attack. I have
myself treated several such cases without alcohol, and have not been
able to perceive that their duration was longer and the result less
favorable than in cases in which it was given in the usual amount. It
is, moreover, not necessary to prescribe it always, even in very
severe cases, at the beginning of an attack. When given at this time,
it not infrequently does harm by increasing the fever. It should be
reserved, therefore, until the action of the heart grows feeble and
the first sound becomes indistinct. It is not possible to lay down any
general rule as to the amount to be given, even in severe attacks.
This will vary in different cases, and to a certain extent will be
determined by the effects it produces. If the pulse grows stronger and
the delirium diminishes under its use, it is doing good and should be
continued; if, on the other hand, there is increase of delirium and
restlessness, the quantity should be diminished.
In cases in which only a gentle stimulus is required wine in the form
of wine-whey will often be found to meet the indication fully.
Generally, however, it will be necessary to have recourse to whiskey
or brandy. The choice between these may usually be left to the
patient's fancy; brandy is, however, to be preferred in cases in which
diarrhoea is a prominent symptom. These stimulants should be given in
small quantities frequently repeated. In many cases a dessertspoonful
every two or three hours, {325} either diluted with water or, when the
stomach is irritable, with carbonic acid water or given in the form of
milk punch, will be sufficient. In others a tablespoonful every two
hours, or even at shorter intervals, will be required, but it will
rarely be necessary to exceed eight ounces a day for more than a few
days at a time.
Although the physician will not often be called upon at the present
day to encounter and combat the prejudice so common formerly against
the free administration of water in the febrile condition, he will
frequently find nurses and others not sufficiently alive to the
importance of supplying it when the patient, having fallen into the
typhoid state, ceases to ask for it. The high temperature which is
generally present in this condition, and the rapid combustion of
tissue which it causes, make a full supply of liquid an urgent
necessity which it is dangerous to disregard. Water is the best of all
diuretics, and it is important in this disease, as indeed it is in
many others, that the functions of the kidneys should be kept active,
so that the products of the combustion of the tissues may be
eliminated with their secretion. Care, however, should of course be
taken, as pointed out by Da Costa,[98] that water is not given in such
quantity that the desire for and capability of digesting food is
destroyed by it.
[Footnote 98: Preface to Wilson's _Treatise on the Continued Fevers_.]
In the few cases which begin abruptly with symptoms simulating those
of a so-called bilious attack the practitioner will usually content
himself with the administration of medicines calculated to allay the
irritability of the stomach and bowels. For this purpose I have found
the bicarbonate of potassa in solution, to which lemon-juice is added
at the moment it is taken, so as to produce an extemporaneous
effervescing draught, often an admirable remedy. In other cases I have
used with advantage small doses of calomel or blue mass, followed, if
necessary, by a gentle saline purge. When the symptoms have occurred
soon after a hearty meal, or when there is evidence that the stomach
is overloaded, it will occasionally be necessary to have recourse to
an emetic. Usually, the indications for treatment at the beginning of
an attack are much less definite, and even in the class of cases just
referred to they become so after the subsidence of the
gastro-intestinal symptoms. Indeed, the treatment in the larger number
of cases must be purely symptomatic until the nature of the disease
has fully declared itself. The presence of fever will suggest the use
of the neutral mixture, effervescing draught, or spirit of Mindererus,
combined, if there is decided tendency to evening exacerbations, with
sulphate of quinia in full doses. If there is much diarrhoea, Hope's
camphor mixture or opium in some other form may be given; if delirium
is a prominent symptom, ice or cloths wrung out of cold water should
be kept constantly applied to the head.
But even after all doubt in regard to the diagnosis has been dispelled
and the existence of typhoid fever has been recognized, the treatment
most in favor with physicians is in large measure symptomatic in
character. It is true that various specific treatments, to which
fuller reference will be made hereafter, have been lately proposed,
but the results obtained by them up to the present time where they
have been fairly tested are not so favorable as to induce the body of
the profession to adopt them to the exclusion of all other methods. It
is certain that no remedy or plan of {326} treatment has yet been
discovered which has the power of cutting the disease short, although
this power has been claimed at different times for several. Thus, at
one time quinia in very large doses was believed to possess it, at
another venesection, and at another cold baths. But experience has
shown that these and other perturbating remedies often do harm, and
there is good reason to believe that the apparent good which has
followed their use in a comparatively small number of instances may be
better explained by supposing that an error of diagnosis has been made
than by attributing to them the power of arresting the progress of the
disease. Medicines are, however, by no means useless in the treatment
of typhoid fever. There is no question that the disease is not only
generally conducted to a favorable issue, but that its duration is
often materially shortened, by their judicious use. It is evident,
however, that the treatment must vary with the severity of the attack.
In a few cases it is scarcely necessary to interfere with the course
of the disease by the administration of medicines. In others, on the
contrary, it is necessary to act promptly and energetically in order
to save life.
When called upon to treat typhoid fever, if the case is a mild one
with no bad symptoms, such as excessive diarrhoea, delirium, tremors,
and the like, and especially if the temperature does not rise higher
than 102° F., I am accustomed, after giving minute directions as to
the diet and general care of the patient, to prescribe from two to
three grains of sulphate of quinia four times daily. No great power in
reducing the temperature of the body can, of course, be claimed for
these doses, but experience has shown that the impression which they
make is useful, and they do not interfere with the administration of
the drug in larger quantities should this become necessary. Their
action, too, is tonic, and, as they rarely produce cinchonism, the
objection often made to the use of larger doses does not apply to
them. I am also in the habit of adding to each dose of quinia from ten
to fifteen drops of one of the mineral acids. These acids were
originally prescribed in typhoid fever under the impression that they
neutralized the cause of the disease, which was supposed to be an
alkaline poison. Although the results of recent research, which tend
to show that the cause of the disease is an organized germ, give no
support to this theory, they continue to be used by a large number of
physicians of experience. I do not know that any satisfactory
explanation of their action in typhoid fever has ever been given. They
are certainly tonics, and are therefore indicated, if not in the
beginning of the disease, as soon as the strength begins to fail. If,
as the disease progresses, the tongue becomes dry and fissured, and if
there is much tympany, it will be well to give, in addition to the
quinia, ten drops of the oil of turpentine in mucilage every two
hours. This was a favorite remedy of the late George B. Wood, the
distinguished professor of the Theory and Practice of Medicine in the
University of Pennsylvania, who attributed the improvement in the
symptoms which generally follows its use to a direct influence of this
medicine upon the ulcers in the intestines. Although inclined to
believe that the correct explanation of this improvement is its
stimulating action upon the circulation and secretions, I fully agree
with him in regard to its usefulness in many cases. Under its use I
have often seen the dry, fissured, and shrivelled tongue {327} grow
moist and throw off its coating much earlier than in all probability
it would otherwise have done.
No other than this simple treatment is required in a large number of
cases, but even in mild cases symptoms occasionally arise which render
necessary some modification of it. It will, however, be more
convenient to postpone the discussion of this part of the treatment of
typhoid fever until after the treatment of the more serious forms of
the disease has been considered.
When typhoid fever assumes a severe type, the success of the physician
in the management of the disease will depend largely upon the
readiness with which he detects indications for treatment and the
promptness with which he meets them. Usually, one of the first
symptoms to demand attention is the high temperature. This is not only
an early symptom in many bad cases, but may continue throughout the
attack; or it may suddenly supervene in cases in which the fever has
previously been moderate in degree, and when excessive may be the
direct or indirect cause of death. The reduction of the temperature is
therefore an indication the importance of which cannot well be
overestimated. Fortunately, there are several methods by which this
end may be accomplished. It will, however, be necessary for our
purpose to consider only two of them in detail: 1, the cold-water
treatment; 2, sulphate of quinia in full doses.
The cold-water treatment is not new, since it was practised in the
form of cold effusion in the treatment of fevers as long ago as 1787
by Currie of Liverpool, who may be said to have introduced it, and who
asserted that it had the power not merely of moderating the symptoms
of these diseases, but also, in many cases, of cutting them short. It
enjoyed at first a high degree of popularity, which lasted for from
twenty to thirty years, but finally fell into disuse, probably in
consequence of the exaggerated character of the claims which were made
for it by its advocates. Although resorted to from time to time in
various parts of the world, the merit of having brought it again into
notice seems to be due to Brand of Stettin, who published a work on
_The Hydrotherapy of Typhoid Fever_ in 1861. Still more recently, the
recorded observations of Bartels, Jürgensen, Ziemssen, and
Liebermeister in Germany, and of Wilson Fox and others in England,
have so far restored the treatment to professional favor that there
are few physicians either in this country or abroad who do not
occasionally have recourse to it.
The cold-water treatment may be applied in several different ways: 1,
the cold bath; 2, the graduated bath; 3, cold affusions; 4, the cold
pack; 5, cold sponging; 6, cold compresses; and 7, frictions with ice.
They all act in the same manner, and depend for their efficacy upon
their power of abstracting heat from the body, and are useful just in
proportion as they do this. There is no reason for believing that they
have the power to modify the conditions upon which the production of
heat depends, but there is, on the other hand, no doubt that under
their use distressing and dangerous symptoms, such as coma, stupor,
subsultus, and the like, are often much relieved. They probably act,
therefore, by diminishing the metamorphosis of the tissues, and the
consequent loading of the blood with excrementitious products which
the hyperpyrexia has a tendency to promote.
The cold bath is the most effective of all the methods of applying the
{328} cold-water treatment. Liebermeister recommends that the bath for
an adult should be at the temperature of 68° F., and its duration
should be about ten minutes; if, however, the patient shows signs of
great weakness, it should not exceed seven. After the bath he should
be wrapped up in a dry sheet or light blanket and put back in bed. If
the pulse should then show signs of failing, or if there should be
shivering or any other evidence of weakness, he should be given a
glass of wine or brandy or a dose of some other diffusible stimulus,
and bottles containing hot water should be applied to his feet. The
process of cooling goes on for some time after the patient's removal
from the bath, for while a thermometer placed in the axilla will show
that the external temperature is immediately affected by it, the same
instrument placed in the rectum will indicate a gradual fall, which
will continue in many cases for at least half an hour. Shortly after
this the temperature will be observed to rise, and in many cases it
will not be more than two hours before it has attained its former
height. Liebermeister therefore recommends that the thermometer should
be frequently used, and that the baths should be repeated as often as
the temperature rises to 103° F. or above it. He has himself given
them as often as every two hours, or as many as two hundred during an
entire illness, but usually finds that not more than six or eight a
day are required. It often requires some persuasion to overcome the
repugnance which most patients feel at first for these baths, and the
shock of being suddenly immersed in cold water is agreeable to very
few. Later, this repugnance, he says, entirely disappears. Intestinal
hemorrhage, perforation of the bowel, and great weakness of the
heart's action are all contraindications to the use of the cold bath.
They are especially to be avoided, according to Liebermeister, when
the force of the circulation is so far reduced that the surface of the
body is cold while the interior is very hot. On the other hand, the
advocates of this plan of treatment contend that the existence of
pneumonia or of hypostatic congestion of the lungs is not a sufficient
reason for abandoning it, the congestion often disappearing under its
use.
The graduated bath possesses some advantages over the cold bath, as
its use involves less of a shock to the system. It is therefore more
suitable than the latter for nervous and excitable patients, for
persons of advanced age or of general feebleness of constitution, or
for very young children. In it the temperature of the water, which at
the time of the immersion of the patient should be at or above 95° F.,
is cooled by the gradual addition of cold water until it is reduced to
72°, or below this point. These baths, to produce the same effect as
the cold baths, must be of longer duration. They are contraindicated
in the same conditions as the latter, but to a less degree.
Although fully willing to admit the good effects of the cold bath in
many cases, having been, of course, myself a witness of them, I am
indisposed to have recourse to it except in cases of hyperpyrexia of
such intensity that death seems imminent and only to be averted by
energetic treatment, or in cases in which other antipyretic remedies
have failed to reduce the temperature; and for the following reasons:
1. In the first place, it is generally possible to produce a decided
effect by the other methods of applying the cold-water treatment, with
much less discomfort to the patient. 2. In a private house it is not
always practicable to have {329} a bath brought to the bedside of the
patient, and in a general hospital to do so often would occasion a
good deal of annoyance to the other patients in the same ward, and I
have seen ill result from carrying him some distance to the bathroom.
But even where the bath is brought directly to his bedside, it
involves so much movement, and is sometimes the cause of so much
excitement, that its good effects are more than neutralized by its
bad.
Cold affusions, while not nearly so efficacious in reducing the
temperature of the body as the cold bath, are open to many of the
objections which may be urged against the latter mode of treatment.
They are, therefore, rarely employed at the present time.
Liebermeister, however, thinks that they may sometimes be resorted to
with good effect for their brisk stimulating effect on the psychical
functions or the respiration.
The cold pack possesses the advantage over the cold bath and cold
affusions of involving less movement on the part of the patient and of
being less terrifying to children, and may therefore be resorted to in
cases in which the latter method of applying the cold-water treatment
is contraindicated, as, for instance, in persons of feeble
circulation. It is, however, inferior to either of them in its cooling
effects, and must be longer applied to produce the same effect.
Liebermeister estimates that a course of four consecutive packs, of
from ten to twenty minutes' duration apiece, is about equivalent in
effect to a cold bath of ten minutes.
Cold sponging is assigned a very low place among the methods of
abstracting heat from the body by many writers. It has, however, often
been in my hands of much service, and its easy application and the
comfort which patients derive from it are certainly strong
recommendations in its favor. I have employed it frequently in cases
of intestinal hemorrhage, and even in cases of great debility, and
have never yet had any reason to repent my having done so. The
addition of a little vinegar to the water has seemed to me to increase
the effect of the sponging.
Cold compresses, either in the form of cloths wet with cold water or
bladders filled with ice, can only produce a local fall of
temperature, and therefore, except when applied to the head, can be of
little service.