THE TREATMENT, MEDICAL COMPLICATIONS AND SEQUELE OF TYPHOID FEVER.

BY H. A. HARE, M.D., PHILADELPHIA, PA.

The subject which I desire to call your attention to today is one which is of far greater importance than it would appear at first sight, although every general practitioner, of course, recognizes that typhoid fever is a disease always with us and of sufficient severity in some cases to produce desperate illness and death. It is so large a subject that it will not be possible for me to do more than to touch upon a number of facts in connection with it, which should be carefully borne in mind.

In a paper which I read before the College of Physicians of Philadelphia thirteen months ago, I showed conclusively that there was a decrease in the frequency and in the mortality of typhoid fever all over the world, which decrease is probably due to improved sanitation and a better knowledge of the methods which should be employed in the treatment of the malady.

The next point which I wish to take up deals with a question of what should be the proper treatment of the average case of typhoid fever. In the paper which I have already quoted I protested against the use of the cold plunge bath in every case of typhoid fever that came into the physician's hands, first, on the ground that routine treatment was never rational, and second, because a certain proportion of patients present contraindications to its use which are absolute, and a still larger class can be treated by properly modified hydrotherapy with excellent results.

In making this latter statement I am well aware that I am doing a dangerous thing, first, because a number of men, eminent in the medical profession, have given their support to the universal employment of the cold bath, and second, because there is a possibility that my own position in this matter may be misunderstood. In other words, it may be that a careless hearer will think that because I do not use the bath in every case I do not use it in any case. This is exactly the opposite of the view which I wish to leave with you. As firmly as I believe that the plunge bath is not for every one, so do I believe that in some cases it is the best and only thing which can be employed with advantage.

I also wish to insist upon the fact that, while the disease has decreased mortality independent of such treatment, that hydrotherapy has saved a great number of lives, and if properly employed will continue to do so. The important points for the physician to decide when treating any case of disease are, first, the remedy which is needed, and second, its dose. In the opinion of those who have the largest experience, hydrotherapy is needed in every case of typhoid, and with this view I most heartily concur. When it comes to the question of dosage my point of view differs from that of some others. I believe that the mode of applying cold should be varied to the needs of the individual patient, and I have yet to see a case in which I have regretted the employment of the modified plunge bath. What, then, are the modifications which I would suggest? First, the use of cold applied to the body of the patient, who is stripped and who lies upon his bed while the nurse gives him the necessary friction and massage. The water is to be varied in its temperature according to the persistency and degree of the fever. If the patient suffers from marked hyperesthesia of the skin, so that the cold and the rubbing make him actually wretched, the first so-called spongings may be made with water at 70 deg.; later on ice-water may be employed, or if the fever is high and persistent, a piece of ice may be rubbed over the body instead of the use of water itself. In other words, the dose of cold varies with the needs of the individual. It is of vital importance that the nurse who employs this modified bath treatment should be trained to her duties. I constantly meet with nurses who conscientiously attempt to carry out my wishes without previous training, and who practically never succeed in reducing temperature of the patient more than a degree when using the plan that I have mentioned; as soon as I place a trained nurse in charge of the case, I am able, almost without an exception, to reduce the temperature many degrees.

During the past three months I have had fifty-eight cases of typhoid fever under my care; every one of these has required hydrotherapy; in only two has the persistency of the fever necessitated the use of the cold plunge, and in both of these, by a curious coincidence, and I do not consider it any more than a coincidence, hemorrhage from the bowel at once occurred. You will notice that almost without exception the temperature under the use of this form of cold falls from 2 to 4 and 6, or even 8 deg., proving two points --first, that if this form of cold is properly applied it reduces the temperature satisfactorily and produces a good reaction, and second, that if such a fall of temperature can be produced by mild means, why should we resort to the labor, the exhaustion and the excessive effect of an actual plunge? I am firmly of the belief that the active rubbing which accompanies the use of cold in the way that I have described is of great advantage to the patient, because I believe that a gentle massage given to patients suffering from typhoid fever, and who are practically taking the rest cure, is an exceedingly useful thing for the maintenance of health; second, because by these frictions we increase reaction, and third, as has been proved by Popischil, friction increases the loss of heat 80 per cent., and the loss of moisture through the skin, according to Weisroch, 50 per cent.

There is only one thing that can be urged against this modified form of hydrotherapy which cannot be urged against the cold plunge and that is, that unless it is given properly it does not reduce the fever in the way in which the cold plunge necessarily reduces it, but I would ask you to remember that any remedy which is powerful for good is equally powerful for harm, and that the cold plunge cannot be used carlessly or without attention to detail any more than can the cold and friction which I have named. Whenever a physician tells me that he is unable to lower the temperature by friction and cold without the plunge, I am confident that it is because the method has not been properly employed, for only rarely is the fever so presistent as to fail to fall.

Of course, in the early stages of typhoid it is a wellknown fact that the fever is peculiarly resistant, not only to cold frictions but also to the plunge itself.

I next wish to call your attention to a number of variations in the character of typhoid fever, which are apt to lead to late or erroneous diagnosis. The first of these is the so-called abortive form, but in emphasizing the fact that abortive forms do occur, let me also emphasize the fact that they do so spontaneously and that it is not in our power to abort the disease. Again, let me emphasize the fact that no conscientious physician should make a diagnosis of abortive typhoid fever until every other possibility is carefully considered and until his diagnosis has been confirmed by the Widal reaction. It is an interesting fact that in most of these cases of abortive typhoid fever the onset of the disease is apt to be severe, particularly in respect to temperature, which is unduly high at the start. On the other hand, typhoid fever may develop in such a mild form that all its characteristic symptoms may be masked and the patient only suffer from moderate fever and general wretchedness for several weeks. Again, exceedingly rare instances occur in which typhoid fever is present without any fever, the socalled apyretic typhoid; here again a diagnosis should only be reached with the utmost care, and finally, let me call your attention to the fact which has so well been emphasized by Osler, that the primary effect of the typhoid infection may be exercised upon other portions of the body than the intestinal canal, and that many cases are on record in which undoubted typhoid fever has been present without there being any intestinal lesions whatever.

Temperature Variations from the Usual in Onset.These variations may be due to the complicating states which are about to be described, or they are manifestations of perversions of the ordinary temperature of the initial days, occurring without assignable cause. The presence of a consolidation in the lung, or a cholecystitis, or of any serious lesion in one of the organs of the body, may entirely alter the chart in this period of the malady. In nervous children or women the irritation of the heat-centers results in a sudden rise like the more acute maladies of an infectious type. Indeed, the onset of typhoid fever-in chil-dren is more apt to be ushered in by a chill and high fever than it is in adults, as has been pointed out by Jacobi and J. Lewis Smith. Thus, a case of this character is reported by Guinon (Revue Mensuelle des Maladies de l'Enfance, 1897, p. 236), in which a child of two and one-half years was seized with high fever and with all the symptoms of pernicious malarial infection. Nine days later it suffered from collapse with all its characteristic symptoms, and the