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THE WW1 DIAGNOSIS AND TREATMENT OF TYPHOID FEVER

 

Enteric, or Typhoid, fever was spread by ingestion of faecally contaminated food or water and caused many deaths and much debility during the Great War period, particularly as trench life was necessarily associated with poor hygiene and lack of sanitation. The vermin and flies that were part of trench life ensured that typhoid fever remained a common affliction of WW1 soldiers.


During the WW1 period Sir William Osler was considered to be the world's leading authority on Typhoid Fever and the following extract on the contemporary diagnosis, treatment and management of typhoid is taken from Osler's famous textbook of medicine "The Principles and Practice of Medicine", Eighth Edition, Butterworth & Company, London and Appleton & Company, New York. 1916. Hydrotherapy, described in detail in the extract, was important in reducing the patient's temperature and could be lifesaving for the dread complication of hyperpyrexia (very high fever) as there was no specific treatment in those pre-antibiotic days.

Vaccination against Typhoid was still in its infancy in 1915, Osler refers to it in his text but it was still not in general use. Osler comments favourably on its value and wrote: "The evidence so far points to a persistence of the protective effect for at least two years after inoculation.".

Typhoid fever remained a serious and common illness until 1948 when Woodward and his colleagues reported on the use of Chloromycetin for this condition (Woodward et al., 1948; "Preliminary report on the beneficial effect of Chloromycetin in the treatment of Typhoid Fever". Ann. Int Med.; 29:131 - 134).

 

Dr M Geoffrey Miller

 


 


 

TYPHOID FEVER

DIAGNOSIS

There are several points to note. In the first place typhoid fever is the most common of all continued fevers. Secondly, it is extraordinarily variable in its manifestations. Thirdly, there is no such hybrid malady as typho-malarial fever. Fourthly, errors in diagnosis are inevitable, even under the most favourable conditions.

DATA FOR DIAGNOSIS.-

(a) GENERAL.

No single symptom or feature is characteristic. The onset is often suggestive, particularly the occurrence of epistaxis, and (if seen from the start) the ascending fever. The steadiness of the fever for a week or longer after reaching the fastigium is an important point. The irregular remittent character in the third week, and the intermittent features with chills, are common sources of error. While there is nothing characteristic in the pulse, dicrotism is so much more common early in typhoid fever that its presence is always suggestive. The rash is the most valuable single sign, and with the fever usually clinches the diagnosis. The enlarged spleen is of less importance, since it occurs in all febrile conditions, but with the fever and the rash it completes a diagnostic triad. The absence of leucocytosis and the presence of Ehrlich's reaction are valuable accessory signs.

(b) Specific.

(1) Isolation of Typhoid Bacilli from the Blood.

New methods have given better results in this procedure, which is especially useful early in the disease. in doubtful cases and in the acute septic forms. The hypodermic puncture of a vein for the blood causes little or no pain.

(2) Isolation of Typhoid Bacilli from the Stools.

Cultures from the, stools have proved of diagnostic value. A satisfactory method is that of. von Drigalski and Conradi (Zeit. f. Hygiene, Bd. 39), largely used in the campaign against typhoid in Germany,, with which those familiar with bacteriologic methods are able to isolate the bacilli in a majority of the cases.

(3) Isolation of Typhoid Bacilli from the Urine.

Neumann, Horton- Smith, Richardson, and Gwyn have shown the great frequency of typhoid bacilli in the urine. In some cases they may be obtained before the Widal test is positive. Routine cultures do not offer great difficulties, and may frequently be of diagnostic value.

(4) Isolation of Typhoid Bacilli front the Rose-spots.

Neufold, Curschmann, and Richardson have demonstrated the presence of the bacilli in rose- spots in 32 of 40 cases examined. As the procedure causes considerable discomfort it can not be used as a routine method.

(5) The Agglutination Test.

ln 1894 Pfeiffer showed that cholera spirilla, when introduced into the peritoneum of an immunized animal, or when mixed with the scrum of immunized animals, lose their motion and break up. This "Pfeiffer's phenomenon" was thoroughly studied by Durham and the specificity of the reaction demonstrated. A. S. Grunbaum and Widal made the method available in clinical work.

Macroscopic Method.

This may be done with living or dead organisms and has the advantage of use away from a laboratory. The diluted serum and organisms are mixed in a tube of small calibre (dilution 1 to 50 or 1 to 100). With a positive reaction there should be complete precipitation leaving a clear fluid above in twenty-four hours.

Microscopic Method.

The serum is mixed with a young bouillon culture of the typhoid bacillus, or with a suspension of a young agar culture, in such a manner as to dilute the serum to the required degree. A hanging-drop preparation of the mixture is made, and if the reaction is positive the bacilli will within a given time lose their motility and collect in clumps. With Dreyer's method of standard cultures of constant and known sensitiveness it is possible to follow the patient's serum changes in typhoid or paratyphoid infection.

Whatever be the infection the agglutination for that bacillus will show (a) a marked rise in an early stage and (b) a marked fall later in the infection.

If the patient's serum already contains agglutinins for one or more of the bacilli (owing to inoculation), the following phenomena will be noted:

(a) there is no change in the inoculation agglutinins or

(b) a slight rise occurs, followed by a slight fall - an alteration which may be caused by a number of nonspecific stimuli.

A well marked rise or fall of the titre is the only positive evidence of active infection that can be obtained with the agglutination test and is probably the best evidence afforded by any test except a successful blood culture.

On the whole the serum reaction is of great value, in spite of certain difficulties and objection., and with the newer methods the reactions of equal importance in inoculated and uninoculated persons and in the paratyphoids.

(6) Ophthalmo-Reaction

A solution of one-third to one-half of a milligram of "typho-protein" derived from many different strains of typhoid bacilli is instilled into the conjunctival sac. A typical reaction is marked by deep congestion of the conjunctiva of the lower lid and the caruncle. It reaches its maximum in six hours. A positive reaction is obtained most often during the febrile period, frequently before the agglutination -reaction is given. The simplicity of the method and the absence of discomfort are valuable features. A cutaneous method has also been employed.

 

COMMON SOURCES OF ERROR IN DIAGNOSIS.

An early and intense localization of the infection in certain organs may give rise to doubt, in certain cases coming on with severe headache, photophobia, delirium, twitching of the muscles and retraction of the head are almost invariably regarded as cerebro-spinal meningitis. Under such circumstances it may for a few days be impossible to make a satisfactory diagnosis. 1 have thrice performed autopsies on cases of this kind in which no suspicion of typhoid fever had been present, the intense cerebro-spinal manifestations having dominated the scene. Until the appearance of abdominal symptoms, or the rash, it may be quite impossible to determine the nature of the case. Cerebro-spinal meningitis is, however, a rare disease; typhoid fever a very common one, and the onset with severe nervous symptoms is by no means infrequent. The lumbar puncture is now a great help.

I have already spoken of the misleading pulmonary symptoms, which occasionally occur at the very outset of the disease. The bronchitis rarely causes error, though it may be intense and attract the chief attention. More difficult are the cases setting in with chill and followed rapidly by pneumonia. I have brought such a case before the class one week as typical pneumonia, and a fortnight later shown the same case as undoubtedly one of typhoid fever. There is less danger of mistaking the pneumonia which occurs at the height of the disease, and yet this is possible, as in a case admitted a few years ago to my wards - a man aged seventy, insensible, with a dry tongue, tremor, ecchymoses upon the wrists and ankles, no rose-spots, enlargement of the spleen, and consolidation of his right lower lobe. It was very natural. particularly since there was no history, to regard such a case as senile pneumonia with profound constitutional disturbance, but the autopsy showed the characteristic lesions of typhoid fever. Early involvement of the pleura or the kidneys may for a time obscure the diagnosis.

Of diseases with which typhoid Fever may be confounded, malaria, certain forms of pyaemia, acute tuberculosis, and tuberculous peritonitis are the most important.

From malarial fever, typhoid is, as a rule, readily recognized. There is no such disease as typho-malarial fever-that is, a separate and distinct malady. Typhoid fever and malarial fever may coexist in the same patient. In patients returning from Cuba and Porto Rico during the late war the two conditions were often found together, but in the United States it is excessively rare. The term typho-malarial Sever should be abandoned. The autumnal type of malarial fever may present a striking similarity in its early days to typhoid fever. Differentiation may be made only by the blood examination. There may be no chills, the remissions may be extremely slight, there is a history perhaps of malaise, weakness, diarrhoea, and sometimes vomiting. The tongue is furred and white, the cheeks flushed, the spleen slightly enlarged, and the temperature continuous, or with very slight remissions.

The aestivo-autumnal variety of the malarial parasite may not be present in the circulating. blood for several days. Every year in Baltimore we had one or two cases in which the diagnosis was in doubt for a few days.

Pyaemia.

The long-continued fever of obscure, deep-seated suppuration, without chills or sweats, may simulate typhoid. The more chronic cases of ulcerative endocarditis are usually diagnosed typhoid fever. The presence or absence of leucocytosis is an important aid. The Widal reaction and the blood cultures now offer additional and valuable help.

Acute miliary tuberculosis is not infrequently mistaken for typhoid fever. The points in differential diagnosis will be discussed under that disease.

Tuberculous peritonitis in certain of its forms has closely simulated typhoid fever, and will be referred to in another section.

The early abdominal pain, etc., may lead to the diagnosis of appendicitis.

The "disease" described by Brill (a mild form of typhus fever) may be regarded as typhoid fever, but the character of the rash, the absence of the agglutination reaction, negative results of blood cultures and its course are against this. However, the majority of cases are probably diagnosed as typhoid fever.

 

PROGNOSIS.

(a) DEATH-RATE.

Mortality is very variable, ranging in private practice from 5 to 12 and in hospital practice from 7 to 20 per cent. In some large epidemics the death-rate has been very low. In the Maidstone epidemic it was between 7 and 8 per cent. In recent years the mortality from typhoid lever has certainly diminished, and, under the influence of Brand, the reintroduction of hydrotherapy has reduced the death-rate in institutions in a remarkable manner, even as low as 5 or 6 per cent. Of the 1,500 cases treated in my wards, 9.1 per cent died. The mortality in the Spanish-American War was very low - 7 per cent.- and may be attributed to the picked set of men and to the care and attention which the patients received.

 

(b) SPECIAL FEATURES IN PROGNOSIS.

Unfavourable symptoms are high fever, toxic symptoms with delirium, meteorism, and haemorrhage. Perforation renders the outlook hopeless unless operation is done early. Fat subjects stand typhoid fever badly. The mortality in women is greater than in men. The complications and dangers are more serious in the ambulatory form in which the patient has kept about for a week or ten days. Early involvement of the nervous system is a bad indication; and The low muttering delirium with tremor means a close fight for life.

Prognostic signs from the fever alone are deceptive. A temperature above 1040 may be well borne for many days if the nervous system is not involved.

(c) SUDDEN DEATH.

It is difficult in many cases to explain this most lamentable of accidents in the disease. There are cases in which neither cerebral, renal, nor cardiac changes have been found; there are instances too in which it does not seem likely that there could have been a special localization of the toxins in the pneumogastric centres. McPhedran, in reporting a case of the kind, in which the postmortem showed no adequate cause of death, suggests that the experiments of McWilliam on sudden cardiac failure probably explain the occurrence of death in certain of the cases in which neither embolism nor uraemia is present. Under conditions of abnormal nutrition there is sometimes induced a state of delirium cordis which may occur spontaneously, or, in the case of animals, on slight irritation of the heart with the result of extreme irregularity and finally failure of action. Sudden death occurs more frequently in men than in women, according to Dewevre's statistics, in a proportion of 114 to 26. It may occur at the height of the fever, and, as pointed out by Graves, may also happen during convalescence. There were four cases in my series.

 

PROPHYLAXIS.

In cities the prevalence of typhoid ever is directly proportionate to the inefficiency of the drainage and the water-supply. With their improvement the mortality has been reduced one-half or even more. Fulton has shown that in the United States, at least, the disease exists to a proportionately greater extent in the country than it does in the city, and that the propagation of this disease is in general from the country to the town. In the water-supply of the latter the chances for dilution of the contaminating fluids are so much greater than in the country, where the privy vault is often in such close proximity to the well.

But it is not only through water that the disease is transmitted. Other methods play an important though not so frequent ro1e. The bacilli may be carried by milk, oysters, uncooked vegetables, etc. Flies play an important part in the spread of the disease. Many cases undoubtedly arise by direct infection. But through whatever channel the infection occurs, for new cases to arise the virus must be obtained from another patient. It has been demonstrated by Jordan, Russell, Zeit and others that under ordinary circumstances the bacilli do not live and thrive long outside the body. To stamp out typhoid fever requires: (1) the recognition of all cases, including the typhoid carriers and (2) the destruction of all typhoid bacilli as they leave the patient. It is as much a part of the physician's duty to look after these points as to take care of the patient. Mild cases of fever are to be regarded with suspicion.

From the standpoint of prophylaxis, the question practically narrows down to disinfection of the urine, stools, sputum (in the few cases where bacilli are present), and of objects which may accidentally be contaminated by the excretions. The nurse or attendant should be taught to regard every specimen of urine as a pure culture of typhoid bacilli, and to exercise the greatest care in preventing the scattering of drops of urine over the patient, bedding or floor, or over the hands of the attendant.

To disinfect the urine the best solutions are carbolic acid, 1-20, in an amount equal to that of the urine, or bichloride of mercury, 1-1,000, in an amount one-fifteenth that of the fluid to be sterilized. These mixtures with the urine should stand at least two hours. Hexamine causes disappearance of the bacilli from the urine when bacilluria is present, but under no circum- stances should its administration permit the disinfection of the urine to be neglected.

For the stools, heat is the most efficient means and can be. employed in hospitals by special hoppers in which steam is used. Of solutions, carbolic acid or freshly prepared milk of lime is most useful. The stool should be mixed with at least thrice its volume of these solutions and allowed to stand for several hours.

With hydrotherapy the disinfection of the bath water offers a somewhat difficult problem.

E. Babucke found chloride of lime the best substance to use, and that even when the water contains coarse faecal matter, 250 gm. (one-half pound) of chloride of lime will render the ordinary bath of 200 litres sterile in one-half hour. If there be any expectoration, the sputum should receive the same care as in tuberculosis. It is best to collect it in small cloths, which may be burned.

All the linen leaving the patient's bed or person should be soaked for two hours in 1-20 carbolic acid solution or 1-2000 bichloride solution, and then sent to the laundry, where it should be boiled. All dishes should be boiled before leaving the patient's room.

The nurse should wear a rubber apron when giving tubs, or working over a typhoid patient, and this should be washed frequently with a carbolic acid or bichloride of mercury solution.

The nurse should wear rubber gloves when giving tubs, or else soak her hands thoroughly in 1-1,000 bichloride solution when she has finished.

It is impossible here to deal with all the possible modes of spread of the infection. Keeping in mind that everything leaving the patient should be sterilized whenever there is a chance of its having been contaminated by the discharges, a nurse of ordinary intelligence, even one of the family, can carry out very, satisfactory prophylaxis.

Should the typhoid fever patient be isolated?

To prevent direct infection of other members of the family a moderate degree of isolation should be carried out, though this need not be absolute as in the exanthemata. The windows should have fly screens in summer. After recovery the room should be disinfected.

An important question is as to the necessity for the isolation of typhoid patients in special wards in hospitals. At present this is not generally done in the United States . When, however, in a hospital with as good sanitary arrangements as the Johns Hopkins possesses, and in which all possible precautions are taken to prevent the infection spreading from patient to patient, 1.81 per cent. of all the cases have been of hospital origin, the advisability of isolation of typhoid fever patients is certainly worth considering. On the other hand, in the general hospital, with students in the wards, the cases are more thoroughly studied, and in the graver complications, as perforation, it is of the greatest advantage to have the early cooperation of the house surgeon.

During the past few years an active campaign has been started in Germany with the object of ultimately stamping out this disease by means of early diagnosis and the institution of rigid measures for preventing the distribution of the infecting agent from the patients so diagnosed. With a corps of assistants Koch fitted up a laboratory in Trier, a locality where the disease had a firm hold. By bacteriological methods he was able to demonstrate that 72 persons were suffering from typhoid infection. So soon as the nature of a case was established, isolation and vigorous disinfection were practised. The result was that within three months no more typhoid bacilli were discoverable, the patients were cured, no fresh cases arose, and, so far as that group of villages was concerned, typhoid was exterminated. When epidemics are prevalent the drinking-water and the milk used in families should be boiled. Travellers should drink light wines or mineral water rather than ordinary water or milk. Care should be taken to thoroughly cook oysters which have been fattened or freshened in streams contaminated with sewage.

While in camps it is easy to boil and filter the water, with troops on the march it is a very different matter, and it is impossible to restrain men from relieving their thirst the moment they reach water. Various chemical methods have been recommended of which chlorination (the use of calcium hypochlorite, 5 to 15 pounds for each million gallons of water) has proved the most satisfactory.

 

ANTI-TYPHOID INOCULATION.

Introduced by Wright the method has proved of inestimable value in the United States Army, in India and during the present war. The material used is a bouillon or agar culture of bacilli heated to a temperature of 530 to 550 C. in order to kill them. Lysol or tricresol may be added. Three inoculations are given at intervals of ten days. A triple vaccine against typhoid and paratyphoid A and B is now prepared and should be used. Untoward results are rare. Of 31,000 inoculated at the Valcartier camp, Quebec, only one had a local abscess and there were no serious sequels. The inoculation fever begins in from four to six hours and may reach 1010 or even 1030 to 100. Headache, chilliness, pains in the back and limbs, and vomiting may occur. In many there is only a transient indisposition. More severe symptoms may occur, such as arthritis, fugitive erythema, (diarrhoea, abdominal pains, septicaemia, with pneumonia, pleurisy and pericarditis. In a few cases a fever resembling typhoid has followed. I was not able to find a fatality due directly to the inoculation. A light diet, avoidance of stimulants and rest lessen the possibility of serious sequels. The evidence so far points to a persistence of the protective effect for at least two years after inoculation.

 

TREATMENT.

(a) GENERAL MANAGEMENT.

The profession was long in learning that typhoid fever is not a disease to be treated mainly with drugs. Careful nursing and a regulated diet are the essentials in a majority of the cases. The patient should be in a well-ventilated room (or in summer out of doors during the day), strictly confined to bed from the outset, and there remain until convalescence is well established. The bed should be single, not too high, and the mattress should not be too hard. The woven wire bed, with soft hair mattress, upon which are two folds of blanket, combines the two great qualities of a sick-bed, smoothness and elasticity. A rubber cloth should be placed under the sheet. An intelligent nurse should be in charge. When this is impossible, the attending physician should write out specific instructions regarding diet and treatment of the discharges and bed-linen.

(b) DIET.

More liberality in diet is now generally practised, as was advised years ago by Austin Flint and strongly supported by Shattuck, Kinnicutt and others. The patient should be nourished as well as possible and food given with a value of 2,500 to 3,000 calories and containing about 70 grams of protein if conditions permit. The bulk of the food should be liquid and milk or its modifications form the largest part. Milk in any form, cream, ice cream, cocoa, tea or coffee with cream, strained soups, eggs, either the white or the whole egg, raw or soft boiled, gruels and jellies may he given. The milk may be boiled or diluted, or some modification given- peptonised milk, fermented milk, malted milk, buttermilk or whey. Soft food is often permissible, such as milk toast, custard, junket, crackers and milk, bread and butter, and mashed potatoes. It is important to give carbohydrate freely to spare the body proteins, and this is aided by the addition of milk sugar to the diet; a teaspoonful can be given with each feeding of milk. Sugar can also be given freely in lemonade. The food should be chosen for each patient and a routine diet not allowed. - In case of digestive disturbance - undigested food in the stools, diarrhoea, meteorism - the diet should be made very simple, buttermilk, whey, peptonised milk or albumin water usually being suitable. The beef extracts, meat juices, and artificially prepared foods are unnecessary, and in private practice among people in moderate circumstances add greatly to the expense of the illness. Water should be given freely at fixed intervals. A good plan is to have a jug of water beside the patient and tubing with a glass mouth-piece, so that he can drink as much as he wishes. It is desirable to have the patient take at least four litres of water daily and larger amounts are an advantage. The water causes polyuria, and is a sort of internal hydrotherapy by which the toxins may be washed out. Barley water, lemonade, soda water, or iced-tea may used.

Special care must be given to the mouth, which should be cleaned after each feeding. A mouth wash should be used freely (such as carbolic acid 1 drachm, 4 cc., glycerine 1 ounce, 30 cc., and boric acid, saturated solution, to 300 cc.). Alcohol is unnecessary in a great majority of the cases. Of late years I have used it much less freely; but when the heart is feeble and the toxic symptoms are severe, eight to twelve ounces of whisky may be given in the twenty-four hours.

(c) HYDROTHERAPY.

The use of water, inside and outside, was no new treatment in fevers at the end of the eighteenth century, when James Currie (a friend of Burns and the editor of his poems) wrote his Medical Report on the Effects of Water, Cold and Warm, as a Remedy in Fevers and Diseases. In this country it was used with great effect and recommended strongly by Nathan Smith, of Yale. Since 1861 the value of bathing in fevers has been specially emphasized by the late Dr. Brand, of Stettin.

Hydrotherapy may be carried out in several different ways, of which in typhoid fever, the most satisfactory are sponging, the wet pack, and the full bath.

(1) Cold Sponging.

The water may be tepid, cold, or ice-cold, according to the height of the fever. A thorough sponge-bath should take from fifteen to twenty minutes. The ice-cold sponging is not quite as formidable as the full bath, for which, when there is an insuperable objection in private prac- tice, it is an excellent alternative. But frequently it is difficult to get the friends to appreciate the advantages of the sponging. When such is the case, and in children and delicate persons, it can be made a little less formidable by sponging limb by limb and then the back and abdomen.

(2) The cold pack is not so generally useful in typhoid fever, but in cases with very pronounced nervous symptoms, if the tub is not available, the patient may be wrapped in a sheet wrung out of water at 600 or 650, and then cold water sprinkled over him with an ordinary watering-pot.

(3) The Bath.

The tub should be long enough so that the patient can. be completely covered except his head. Our rule for some years has been to give a bath every third hour when the temperature was above 102.50. The patient remains in the tub for fifteen or twenty minutes, is taken out, wrapped in a dry sheet, and covered with a blanket. While in the tub the limbs and trunk are rubbed thoroughly, either with the hand or with a suitable rubber. It is well to give the first one or two baths at a temperature of 800 to 850. There is no routine temperature and that between 700 and 850 which suits best is chosen. It is important to see that the canvas supports are properly arranged, and that the rubber pillow is comfortable for the patient's head. The first bath should not be given at night, and it should be superintended by the physician. The amount of complaint made by the patient is largely dependent upon the skill and care with which the baths are given. Food is usually given, sometimes a stimulant, after the bath. The blueness and shivering, which often follow the bath, are not serious features. The rectal temperature is taken immediately after the bath, and again three-quarters of an hour later. Contra-indications are peritonitis, haemorrhage, phlebitis, severe abdominal pain, and great prostration.

The good effects of the baths are:

(i) The influence on the nervous system; delirium lessens, tremor diminishes and toxic features are less marked.

(ii) increased excretion of toxins by the kidney.

(iii) The tonic effect on the circulation; the heart rate falls, the pulse becomes smaller and harder. and the blood pressure rises. Vaso-motor paresis is lessened.

(iv) With hydrotherapy the initial bronchitis is benefited, and there is less chance of passive congestion of the bases of the lungs.

(v) The liability to bedsores is diminished and the frequent cleansing of the skin is beneficial. The addition of half a pound of alum to the water is an advantage. Should boils occur, one bath-tub should be used for that patient alone.

(vi) Reduction of the temperature may occur but is not an important effect.

(vii) The mortality is reduced.

In general hospitals from six to eight patients in every hundred are saved by this plan of treatment. At the Brisbane Hospital, where F. E. Hare used it so thoroughly, the mortality was reduced from 14.8 per cent. to 7.5. There is a remarkable uniformity in the death-rate of institutions using the method - usually from 6 to 8 per cent.

 

MEDICINAL TREATMENT.

There is no specific drug treatment, but it is usually advisable to give hexamine after the second week, twenty to thirty grains (1.3 to 2 gm.) daily. In private practice it may be safer, for the young practitioner especially, to order an acid or a mild fever mixture. The question of medicinal antipyretics is important: they are used far too often and too rashly in typhoid fever. An occasional dose of antifebrin or antipyrin may do no harm, but the daily use of these drugs is most injurious. Quinine in moderate doses is still much employed, but its value is doubtful. In the various antiseptic drugs which have been advised I have no faith. Most of them do no harm, except that in private practice their use has too often diverted the practitioner from more rational and safer courses.

(a) VACCINE AND SERUM THERAPY.

Treatment by vaccines during the height of the disease is still in an experimental stage. Various forms of vaccines are used, and given subcutaneously or intravenously. Doses varying from 50 to 500 million bacilli are given, usually three or four days apart. As patients react very differently, the smaller doses are safer at first, especially if given intravenously. In long-continued attacks when progress is slow, for complications due to the presence of typhoid bacilli in organs or tissues, and for carriers vaccine therapy is helpful. No serum of proved value has been obtained.


(b) TREATMENT OF SPECIAL SYMPTOMS.

For severe toxaemia water should be given freely by mouth if possible, otherwise by the bowel or by infusion. Hydrotherapy should be used actively, best by tub baths. Whisky is generally indicated, four to ten ounces being given in the twenty-four hours. For headache and delirium an ice-bag or cold compresses should be kept to the head. If the patient is very delirious and restless a dose of morphia hypodermically is the best treatment. Lumbar puncture is also useful, the fluid being allowed to run as long as it flows under pressure. Every delirious patient should be constantly watched. It is important to secure sleep in the case of these patients, for which morphia is most reliable. Hydrotherapy, internal and external, is our greatest aid in the treatment o the nervous conditions. The abdominal pain and tympanites are best treated with fomentations or turpentine stupes. The latter, if well applied, give great relief. Sir William Jenner used to lay great stress on the advantages of well-applied turpentine stupe. He directed it to be applied as follows: A flannel roller was placed beneath the patient, and then a double layer of thin flannel, wrung out of very hot water, with a drachm of turpentine mixed with the water, was applied to the abdomen and covered with the ends of the roller. When the stomach is greatly distended the passage of a stomach tube gives relief. When the gas is in the large bowel, a tube may be passed or a turpentine enema given. For tympanites, with a dry tongue, turpentine may be given, 15 minims (1 cc.) every three hours, or the oil of cinnamon, 3 - 5 minims every two hours (Caiger). If whey and albumen-water are substituted for milk, the distension lessens. Charcoal, bismuth, beta-naphthol, and eserine, 1/50 grains hypodermically, may be tried. Opium should not be given. For the diarrhoea, if severe- that is, if there are more than three or four stools daily - a starch and opium enema may be given; or, by the mouth, a combination of bismuth, in large doses, with Dover's powder; or the acid diarrhoea mixture, acetate of lead (1/6 -1/8 grains, dilute acetic acid (15 - 20 minims), and acetate of morphia (1/ - 1/8 grains). The amount of food should be reduced, and whey and albumen-water in small amounts be substituted for the milk. An ice-bag or cold compresses relieve the soreness which sometimes accompanies the diarrhoea.

Constipation is present in many cases, and though 1 have never seen it do harm, yet it is well every second day to give an ordinary enema. The addition of turpentine (½ ounce, 15 cc.) is advisable if there is meteorism.

Haemorrhage. As absolute rest is essential, the greatest care should be taken in the use of the bed-pan. It is perhaps better to allow the patient to pass the motions into. a large pad. Ice may be given, and a light ice-bag placed on the abdomen. The amount of food should be restricted for eight or ten hours. If there is a tendency to collapse, stimulants should be given, and, if necessary, hypodermic injections of camphor. Injection of salt solution beneath the skin or directly into a vein may revive a failing heart, but should only be done in case of emergency. Turpentine is warmly recommended by certain authors.

Should opium be given ?

One-fifth of the cases of perforation occur with haemorrhage, and the opium may obscure the features upon which alone the diagnosis of perforation may be made. Opium increases any tendency to tympanites. We have abandoned the use of opium and have given calcium lactate in doses of gr. xv (1 gm.) every four hours. The injection of blood serum is sometimes of value.

Perforation and Peritonitis

Early diagnosis and early operation mean the saving of one-third of the cases of this heretofore uniformly fatal complication. The aim should be to operate for the perforation, and not to wait until general peritonitis diminishes by one-half the chances of recovery. An incessant, intelligent watchfulness on the part of the medical attendant and the early co-operation of the surgeon are essential,. Every case of more than ordinary severity should be watched with special reference to this com plication. Thorough preparation by early observation, careful notes, and knowledge of the conditions will help to prevent needless exploration. No case is too desperate; we have had one recovery after three operations. Twenty cases of perforation in my series were operated upon with seven recoveries; in an eighth case the patient died of the toxaemia on the eighth ,lay after the laparotomy. In doubtful cases it is best to operate, as experience shows that patients stand an exploration very well.

Cholecystitis.

A majority of the cases recover, but if the symptoms are very severe and progressive, operation should be advised. For chronic cholecystitis, hexamine should be given in large doses and the vaccine treatment employed.

With signs of failure of the circulation, hydrotherapy should be carried on actively and strychnine given hypodermically (1/50 to 1/20 grains) every three hours. Saline infusions

(500 cc.) are useful especially if the patient is not taking much water by mouth. Alcohol is generally of value. Digitalis may be given as the tincture (mxv, 1 cc.) or digitaline (1/30 grains or 0.002 gm.) intramuscularly. For collapse, camphor (gr. ii, 0.13 gm.) or ether hypodermically should be given. The bath treatment is the best preventive of circulatory failure. For phlebitis the limb should be kept absolutely at rest and wrapped in raw cotton. The application of a sedative lotion may relieve pain.

Bacilluria.

When bacilli are present, as demonstrated by cultures or shown by the microscope, hexamine may be given in ten-grain doses and kept up, if necessary, for several weeks. A patient should not be discharged with bacilli in his urine.

For orchitis, mastitis, parotitis, etc., an ice-bag should be applied. Incision and drainage are advisable on the first signs of suppuration.

In protracted cases very special care should be taken to guard against bed-sores. Absolute cleanliness and careful drying of the parts after an evacuation should be enjoined. Pressure should be avoided by the use of rubber rings. The patient should be turned from side to side and propped with pillows, and the back can then be sponged with alcohol.

Bone Lesions.

The use of a typhoid vaccine is well worthy of trial. Typhoid periostitis does not always go on to suppuration, though, as a rule, it requires operation. This should be done very thoroughly and the diseased parts completely removed, as otherwise recurrence is inevitable. For typhoid spine fixation by a plaster jacket or some form of apparatus is advisable. Trauma should be guarded against. In the milder cases active counter-irritation is useful. If pain is severe, large doses of sedatives are necessary.

(c)THE MANAGEMENT OF CONVALESCENCE.

Convalescents from typhoid fever frequently cause greater anxiety than patients in the attack. The question of food ha's to be met at once, as the patient acquires a ravenous appetite and clamours for a fuller diet. My custom has been not to allow solid food until the temperature has been normal for ten days. This is, I think, a safe rule, leaning perhaps to the side of extreme caution; but, after all, with the many soft foods, the patient can take a fairly varied diet. Many leading practitioners allow solid food to a patient so soon as he desires it. I had a lesson in this matter which I have never forgotten. A young lad in the Montreal General Hospital, in whose case 1 was much interested, passed through a tolerably sharp attack of typhoid fever. Two weeks after the evening temperature had been normal, and only a day or two before his intended discharge he ate several mutton chops, and within twenty-four hours was in a state of collapse from perforation. A small transverse rent was found the bottom of an ulcer which was in process of healing. It is not easy say why solid food, particularly meats, should disagree, but in so many instances an indiscretion in diet is followed by slight fever, the so called febris carnis, that it is in the best interests of the patient to restrict the diet for some time after the fever has fallen. Whether an error in diet may cause relapse is doubtful. The patient may be allowed to sit up for a short time about the end of the first week of convalescence, and the period may be prolonged with a gradual return of strength. He should move about slowly, and when the weather is favourable should he in the open air as much as possible. He should be guarded at this period against all unnecessary excitement. Emotional disturbance not infrequently is the cause of recrudescence of the fever. Constipation is not uncommon in convalescence and is best treated by enemata A protracted diarrhoea, which is usually due to ulceration in the colon, may retard recovery. In such cases the diet should be restricted to milk and the patient confined to bed; large doses of bismuth and astringent injections will prove useful. The recrudescence of the fever does not require special measures. The treatment of the relapse is essentially that of the original attack

Post-typhoid insanity requires the judicious care of an expert. The cases usually recover. The swollen leg after phlebitis is a source of great worry A bandage or a well-fitting elastic stocking should be worn during the day The outlook depends on the completeness with which the collateral circulation is established. In a good many cases there is permanent disability.

The post-typhoid neuritis, a cause of much alarm and distress, usually gets well, though it may take months, or even a couple of years, before the paralysis disappears. After the subsidence of the acute symptoms systematic massage of the paralysed and atrophic muscles is the most satisfactory treatment.

Typhoid Carriers.

Treatment of these is difficult. Hexamine should he given persistently and in large doses. Drainage of the gall bladder and X-ray exposures over it have been successful in some cases. The employment of an autogenous vaccine offers the best chance of success. Doses increasing from 25 to 1,000 or 1,500 million bacilli are given at intervals of 10 days.

Lastly, no patient should be discharged from observation until we are certain that he can not infect others.


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