of the body, and may therefore be resorted to in cases of intense
hyperpyrexia when for some reason the cold bath cannot be obtained,
and when there are no contraindications to the latter.
Liebermeister classes cold drinks, the internal administration of ice,
and the injection of cold water among the means of cooling the body in
fevers; but it is doubtful if any great reduction of temperature can
be brought about by any of these remedies in the quantities in which
it would be safe to use them. The first two, and to a less extent the
last, meet a very important indication, that of supplying water to the
system. Their free use, therefore, forms a very important part of the
treatment of typhoid fever.
Luton of Rheims[99] extols the Diæta hydrica in the treatment of
typhoid fever. The patient receives absolutely nothing else to drink
but water, which is given in large quantities, for from four to six
days. No nourishment is given until the beginning of the third week,
and first of all milk. If fever returns, the water is given again.
Medicines such as {330} quinia and eucalyptus are given in adynamic
conditions, which Luton says are rare under this treatment. He
believes that the increase of the typhoid germs is prevented by
absolute diet and abundant supply of water.
[Footnote 99: _Journal de thérapie_, Oct., 1880.]
Quinia to produce a decided antipyretic effect must be given in large
quantities. Murchison says that a dose of from fifteen to twenty
grains causes within an hour or two a fall of the temperature, and, to
a less extent, of the pulse, which may last from twelve to eighteen
hours, and that he has never known any other disagreeable symptoms
result from its use than noises in the ears, temporary acceleration
and irregularity of the respiration, and occasional vomiting. This
quantity will often, however, be found to be insufficient to produce a
notable reduction of the fever, and it is therefore necessary
occasionally to increase it. Liebermeister usually gives to adults
from twenty-two to forty-five grains of the sulphate or the muriate of
quinia, and this dose must positively be taken within the space of
half an hour, or, at the most, an hour, as it is useless, he says, to
expect the full benefit of this dose to appear if the dose is divided
and its administration is extended over a longer time. He never
repeats it in less than twenty-four hours, and, as a rule, does not
give it again under two days. Jürgensen has exceeded the dose of
forty-five grains without observing any bad effects from it. When
these large doses are taken the fall of the temperature usually begins
a few hours after the administration of the medicine, the minimum
being reached in from six to twelve hours, and it is usually not until
the second day that the temperature attains its former height. It is
found in practice that the most decided results are obtained when the
medicine is given in the evening, so that the time of its fullest
antipyretic effects will coincide with that of the morning remission.
When these large doses produce vomiting, as they occasionally will,
the quinia must be given by the rectum or hypodermically.
Quinia possesses the great advantage over the cold bath that it may be
given in conditions in which it would be dangerous to resort to the
latter. The existence of great cardiac weakness, of perforation of the
bowel, or of intestinal hemorrhage do not usually constitute
contraindications to its use. In my own practice I have not often
found it necessary to have recourse to much larger doses than those
recommended by Murchison, preferring to repeat them if necessary
rather than to give a single dose of even half a drachm.
It will be well, in this connection, to allude briefly to a few other
remedies which have been given for their antipyretic effect. One of
these is digitalis, which has been administered for this purpose in
very large doses. Thus, Liebermeister recommends that from eleven to
twenty-two grains should be given in the course of thirty-six hours. I
have never used this drug in these doses, and therefore cannot speak
of its effects from personal knowledge of them. I have frequently had
recourse to it, however, in more moderate doses, and I think with
advantage.
Another is sodium salicylate. This remedy has been used largely in
England and Germany, and to a less extent in this country. It has been
claimed for it that it has the power of destroying the germs of
typhoid fever, but Stricker[100] finds it difficult to accord it this
property in the face {331} of the fact that he has had three cases of
typhoid fever under his observation which occurred in patients just
recovered from rheumatism, which had been treated by this drug. My own
experience with it in the treatment of this disease is small, but has
been unsatisfactory. While it is undoubtedly an antipyretic, the pulse
becomes weak and the inspiration less strong under its use. The brain
symptoms do not diminish under its use. Indeed, it is said to produce
narcotism in some cases. Dr. Jahn[101] and Dr. Jh. Platzer[102] speak
more favorably of it, but admit that its administration is
occasionally attended by the inconveniences above referred to. The
verdict of the profession in regard to it, tersely expressed by one
who had given it a fair trial, appears to be that it is a remedy that
brings nothing but disappointment to the physician and disaster to the
patient.
[Footnote 100: _Deutsche Milit.-arztl Zeitsch._, 1877.]
[Footnote 101: _Deutsches Arch. f. klin. Med._, 1877.]
[Footnote 102: _Bayr. Arztl. Intell. Bl._, 1877.]
Eucalyptus, in the form of the tincture, is also a favorite remedy
with many practitioners. Dr. Benj. Bell[103] is in the habit of giving
a teaspoonful every three or four hours in a wineglass of water, and
asserts that it diminishes the tendency to diarrhoea and the duration
of the illness.
[Footnote 103: _Edin. Med. Jour._, Aug., 1881.]
The different varieties of typhoid fever require slight modifications
only of the treatment laid down above. In the typho-malarial form,
especially in those cases in which the malarial element predominates,
and in which there is a marked tendency to remission, the early
administration of quinia in full antiperiodic doses is urgently called
for. In some cases which he had the opportunity of observing in the
army, A. L. Cox[104] found great advantage from the use of arsenious
acid in rather large doses. When the disease attacks elderly people,
an early resort to alcoholic stimulants is usually necessary, in
consequence of the excessive prostration it induces in them. Henoch
and Steffen[105] assert that cold baths are not so well borne in
children as in adults. Their influence is transitory only, and their
use has sometimes been followed by fatal collapse. In the renal form
dry, and in some cases cut, cups should be applied externally and
saline diuretics given internally.
[Footnote 104: _Outlines of the Chief Camp Diseases of the United
States Armies_, by Joseph Janvier Woodward, M.D., Philada., 1863.]
[Footnote 105: _Jahrb. f. Korhde_, 1880.]
SYMPTOMS REQUIRING SPECIAL TREATMENT.--Vomiting, when it occurs early
in the disease, is usually checked by the administration of an emetic
and by the application of sinapisms to the epigastrium. The use of
emetics is no longer advisable when it occurs after the first week. It
is better then to trust to small doses of hydrocyanic or carbolic
acid, aromatic spirit of ammonia, or bismuth. It will often be found
that lime-water and milk will remain upon the stomach when every other
article of food or medicine is rejected. In some severe cases which
have been under my care the symptom was permanently relieved by the
frequent administration of small quantities of brandy in iced
soda-water. When vomiting is a consequence of peritonitis it usually
resists every form of treatment.
Diarrhoea, if the number of the stools does not exceed two or three in
the course of twenty-four hours, does not need special treatment.
When, however, it is more severe, prompt measures should be taken to
check it. Under these circumstances laudanum injections have seemed to
me to be {332} by far the best remedy. It is not necessary that these
injections should always contain a large amount of laudanum or that
they should be repeated frequently. In many cases twenty drops once a
day will be found to be sufficient, and it is rarely necessary to
exceed forty drops twice daily. Opium given by the mouth or in
suppository in equivalent quantity does not act with anything like the
same efficacy. If the laudanum injections fail to restrain the
diarrhoea, it will be well to have recourse, in combination with
opium, to the subnitrate of bismuth or the acetate of lead. Nitrate of
silver was at one time much employed in the treatment of typhoid
fever, especially by the late J. K. Mitchell of this city, but was
afterward suffered to fall into neglect. Its use has been recently, to
a certain extent, revived in consequence of the recommendation of
William Pepper,[106] who claims for it the power of modifying the
course of the disease. I have given it in a number of cases, but have
never been able to satisfy myself that it possessed this power. I have
therefore ceased to prescribe it except in the later stages of the
disease, when the symptoms indicate that the intestinal ulcers are in
an atonic condition. Under these circumstances it has appeared to me
to promote their cicatrization. It is important, however, to remember
that diarrhoea is occasionally caused and kept up by more food being
given to the patient than he can assimilate, and it is therefore a
good rule to examine the stools from time to time to see whether they
contain curds of milk or other undigested food. If such is found to be
the case, the amount of nourishment should be diminished, and it will
be well also to prescribe pepsin either in powder or in solution.
[Footnote 106: _Philadelphia Medical Times_, Feb. 12, 1881.]
Tympanites also occasionally requires treatment, for in addition to
interference with the descent of the diaphragm and other discomfort it
produces, the distended condition of the bowels directly increases the
risk of perforation. It is usually sufficient to employ embrocations
or stupes of equal parts of sweet oil and oil of turpentine, or of
camphor liniment. If the tympanites coexist with constipation,
enemata, either with or without a small quantity of oil of turpentine,
may often be used with advantage. If it is extreme, an intestinal tube
should be introduced very carefully into the rectum and the gas drawn
off. Charcoal has occasionally been administered in this condition
with a view of preventing decomposition of the intestinal contents.
Tympanites occasionally rapidly supervenes upon the occurrence of
perforation, and must then, of course, be treated with due reference
to the latter condition.
Intestinal hemorrhage is a symptom which always demands prompt
attention, no matter how slight it may seem to be, for it is to be
remembered that not only is there a danger of its recurrence, but that
the quantity of blood which appears in the stools is by no means a
reliable measure of that actually lost, as more blood frequently
remains in the intestines than appears externally. In estimating its
severity, it is therefore proper to take into consideration the
gravity of the other symptoms which attend it, such as the fall of
temperature, feebleness of the pulse. In many cases the enforcement of
absolute rest, with the administration of cold drink and a small
amount of opium to diminish peristaltic action, is all that is needed.
In cases in which the symptoms are graver it will be necessary to have
recourse to more energetic {333} measures. Under these circumstances
the hypodermic injection of from three to five grains of ergotin,
repeated if necessary, has seldom in my experience failed to check the
hemorrhage. Dilute sulphuric acid, oil of turpentine, and acetate of
lead have also proved themselves useful remedies in my hands. The
application of ice to the surface of the abdomen has also been said to
be attended with good results, but the objections to the use of this
remedy in the condition of collapse, which is so apt to accompany
profuse intestinal hemorrhage, are so evident that it is unnecessary
to discuss them here. Monsel's solution, tannic acid, and various
other mineral and vegetable astringents have been recommended for
their direct effect upon the bleeding surface, but, even admitting
that they can, when administered by the mouth, reach this unaltered or
in a sufficient state of concentration to be active, it is evident
that they could only do so after the loss of valuable time.
When perforation occurs, it is obvious that the indications for
treatment are to preclude the extravasation of the contents of the
intestine into the cavity of the peritoneum, and to prevent the
peritonitis which is a consequence of this accident from becoming
general. Both of these indications are met by the administration of
opium, which diminishes, and, if pushed, arrests, the peristaltic
action of the intestines. By means of it the bowels may be kept as
free from movement as if "placed in splints." A grain of solid opium
may be given every hour until a decided effect is produced, or if it
is found to disagree with the stomach an equivalent quantity may be
given by the rectum, or it may be substituted by morphia administered
by the mouth or hypodermically. With the same view, food is to be
allowed in small quantities only at a time, and of a character capable
of digestion by the stomach. A light poultice, or, if there is much
evidence of inflammation, ice should be applied to the abdomen. It has
been recommended also, in cases in which the peritonitis has become
general, to apply leeches to the abdomen, but few patients in this
condition will readily bear the loss of much blood. It is very
important not to interfere with the constipation which results from
the above treatment, and which it is one of its objects to promote,
until all inflammatory symptoms have been absent for at least a week,
when a simple enema may be administered. Peritonitis resulting from
other causes than perforation of the intestine does not require any
modification of the above treatment.
Severe abdominal pain, when it occurs independently of inflammation,
is best treated by the application to the abdomen of light poultices,
to which two or three teaspoonfuls of laudanum may be added.
Constipation is an occasional symptom, but it rarely calls for active
interference. When it is present so early in the course of the disease
that the diagnosis is still uncertain, and has continued for several
days, it is best to prescribe a small dose of castor oil; a
dessertspoonful is generally sufficient. The late Dr. Gerhard was in
the habit of giving a tablespoonful of sweet oil in this condition.
The inordinate action which frequently follows the administration of
these mild purgatives will often dispel all uncertainty as to the
nature of the disease we have to do with. When it occurs in a more
advanced stage of the disease it is best met by the administration of
enemata, which may contain, if there is much tympanites present, a
small quantity of oil of turpentine. Under all {334} circumstances it
will be well to remember the advice given by Baglivi two centuries
ago, to avoid the use of active cathartics in this disease.[107]
[Footnote 107: "Fuge purgantia tanquam postem," _Opera Omnia
Medico-Practica et Anatomica_, Georgii Baglivi, 1788.]
The headache which is sometimes a distressing symptom in the beginning
of the disease is usually relieved by the application to the head of
cloths constantly wet with ice-water or by that of a bladder filled
with ice and lard. If it is very severe and does not yield to these
remedies, a few leeches applied to the temples often have a very happy
effect in moderating the pain. Murchison recommends that the cold
affusion should be administered by simply placing the patient's head
over a basin at the edge of the bed and pouring water on it from a
height of two or three feet. He also says that warm fomentations are
to be preferred to cold in aged and infirm persons of feeble
circulation. Sleeplessness will often disappear under the use of
remedies presented for the relief of the headache and other nervous
symptoms. It is occasionally so persistent as to call for special
treatment. If it occur early in the disease, it will generally be
sufficient to prescribe at bedtime ten grains each of potassium
bromide and chloral, repeated once or twice during the night. Later in
the disease this combination ceases to produce any effect, besides
which chloral cannot be administered with safety after the action of
the heart becomes feeble. It is therefore necessary to have recourse
to opium in some form or other. There are, it is true, theoretical
objections to its use in typhoid fever, such as its interference with
digestion and its tendency to lock up the secretions; but these will
hardly weigh in the balance against the fact that the patient will die
of exhaustion if the insomnia is allowed to continue, and that under
certain circumstances opium is the only drug which will procure the
needed sleep. The form in which it is given is not a matter of much
importance. I prefer the deodorized tincture, twenty or thirty drops,
repeated if necessary in an hour or two, but I have seen good results
from the solid opium and from the hypodermic injection of morphia.
When the insomnia is attended by much tremor and muttering delirium,
camphor may be added to the opium, and given throughout the day as
well as in the evening. Violent delirium is sometimes also relieved by
administration of opium and alcoholic stimulants, and by the
application of cold to the head. It is also much lessened by the
cold-water treatment. When the delirium is so violent that restraint
is necessary, it is better that this should be mechanical than that it
should be left wholly in the hands of ignorant and untrained nurses. A
folded sheet passed over the chest of the patient and fastened to the
sides of the bed is frequently all that is needed. Stupor requires
very much the same kind of treatment as that suitable for the other
forms of nervous derangement. If it is extreme, counter-irritants
should be applied to the nape of the neck and cold to the head. The
late Dr. Wood was in the habit of shaving the hair and applying a
blister to the scalp of a patient in this condition, and I have seen
good in more than one instance result from this treatment. The urine
should also be examined, and if the quantity be insufficient diuretics
should be given. If it contain albumen or blood, counter-irritants and
even cut cups should be applied to the loins. It is also important, if
the patient be in this condition, that the physician should not rest
satisfied with the nurse's {335} assurance that the urine is passed
freely, but should from time to time examine the supra-pubic region
himself. It is not infrequently found under these circumstances that
there is really retention, and that the wetting of the bed upon which
the nurse has based her assurances is really the consequence of the
dribbling of urine from an over-distended bladder. I have known of
serious results, such as cystitis, paralysis of the bladder, having
followed the neglect of this very simple precaution. Convulsions when
they occur are to be treated by the application of cold to the head
and counter-irritants to other parts of the body.
Epistaxis is rarely so severe as not to yield to the use of simple
remedies, such as the application of ice to the forehead or back of
the neck, or of styptics locally. In a few cases, however, it is
profuse, and it will then be necessary to have recourse to hypodermic
injections of ergotin, as in the case of hemorrhage from the
intestines, or to plug the nostrils.
TREATMENT OF COMPLICATIONS.--Hypostatic congestion of the lungs, as it
is usually the consequence of feeble action of the heart, is best
treated by frequently changing the position of the patient, and by
remedies calculated to increase the power of the organ, such as
alcoholic stimulants, ammonium carbonate, oil of turpentine, and
digitalis. Recent German authors, however, regard digitalis as a
dangerous remedy when the heart has undergone the granular
degeneration peculiar to fevers. It had, therefore, better not be
given if the congestion occurs late in the disease. I have myself
always found advantage from the application of turpentine stupes to
the chest, and occasionally from the application of dry cups.
Pneumonia when it occurs as a complication does not render necessary a
material modification of the above treatment. It may sometimes be
well, if it occur early in a robust subject, to take blood locally,
but it can rarely be justifiable to do so by venesection.
Bed-sores may generally be prevented by frequently changing the
position of the patient, by scrupulous attention to cleanliness, and
by bathing prominent parts of his body with whiskey and alum. These
parts should also be protected from pressure by the judicious
arrangement of pillows and cushions. When redness or abrasions appear
the part should be covered with soap plaster smoothly spread upon kid.
This application may be continued even after the formation of sloughs.
As soon, however, as these show a tendency to suppurate poultices
should be applied, and the resulting ulcer treated as if occurring
under other circumstances.
Thrombosis of the femoral vein is best treated by elevating the
affected leg and enveloping it with flannel cloths saturated with hot
vinegar and water. Thrombosis of other veins is to be treated on the
same general principles. When an artery becomes obliterated, whether
from embolism or thrombosis, the part which it supplies should be
surrounded with cotton wool and every effort made to favor the
establishment of the collateral circulation. If sphacelus occurs, it
should be treated on general surgical principles.
TREATMENT OF CONVALESCENCE.--The importance of a strict adherence to a
liquid diet in the early part of the convalescence of typhoid fever
has already been alluded to. The ulcers in the intestines often remain
unhealed for some time after the subsidence of the fever, and errors
in diet may therefore readily cause recrudescences of fever, if not
true relapses. {336} These recrudescences are sometimes produced by
very slight causes. I have seen them follow undue mental exercise or
worry, or sitting up too early or too long. It is therefore important
to guard our patients at this stage of the disease from undue fatigue
or excitement of any kind. Medicines calculated to build up the
strength and to improve the nutrition are clearly indicated at this
time. If the diarrhoea should persist, nitrate or oxide of silver,
sulphate of copper, and subnitrate of bismuth in appropriate doses,
given with a little opium, will all be found to be useful remedies.
When, on the contrary, constipation exists, it is still necessary to
avoid the use of drastic cathartics; indeed, even mild laxatives
should be given by the mouth only after enemata have failed to produce
a movement of the bowel.