Part 51

All authors agree that the prognosis is unfavorable in corpulent persons, not only on account of the diminished power of resistance to disease generally which such persons exhibit, but also because the febrile movement is often intense in them, and the degenerative changes of the muscles and organs of the body which it induces are generally early developed and of high grade. Liebermeister goes so far as to say that even in the case of ill-nourished, anæmic, or chlorotic individuals the chances for life are better than in the corpulent. Murchison has also expressed the opinion that a large, muscular development is likewise an unfavorable element in prognosis, having seen the strong and robust succumb to the disease oftener than the feeble. The mortality from the disease appears to be greater in certain families than in others. This has been ascribed by some writers to peculiarities of constitution, but it may be due to other causes, as, for instance, difference in the intensity of the poison. The disease is also often very fatal among the intemperate, who usually bear the disease badly in consequence of the presence of various degenerations of one or more of the important organs of the body caused by the excessive indulgence in alcoholic stimulants; paralysis of the heart being not an infrequent cause of death among them.

Certain epidemics have been exceedingly fatal, while in others the percentage of deaths has been very small. There can be no doubt that in most of these cases there has been a difference in the virulence of the poison. Recent residence in an infected locality has been shown by Murchison and other writers to have a decided influence in increasing the fatality of the disease. Second attacks are, on the other hand, usually mild. Some diversity of opinion exists among authors in regard to the effect that pregnancy has upon the course of the disease. Murchison believes that it is a far less formidable complication than is usually thought, while Liebermeister, on the contrary, holds a directly opposite opinion. He also regards the prognosis as unfavorable when the disease occurs in childbed or a short time afterward. Individuals with disease of the heart, emphysema, or bronchial catarrh who contract typhoid fever are said to be more liable to paralysis of the heart than others, hence the existence of these diseases materially diminishes their chances of recovery.

TREATMENT.--Inasmuch as the spread and propagation of typhoid fever may be prevented to a great extent, if not entirely, by the {321} employment of judicious sanitary measures, it is proper, before entering upon the discussion of its curative treatment, to devote a few words to the prophylaxis of the disease.

Whether the physician accepts the theory so ably advocated by Murchison, that typhoid fever may arise from exposure to the products of the fermentation of healthy feces, or adopts the view now held by a large number of investigators, that the disease is never generated in the absence of the specific germ, he will admit the great importance of an efficient system of sewerage, with a thorough flushing of the sewers at regular and frequent intervals, for disposing of the fecal discharges of the population of all towns, no matter how inconsiderable in size. No less important is it that the drains of every dwelling should be well constructed and kept in good order. They should be trapped just before they empty into the sewer, and should be provided with the means of thorough ventilation between the trap and the walls of the house by a free communication with the outer air. The soil-pipe should be carried up three or four feet above the top of the house, and every water-closet, bath-tub, stationary washstand, and sink should have its own separate trap, and none of them should be placed in rooms unprovided with a window or with some other sufficient means of ventilation. Physicians should, as sanitarians, urge upon the authorities of all cities and towns the importance of deriving their water-supply from a source unpolluted by sewerage or by any other substances likely to be deleterious to health. They should also see that when water is stored in a tank inside of a house the overflow pipe does not communicate directly with the drain, since if this is allowed to occur the water may very soon become contaminated with sewer gas, and consequently unfit for internal use.

In the case of isolated country-houses and of small villages some other means of disposing of the fecal discharges of the inhabitants than by sewers has to be found. In the great majority of instances no better way presents itself than by the ordinary cesspool. Care should, however, be taken that this is so constructed and situated that there can be no filtration of its contents into wells from which water for drinking is obtained.

As the alvine dejections of the sick are beyond question the medium by which typhoid fever is most frequently communicated to others, the importance of thoroughly disinfecting them before they have acquired the power of imparting the disease cannot well be overestimated. Liebermeister recommends that the bottom of the bed-pan should be strewed, each time before being used, with a layer of sulphate of iron, and that immediately after a passage crude muriatic acid should be poured over the fecal mass, as much as one-third or one-half of the bulk of the latter being used. He also urges, whenever it is practicable, that the contents of the bed-pan should be emptied into trenches dug anew every two days and filled up when discarded, care being of course taken that they are not located anywhere in the vicinity of wells. Murchison seems to prefer carbolic acid to other chemical agents as a means of preventing fecal fermentation. For this purpose the liquid carbolic acid may be diluted with water in the proportion of 1 to 40 to 1 to 20, or it may be mixed with sand or sawdust. I have myself employed as a disinfectant with success the solution of the chlorides sold under the name of Platt's chlorides. As the discharges must in cities, in the great majority of instances, be emptied into {322} water-closets, these should be freely flushed with water after every time they are used; and it is well to impress upon the attendant on the sick the importance of doing this. The bed-linen of the patient and his clothes, if they are soiled by his discharges, should be removed as soon as possible, and subjected to a high degree of heat (248° F.) or soaked in a solution of the chlorides or of carbolic acid for several hours before being washed. If these precautions are observed, cases of typhoid fever may be treated in the wards of general hospitals without danger to the other patients.

In the doubt and obscurity which generally envelop the diagnosis of the disease when the physician is first called upon to treat it, it is impossible to lay down any positive rules for the management of typhoid fever at its commencement. But even in those cases which begin insidiously, if the patient is carefully examined enough of the early symptoms of typhoid fever will be detected to put the physician on his guard. The thermometer will show the existence of fever, which has a tendency to increase at night. There will generally be found to be a little diarrhoea, or at least an increased susceptibility to the action of purgative medicines; perhaps a little tympany and tenderness in the right iliac fossa, and moreover a prostration which is out of all proportion to the other symptoms.

These symptoms, it is true, are not infrequent concomitants of many diseases besides the one under consideration; but when their presence cannot be otherwise satisfactorily explained, especially if they have continued for several days, it is a safe rule in practice to regard the case as one of typhoid fever, and to regulate the treatment accordingly. The patient must be put to bed at once, and not allowed to leave it on any pretext, not even to empty his bladder, after the first week. This is a rule which should be rigidly enforced in every case, no matter how mild the symptoms may be. Its non-observance, either through the neglect of the physician or the ignorance or wilfulness of the patient, has been the cause of some disastrous results; in illustration of which it is only necessary to refer to the frequency with which perforation of the bowel occurs in walking cases of typhoid fever. Perfect quiet should be maintained in the sick room. Visitors should be excluded from it, and the attendants limited in number to those actually necessary to carry out the directions of the physician. All unnecessary talking is to be avoided, and especially conversation carried on in a low tone of voice, which is always annoying to the sick.

There is only one condition under which I should be disposed to break 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 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.

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, that water is not given in such quantity that the desire for and capability of digesting food is destroyed by it.

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.