The treatment of typhoid fever may be considered under three headings: First, the nursing; second, the prescription of the indicated remedy, and third, the treatment of the complications. Not less important, however, is the prophylaxis of the disease and the management of the period of convalescence.
The prophylaxis of this disease and its relation to sewage disposal and water supply became the foundation of the modern science of hygiene and furnished the impetus for the vast amount of work accomplished along such lines. The presence of the typhoid bacillus in the dejecta of persons in good health who have had the disease, and also in the dejecta of others who have not had the disease has been demonstrated, and reveals the necessity of much more thorough measures for the prevention of the disease and a much less hopeful outlook for its eradication. The impossibility of adequately guarding the water and food supply and the existence of unknown and unsuspected foci of infection in the shape of carriers of the bacillus in good health means the more or less constant presence of the disease, and makes it the most common continued fever now met with.
The prophylaxis of typhoid fever as generally considered embraces well known measures for the protection of the community and special measures for the protection of the individual. Supervision of the water, milk and food supply, with disinfection of the stool, urine, sputum, water used in bathing the patient, and such clothing and utensils as may come in contact with the sick, are the measures which have been the most helpful in limiting its spread. The education of the community in the essentials of this prophylaxis has accomplished much, but there is yet room for great good along the same line. Prophylaxis as generally considered, deals only with the prevention of the disease, but we could well include under the same head, measures which, properly a matter of treatment relative to the diet in the early days, are prophylactic against the serious type of the disease. The earlier a patient can be placed upon a liquid diet and put to bed the less liable is he to experience a severe attack of the disease. It is the universal experience that those cases which have come under treatment late and have been allowed solid food for a considerable period furnish the larger number of fatalities. With this in view the public should not only be instructed in the hygienic principles for the prevention of the spread of the disease but should be brought to know that with the beginning of illness of whatever character, liquid diet only should be allowed. They should not only know that water may be infected with typhoid germs, that oysters may be dangerous, but they should be taught that a slight rise of temperature with headache or backache and a general feeling of malaise requires attention. The intense commercialism of the present age is distinctly opposed to the adequate care of the individual in trivial illness. Business is before everything, and the business man spares himself nothing until he is so ill he can go no longer. Young, healthy, strong men among whom this disease finds its greatest number of victims are especially imbued with this spirit. This attitude is entirely wrong. The initial stage of all illness demands that the victim should cease his ordinary avocation and stop eating until the disease improves or its serious character is evident. Should it prove trivial, there is no harm done, and such an attitude toward the inception of disease, opposed as it is to the spirit of the day, should be advanced by the medical profession. It should be advanced not only in the interest of typhoid fever but in the interest of several other diseases. Even pneumonia finds its victims up and out for the first, and sometimes the second, day of the disease. A natural pride in good health and a robust constitution which does not give up to trifles, so characteristic of the young man and vigorous man, makes him an easy victim. The child is put to bed as soon as it is ill, and the disease is usually mild in children.
The early stage of typhoid is sometimes in the hands of the doctor, who need not be an expert diagnostician in order to handle it properly. He should put all cases with a rise in temperature in bed, and restrict the diet to liquids. The diagnosis does not matter, all cases are benefited by rest, and most people eat too much. One young man was allowed up every day and kept on a generous diet of meat and vegetables with a diagnosis of malaria, and another was threatened with a brain abscess, the diagnosis being confirmed by eminent consulting authority. A solid diet was not contradicted, and in both cases was allowed until between the tenth and fourteenth day. A diet does not do a case of malaria any harm, and it does not do a brain abscess any harm, but these two young men both had typhoid fever and died of typhoid fever. It might have been otherwise had the diet been limited at the outset. The essential point of the matter is that the physician should practice and preach that all cases of sickness, no matter what the suspected diagnosis, should be placed upon such a diet that the late recognition of the existence of typhoid infection in the case will not be the source of any regret.
The first consideration in treatment is the nursing. The detail of this need not detain us, as its principles are well understood. The patient should be immediately placed in bed and kept there during the entire period of the disease. He should evacuate the bladder and bowel in the horizontal position. Visitors should be excluded, and the patient should be kept perfectly quiet. The great essentials of rest and diet must take precedence of all else.
The anorexia which often marks the early stages of the disease is an indication for a very limited dietary. This symptom, as with many other cases where the dictates of nature become imperative, is to be viewed as a reaction of the organism against the disease, a phenomenon whereby nature, through the survival of the fittest, has developed a method by which the individual has been able to rise superior to the typhoid disease and conquer in the struggle for existence. This with the rise of temperature and all the other symptoms which make up the reaction of the organism to the disease is vis medicatrix naturae. It is a reaction which has developed through long ages of conflict between the human organism and the typhoid bacillus. It is a reaction which has enabled the organism to kill the germ of the disease, to combat its poison and to accomplish the salvation of the survivors in this very disease which the modern physician is endeavoring to overcome. When we view the symptoms as the indications of the curative reaction stamped upon the survivors through an expression of thousands of years, then they become sure indications of correct methods of treatment. With loss of appetite the typhoid patient in the early stages should not be fed. Such a plan is eminently successful for a time.
However, the necessities of maintaining the nutrition of the patient make it advisable that we should consider other features of the situation. In general, the difficulties in the nourishment of the typhoid patient are to be looked for in two directions: Firstly, those conditions which are attendant upon the infection or febrile state, and secondly, those associated with local changes induced by the typhoid process, particularly in the intestines. The manifestations of toxic action, especially the febrile reaction, are attended with profound metabolic changes among which the destruction of the body proteid plays an important role. As the direct replacement of the disintegrated proteid through the food is possible only in a wholly inadequate manner on account of the febrile derangement in the digestive activity, it is most important, as far as possible, to shield the body proteid by the use of carbohydrate and energy sustaining substances. Therefore, the starvation plan of treatment presents the grave question as to whether we may not permit a disintegration of this body proteid by this method to a wholly unnecessary extent. There are other important nutritive changes which take place, particularly in relation to the destruction of carbohydrate and fats. The digestion, both in the stomach and intestines, is impaired. The secretion of saliva, the pancreatic secretion, and the functions of the liver, and all of the processes which have to do with the absorption and assimilation of the food, are impaired. Then the long duration of typhoid fever and the consequent high grade which the nutritive changes necessarily reach under any circumstances, are to be seriously considered. Of the considerations arising from the local changes those dependent upon the specific intestinal lesion predominate. These lesions bear no relation to the severity of the symptoms, and, therefore, every case, even the mildest, must be dealt with as those which present the severest ulceration. The starvation treatment makes perfect allowance for the local condition, but leaves the body nutrition and the destruction of the body proteid entirely out of consideration. Fortunately it is entirely possible to provide adequately for the considerations dependent upon the intestinal ulceration, and at the same time protect the body proteid to a reasonable extent. Just what food will accomplish this end most satisfactorily is dependent to a considerable extent upon the facility with which it is assimilated by the particular case, but that the residue which passes over the ulcerated area of the bowel should be non-irritating is essential. Food in a liquid, and, therefore, finely divided state, fulfills this consideration best, and although milk, which is liquid when taken, becomes solid in the stomach, the further process of its digestion is such that it need not be excluded, in the great majority of instances. The conditions which call for the exclusion of milk are of a toxic character, and an elevated temperature rather than any which arise from its solid character while in the stomach.
Food should be given regularly and in small quantities, both day and night, and care should be taken that somnolent patients are urged by their attendants to take it regularly. Overfeeding must be rigorously avoided; the dangers which come from too much food are greater than the loss of vtial resistance, which results from too little. While a repugnance for food on the part of the patient is an indication to reduce the amount given or even to discontinue feeding for a time, the desire for food and the hunger which many patients experience is not an indication for increasing the diet beyond a certain safe limit.
Among the admissible articles of food the first place should be given to milk. It is an ideal combination of proteid, fat, carbohydrate and salts in a liquid form. Fats are especially important for febrile patients, and are utilized with much difficulty. In milk they are finely divided in a permanent emulsion and are as assimilable as possible. In connection with the carbohydrates they are to be relied upon to shield the body proteid as much as possible from the destructive processes which the fever entails. The proteid element of the milk is not as readily assimilated or digested. The use of top milk diluted with water and with the addition of sugar of milk, thus increasing the carbohydrate and fat and diminishing the proteid in the diet, is a desirable modification of the ordinary milk diet. Eight ounces of milk, preferably in this modified form, should be given in alternation with eight ounces of water every two hours. If milk is distasteful or does not agree, as indicated by the presence of toxic symptoms and high temperature with distention of the abdomen, it should be replaced by a diet which contains the carbohydrates in the form of a thin strained gruel, possibly flavored with a meat extract, or a malted milk preparation may be used, or the patient may be given white of egg in water. With such a diet grape juice or orange juice may be used, and this proves very grateful to the majority of the patients.
The importance of water internally exceeds its importance externally. If a sufficiency is given so that the quantity of urine is increased and of a light color, and if the diet is judiciously managed, there will be little need for baths. In the exceptional cases where, even under judicious management, the temperature is unduly high, tepid sponging is to be preferred to the cold bath as a means of controlling the temperature. The elevation of the body temperature was at one time looked upon as the most worthy point of attack, as it was the most conspicuous symptom of the disease. At present much less importance is attached to the direct control of the fever.
Should enfeeblement of the circulation make itself manifest, alcohol is probably the best means of stimulating it to renewed activity. The use of alcohol from the beginning has been advocated by some, but it is now recognized as the more judicious plan to withhold it altogether when possible, and use it only when stimulation becomes imperative.
Meteorism is in some cases due to the use of a milk diet, and will disappear when another form of feeding is substituted. When it occurs in a marked manner in those cases whose diet has been suitably adjusted, it is always an expression of profound intoxication. Rectal irrigation night and morning is useful in relieving this condition. It supplies an amount of water to the circulation by absorption, and thus causes a washing out of toxic material by the kidneys. It empties the bowel and has a tendency to bring down the temperature, and at the same time controls the abdominal distention. In cases where better measures already detailed have no effect the use of turpentine, the high rectal tube or puncture of the bowel with a fine needle will also prove disappointing.
In case of intestinal haemorrhage absolute rest in the dorsal position is necessary. Irrigation of the bowel if previously resorted to should cease and feeding should be discontinued. Cold may be applied to the abdomen, but the use of opium is not desirable. It obscures the symptoms of perforation, which may occur, and has been discarded for this and other reasons. Moderate collapse, if intelligently controlled, will permit the closing of the bleeding vessel, and the use of stimulants is likely to defeat this most desirable end. It must be remembered that haemorrhage in typhoid is usually not fatal, and the utmost discretion is necessary in order that the measures adopted may not do more harm than good. Under these trying circumstances the properly selected remedy holds out the most promising assistance. Rhus, Ipecacuanha, Cinchona, Ham., Secale, Lach., the mineral acids, particularly nitro-muriatic acid, have proven themselves invaluable.
In case of intestinal perforation a resort to immediate operative procedure offers the only hope of saving the patient.
Specific treatment for typhoid fever by the use of serum has been attempted, but up to the present time has not been successful. Among some of the earlier methods we find efforts at intestinal antisepsis, and among other substances used calomel, then, had and still has its advocates. It has been repeatedly pointed out that the bacilli in the early stages before the case comes under the charge of the physician, have passed from the intestine into the follicles, the mesenteric glands, etc. Therefore, even though it were assumed that there was a method capable of injuring the pathogenic germ micro-organisms more than their host, the futility of the proceeding would be apparent. Calomel has been recently advocated in the beginning of the disease, but it seems only to increase the number and greenish character of the stools with possibly some depression of temperature, but without any abortive or abbreviative action upon the disease.
In taking up the consideration of the appropriate remedy for the patient, space and the character of this paper does not permit an exhaustive consideration of the subject. The valuable analysis of our drugs by Dr. Wells in the American Homoeopathic Review, Vol. III, is still a worthy model. He states that the symptoms of the disease are such that we may classify the cases in groups, one in which cerebral symptoms predominate and resemble a class of drugs for which Belladonna is selected as the model, another in which abdominal symptoms predominate with Arsenicum as the model of the drug type, and a third group where the symptoms are of a mixed type with Bryonia as the drug model. With Belladonna are classed Hyos., Lach., Opium and Stram. With Ars. are grouped Carbo veg., China, Colch., Merc., Nux vom., Secale and Sulphur. With Bryonia are classed Arnica, Calc., Nux vom., Puls., Rhus and Veratrum. His detailed description of their symptomatology and differentiation should be referred to.
The modern type of the disease falls more often under the class of symptoms represented by Bryonia, and to this class should be added Gelsemium and Baptisia. Bryonia itself is of all most often indicated, and the headache, prostration, backache, aggravation from motion, thirst, etc., etc., of this remedy mark a great many cases in their beginning, and frequently correspond closely to the conditions presented throughout the disease. When muscular soreness with a dull, besotted expression, mental cloudiness and diarrhoea of an offensive character are present. Baptisia is to be preferred, or possibly the disease may set in with the chilliness, drowsiness, and trembling prostration, vertigo, dimness of vision, and thirstlessness of Gelsemium. Later, symptoms of Rhus frequently present themselves with the development of restlessness, which, if present from the first, will probably have called for that remedy early. It may be that the restlessness will be that of Arsenicum with its exhaustion. This remedy, though, is said to be disappointing in typhoid, and should not be prescribed unless well indicated by its more detailed symptoms. Or the condition may be one of stupor and restlessness where many of the symptoms of Lachesis are present, or, again, it may assume the stupor without the restlessness and present symptoms calling for Phosphoric acid, or Opium, and with the advance of the disease a condition of exhaustion may develop, which will demand Carbo veg. or Muriatic acid. But the selection of the helpful remedy requires a much more detailed consideration of the symptoms of each individual case than can possibly be considered except with a particular case in view.
Dr. John W. Dowling: Dr. Minton has rightly given first place, after the nursing, to the administration of the indicated remedy, and for the reason that the proper remedy is good insurance against accidents due to complications, and also because it undoubtedly shortens convalescence. We should strive to avoid the routine prescription of Baptisia or Bryonia just because typhoid is suspected. It is often several days before we can be certain of the diagnosis, and during these days much can be done by careful prescribing to mitigate the symptoms of the succeeding weeks, and one cannot emphasize too strongly the wisdom of at once putting suspected cases on a non-irritating diet. No one is harmed by eating little or nothing for a few days, and if typhoid is to come semi-fasting will do much good in the way of freeing the intestinal canal of fermenting waste products, harmful in any sickness, and a source of much danger in typhoid.
The point made by the author, as to the unwillingness of the public to give up work in time, is strongly emphasized in our hospital practice, where patients are not, as a rule, admitted until unable to work, because their livelihood depends upon a daily wage, and it is for this reason our hospital records show a higher mortality. As Dr. Minton says, we can do much along this line of preventive medicine by inculcating a spirit of wise forethought in our family practice. A natural corollary of this is the necessity for combating the layman’s desire to shorten the period of idleness following convalescence. As we know, much damage is done to the heart muscle during typhoid, and often there is also set up an endocarditis, and all too soon for their own good, patients feel able to return to their usual vocations, and do so, later, to find themselves partial cripples from a dilated and damaged heart. Three weeks, at least, four if possible, should ensue fom the date of the crisis before exertion of any moment should be permitted.
Next to the remedy the question of diet is the one which has given rise to the most discussion, and has ranged all the way from the milk diet of twenty years ago and the full mixed diet of some writers of to-day, to the starvation diet with plenty of water continued throughout the entire three weeks. Personally, my experience has led me to favor the latter, as I have before stated to this body. For many years and with much hospital practice I have been led to leave out one article of food after another, finally coming down to water alone, with the confidence that my cases will not run a high temperature, will have little delirium, and will avoid many complications. And if water be given regularly it is surprising how little emaciation occurs; after three weeks of a water diet, one does not expect to see a plump and well-rounded body contour, but that this does occur, I know by experience. I think the explanation of this lies in the fact that almost all body wear and tear is suspended, the fever alone using up the body reserve and fever averages lower when not aggravated by the effort to digest food, and by the absorption of intestinal toxic products resulting from incomplete digestion. I believe these very products by generating intestinal gases with distention, increase the danger of perforation. I have yet to see this accident result in a water fed patient, and only recently, yielding to the anxious solicitude of a hospital interne and permitting him to give a small quantity of liquid food. I was chagrined to have him report that the gut was perforated, following which the patient died. This may not have been a case of “post hoc, propter hoc,” but it did serve to confirm my opinion that it would have been better to have waited.
I know I am at odds with many men of experience, but I believe a trial will demonstrate the truth of these views.
W. W. Blackman, Brooklyn, N. Y.: Dr. Minton has covered the ground in the treatment of typhoid fever so well that there is little to add, but much to commend; therefore, in the discussion of his paper, the emphasizing of some points and a reference to a few not mentioned seems all there is left to do.
Careful nursing and proper diet regulations are undoubtedly the prinlipal life-saving agents of typhoid fever. An article of this kind is necessarily too brief to mention all the details of nursing but the simple care of the mouth is worthy of special attention, and is too often neglected. Wash the mouth frequently, and always after taking food. A coated tongue and foul mouth afford a field for the development of bacteria, which are constantly being carried into the stomach, often exciting indigestion and flatulency. If the patient is too feeble to rinse the mouth, the nurse should swab it out with a bit of cotton. Nurses should be made to understand the importance of this simple detail. A patient may often learn to use a “tongue bath” to advantage, that is, to hold the mouth full of water for a short time, when much moisture is absorbed by the mucous membrane. When these things are faithfully done, one seldom sees the typical “typhoid tongue,” brown, dry, hard and so stiff that it is useless to the patient, and the liability to parotitis is greatly lessened.
In few diseases does a closer relation exist between right feeding and symptoms, and in no other disease is the necessity as great for the individualization of the diet. A routine diet is as irrational as routine prescribing of the remedy. It is admittedly easier to put all patients upon a routine diet, but it is far better and of the utmost importance to secure a suitable variation of food and one adapted to each particular case.
Probably no other article or form of food is as important as water in typhoid fever. As a “force producer” within the body, it is of comparatively little value. But the fact that it enters into the structural composition of all the tissues of the body and forms a large percentage of the entire body weight entitles it to be ranked as a food. In all fevers, and especially in typhoid, water is absolutely essential. The drain of water from the blood and eventually from other tissues of the body is excessive, and patients who are extremely feeble or not wholly rational may not ask for a drink, although their mouths are dry and parched. In all cases, pure fresh spring water should be given in proper amounts at regular intervals.
Much is said nowadays about intestinal antisepsis especially in its relation to diet. Rachford says that “bacilli fed on beef juice produce ptomaines, which act more strongly upon the nervous system than if they are fed on milk.” Starches do not make ptomaines. “Typhoid germs certainly thrive in nitrogenous media, but not upon carbohydrates. Their development in the former is accompanied by the production of toxic material in the intestines, which, on being absorbed into the system, produces the symptomatic phenomena of the disease.” For this reason, the use of meat broths, beef juice or animal extracts of any form should be avoided in all stages of the disease. Nor should they be allowed until the temperature of the patient has remained normal for several days.
For years text-books and teachers in medical colleges have taught the avoidance of fruit juices in typhoid. From a theoretical standpoint, this may seem correct, but practical experience teaches that the juices of acidulous fruits are not only permissible but decidedly beneficial, and are often tolerated when other forms of ailment are rejected or aggravate. Their acidity is due to the acid salts, such as malates, citrates, tartrates, etc. These salts are transformed in the system by the complete combustion of their organic parts into soluble carbohydrates which alkalize the blood. Moreover, they are rich in sugar and are usually taken with a relish. Sometimes a patient may be fed for five to ten days on grape juice alone.
“The question of how far alcohol serves the purpose of food and a ‘force regulator’ in typhoid fever is very important.” Probably no point in the care of the typhoid patient has proven so wide a difference of opinion. Its employment as a routine treatment is generally to be deplored. It is seldom required at all. When used, its administration should be as carefully considered as the selection of any other remedy for the case. Alcoholic drinks should not be taken in cases of severe cephalalgia, acute delirium, extreme dryness of the skin, haemorrhage or albuminuria. Never use it when the pulse is hard, but when the pulse is soft and compressible, alcohol in small quantities is often beneficial. Sometimes during convalescence a good, old red wine may render good service, but should be allowed only in small spoonfuls at a time, and always at the end of a meal.
A remedy of considerable importance not mentioned in the paper by Dr. Minton is Echinacea. In cases of a low type with offensive breath and foul discharge, where Baptisia fails – especially where ulceration seems extensive – this remedy is often indicated, and is frequently effective.
Dr. P. P. Wells’s article on the medical treatment of typhoid fever alluded to by Dr. Minton is a classic in homoeopathic literature, and should be in the possession of every homoeopathic physician.
E. W. Sawyer, M. D., Chicago: This paper to which we have just listened is, in my judgment, the best paper on typhoid fever that I have ever heard presented to a homoeopathic society. I have only a few words to say on the preventive measures. One remedy was omitted that I would recommend to your consideration, as it has broken up several incipient typhoid cases for me, and that remedy is Pyrogen. There seems to be a difference of opinion in the profession on the question of feeding. I have treated about 3,000 typhoid fever and typho-malarial fevers, and I have fed them on milk or buttermilk exclusively. The nurse would say to me: “How much shall I allow the patient to have, Doctor?” My invariable answer was, do not give them any more than they can hold. No limit. Another question raised here that interests me greatly is in regard to emptying the alimentary canal during typhoid fever. Hahnemann, Boenninghausen and Hering said they had never known a death from typhoid fever where that patient was constipated. I never saw a typhoid patient die when constipated except death occurred under allopathic hands, where the patient was treated to death and they denied it was typhoid because there was no diarrhoea but post mortem confirmed the diagnosis, because there was the characteristic ulceration of the Peyer’s glands. A large proportion of my patients did not stool before the eighteenth day. The first stool would be normal and continue so. Some of you might ask: “What was your death rate after allowing your patients to have all the milk or buttermilk they wanted, and letting the bowels go without ever emptying them?” My death rate was less than one-third of one per cent. Constantine Hering gave out what he called “symptomatic indications for fever,” and I have found that during between thirty and forty years’ use it has met the requirements everywhere. It is out of print, and I have tried several times to get it published again. Dr. James, of Philadelphia, promised to do it, but he never did. One point more. In all the cases I have treated I have never had a case of haemorrhage from the bowels. As long as the Peyer’s glands are not raked over or interrupted the ulceration will remain so small that not one case will be troubled with haemorrhage. I have had some cases of haemorrhage from the bowels come to me from other practitioners, and I have found a high potency of China or a low potency of Phosphoric acid all-sufficient, and fortunately have not lost a single case.
H. V. Halbert, M. D., Chicago: May I ask you one question: If your cases all presented a weak bowel reaction, and if the cases of typhoid fever which you have reported with such remarkable percentage of cure all presented the Widal reaction?
E. W. Sawyer, M. D.: I do not know anything about your Widal reaction.
H. V. Halbert, M. D.: That is why I asked you.
E. W. Sawyer, M. D.: I know they had all the indications of typhoid or “typho-malarial” given in text-books, and the prevailing fever was universally declared typhoid or “typho-malarial.” At the same time the “old school” in many instances lost as high as sixty per cent. of cases. I do not give this percentage as anything remarkable under homoeopathic treatment. Hering says in “Symptomatic Indications:” Not only the duration of the fever ought to be a great deal shorter, but the mortality ought to be considerably less. The latter ought to be restricted to patients with such organic diseases as are developed by the fever, or such relapses as are brought on by neglecting the rules during convalescence.” We have the best of reasons for believing that Hering knew what he was talking about.
H. V. Halbert, M. D.: If you will allow me I feel it is against the rule of our school or any school to allow statistics to go out without thorough diagnosis. We all can make mistakes in diagnosing typhoid fever, and we all have made mistakes and to give the percentages which you give without positive diagnosis I do not believe is quite fair.
E. W. Sawyer, M. D.: What do you mean by positive diagnosis?
H. V. Halbert, M. D.: The Widal reaction.
Wm. J. Hawkes, M. D., Los Angeles: I am very glad this subject has come up. The paper is an excellent one. I think there have been more relapses from over-feeding than from any other cause in typhoid fever. My rule now invariably is to give the patient nothing at all to eat so long as the tongue is coated and the fever high. He gets all the water he can drink. Pure water is the food for a typhoid fever patient, until his tongue clears, his fever disappears, and he asks for some simple, wholesome article of food, showing nature has reached a point when she is able to take care of food. As soon as the patient is able to digest food there will be an indication in his or her desire for food. Until that time comes, give nothing but water or fruit juices that you are sure are clear of microbes, and you will never have these set-backs.
In regard to the bowels, I agree partly with the one who empties the bowels regularly. I agree partly with the one who empties them only by high colon injections once or twice at the beginning. I believe the less we irritate the upper bowel in typhoid fever the better, other things being equal, our results will be. The name of the disease indicates the locality where the lesion is, ileo-typhus, typhus abdominalis, it means the seat of the disease, pathologically, is in Peyer’s patches in the ilium, and it is perfectly reasonable to suppose the less you irritate by external friction any inflamed surface the better chance that lesion will have to heal; the more you irritate it by either purgatives or food that can not be digested, the less chance you have for those ulcerations or irritated points to heal. Consequently my course in treatment is, if the bowels have not moved freely within a day before I have been called, I use an enema and empty the colon and rectum completely. After that they are not disturbed until the fever disappears and if you do follow my advice, follow my practice and give them nothing but water or fruit juice until the indications call for food. I believe this firmly, and have not one shadow of doubt about the correctness of this mode of treatment, and have not a shadow of doubt about the incorrectness of feeding typhoid patients during the existence of fever. Give them all the water they can drink until they ask for some simple, plain thing, not for some fancy dish, and then give them the simple thing in moderation to start with, and you will never have relapses.
One speaker calls this “the starvation method.” It is in fact the opposite of “starving.” People are often “starved” by over-feeding. Food in the stomach is not always nourishment. More are “starved” in well-to-do civilized life by over-feeding than by under-feeding.
A. Jerome Robbins, M. D., Jamestown, N. Y.: Ladies and Gentlemen – The first thing I want to challenge in the paper is the statement that we find a very mild form of typhoid fever in children. That does not correspond with my experience with that disease in children. Then in regard to feeding; I do not think it is advisable to feed even an infant every two hours. I think there should be a little time for rest between the time of feeding and the time when the stomach has emptied itself, which usually takes place in about two hours; I think you will cause a great deal of disturbance in attempting to feed even an infant every two hours, let alone a grown person. I have fed some patients on water, I have fed others on butter milk, and others on sweet milk, still others on bean porridge, and I have had patients who ate three square meals a day, meat included, and they recovered. They were tested with the Widal test.
Now, in regard to the effect of calomel and in regard to the effect of the bacteria having passed out of the intestine into the general system, the blood, etc., at the time that we get these patients if it has gone that far, we can get a positive diagnosis with the Widal test. When we first get hold of the cases, if the bacteria have not passed out, it is up to us to clear that intestine in some way and keep these bacteria from getting into the blood and general system. Then you will have what is called aborted, or modified, typhoid fever, where the patients will be up and going about their business in a week to ten days. But if they have passed out into the blood and into the system, you cannot cut it so short; these bacteria grow and multiply in that intestinal tract, and it is simply common sense and good judgment, in my opinion, to clean out that intestine and keep them from developing and further infecting the system.
H. V. Halbert, M. D.: I want to make a correction before we go further. I do not mean to stand here and say in every case of typhoid we get the reaction. I said that a little too hurriedly. But what I mean to say is, we have not a right to pass out statistics on a lot of cases we think may be typhoid fever. We can get additional help in the blood count in the early stage, and in the majority of instances we may get the Widal reaction, but I believe it necessary to have positive proof when we give statistics. However, I do not intend to say that in every case we can demonstrate the Widal reaction.
Wm. H. Van den Burg, M. D., New York: I want to emphasize the recommendations of the paper in reference to foods. The essayist’s diet calls for about forty-eight ounces of milk, plain or modified, in twenty-four hours with an ample quantity of water. There has been a tendency (fortunately now being overcome) to starve typhoid patients too much and I have personally seen a number of cases that I am sure were starved to death. I simply want to add my testimony in favor of rational feeding in this exhausting disease.
I also want to call attention to the statement relating to the continued use of so-called intestinal antiseptics. I fear from some considerable observation that our school is not entirely free from this practice. It has been demonstrated that intestinal antisepsis is impossible with drugs. If enough drug be given to materially after the bacterial contents of the bowel the disease picture is so complicated by the drug picture that it is impossible to follow the course of the disease or recognize complicating symptoms. It has also been proven time and again that the antiseptic treatment does not shorten the disease or lessen the severity of the attack. I am sorry, therefore, that Dr. Minton did not emphasize more fully the futility of this form of treatment.
There is one other method of treatment that he rather ignored which seems to me a very important one, i. e., the use of the Brand bath, not necessarily the cold or ice bath. Unquestionably the Brand bath has a place, and a very important one, in the therapeutics of typhoid fever. The method, however, is of little use unless the proper technique can be strictly adhered to. (Question: Temperature, please) The temperature should vary with the condition of the patient from 90 degrees to 65 degrees, depending upon the reaction of the patient. The method of using the bath can be learned from any good text-book, always bearing in mind that the minute details are all important. One more word in regard to this method; it is practically impossible to carry out the Brand method in private houses unless you have ample facilities and abundance of skilled help. It is better not used unless properly used. In hospitals where there is sufficient skilled help and the Brand method is used as a routine the death rate in typhoid fever is lower by from 5 to 15 per cent. than where the method is not used. Bear in mind that the purpose of the Brand bath is not to reduce temperature but is for the purpose of eliminating toxins and stimulating vital resistance.
I also want to advocate the use of intestinal irrigations where there are no complications. I believe this to be a very efficient means of assisting in eliminating toxins from the system.
C. S. Ames, M. D., Ada, O.: Two or three have spoken of relapses being caused by error in diet or by over-feeding. I believe that; as a rule, relapses in typhoid fever come not from over-feeding or errors in diet but simply from the fact that that patient has not acquired what we call immunity. A typhoid fever runs its course and ceases because there has been produced in the system an anti-toxin which checks the development of the typhoid bacillus, and the fever subsides. Otherwise the disease would run on until the patient’s life was destroyed. We have about ten or twelve per cent. of typhoid fever patients who suffer relapses. In these patients immunity is not acquired immediately or is not sufficient to prevent a relapse. There is still development of the bacilli in the system, and the patient goes through another attack. You occasionally see a case that will run through three or four relapses simply because the patient has not until that time acquired immunity.
Lincoln Phillip, M. D., Cincinnati, O.: Typhoid fever can lack potency, can stay until doomsday or be irregular. Typhoid is one of those conditions which oftentimes gets well in spite of the doctor, and I believe that the thing to do in the treatment of typhoid is to steer clear of foods and use gray matter.
J. T. Simonson, M. D., New York: I want to commend one statement in Dr. Minton’s paper and disagree with one of the discussers. Typhoid fever in children, and especially in infants, unless the infant is under a year old, and very, very few such cases that are authentic are on record, is always light. It is so light and so mild in the great majority of cases that it is not recognized and in a series of 3,000 autopsies in the Foundling’s Asylum in New York no evidence of typhoid was found in any one of them. Nothing but the grossest kind of ignorance would kill a child with typhoid fever. They would get better in spite of you. The great majority of cases are not recognized at all in children, and I would again commend very strongly, in children having infantile typhoid, the use of intestinal irrigation. I believe typhoid in children is always light, though it has often been denied. I believe Holt denied he ever saw a case under one and one-half years old, and cases under three years old he says are very rare. I believe the opposite to be true. Under three years of age it is very common. It runs a very short and mild course, and is usually called either a mild intestinal catarrh or intestinal toxaemia, and when the laboratory test is made, nine times out of ten you will find the Widal reaction. The Widal reaction is always light in infantile and children’s typhoids. It usually appears when the case is nearly well, and they say they get no Widal reaction, and, therefore, they think they have no typhoid. You can always make a correct diagnosis if you will take into account two things: One is the character of the temperature, which does not step and step, but goes up with a jump, the child vomits, has headache and convulsions: the other is the remarkably slow pulse with that amount of temperature for a child of that age. That is a combination met with in only two diseases in children. If you have a child with a high temperature and slow pulse, if it has no organic heart disease, it is either typhoid or meningitis. I do not care whether it is stupid or not. I have in the Flower Hospital now two infants with a temperature over 103 and a pulse not over 108 or 110, and that means either typhoid or meningitis; but if with that you get a leukopenia you are not likely to get the Widal reaction. If you will let me quote the hospital again, I may say I have two with a white count of 23,600, and could not get the Widal reaction, and have tried for it six times. We will get the Widal when nearly well, or they won’t show it at all. It is never recognized in children, and that I believe is one of the causes of the spread of typhoid in the family among adults, the carelessness of disposing of urine and other discharges of a child with typhoid that is not recognized.
J. C. Fahnestock, M. D., Piqua, O.: I thank Dr. Minton for this very excellent paper. When the patient can digest and assimilate he is in readiness (no matter at what period during his sickness) to take food. Insist upon giving water, and treat that patient suffering from typhoid fever. In all probability he was not a well individual before he took the fever or his resistance would have been such that he never would have suffered with typhoid fever. It matters not what remedy is indicated. Treat the patient and forget your name, “typhoid fever,” and the patient usually gets well.
Dr. Minton: In closing, I wish to refer to the feeding of typhoid patients every two hours. What I said was that eight ounces of milk, preferably in this modified form, should be given in alternation with-eight ounces of water every two hours. That is feeding every four hours. There was a misapprehension in the notion of feeding every two hours, and I have not included any such idea in the paper. I think myself it would be too frequent. Any other matters I had intended to refer to have been already covered by the various members discussing the paper.