Complications and Sequels.—These are very numerous. Among the former are diarrhea, delirium, mental and nervous diseases, bronchitis, pleurisy, pneumonia, ear abscess, perforation of and hemorrhage from the bowels, inflammation of the gall bladder, disease of heart, kidney, and bladder, and many rarer conditions, depending upon the organ which the germ invades. Among sequels are boils, baldness, bone disease, painful spine, and, less commonly, insanity and consumption. While convalescence requires weeks and months, the patient often gains greatly in flesh and feels made over anew, as in fact he has been to a great extent, through the destruction and repair of his organs.
Outlook.—The death rate varies greatly in different epidemics and under different conditions. During the Spanish-American War in the enormous number of cases—over 20,000—the death rate was only about seven per cent, which represents that in the best hospitals of this country and in private practice. Osler states that the mortality ranges from five to twelve per cent in private practice, and from seven to twenty per cent in hospital practice, because hospital cases are usually advanced before admission. The chances of recovery are much greater in patients under fifteen years, and are also more favorable between the twenty-second and fortieth years.
Treatment.—There is perhaps no disease in which the services of a physician are more desirable or useful than in typhoid fever, on account of its prolonged course and the number of complications and incidents which may occur during its existence. It is the duty of the physician to report cases of typhoid to the health authorities, and thus act as a guardian of the public health. If, however, in any circumstances one should have the misfortune to have the care of a typhoid patient remote from medical aid, it is a consolation to know that the outlook is not greatly altered by medicine or special treatment of any sort. There have been epidemics in remote parts of this country where numbers of persons have suffered with typhoid without any professional care, and yet with surprisingly good results. Thus, in an epidemic occurring in a small community in Canada, twenty-four persons sickened with typhoid and received no medical care or treatment whatever, and yet there was but one death. The essentials of treatment are comprised in Rest, Diet, and Bathing. Rest to the extent of absolute quiet in the horizontal position, at the first suspicion of typhoid, is requisite in order to avoid the dangers of bleeding and perforation of the bowels resulting from ulceration of structures weakened by the disease. The patient should be assisted to turn in bed, must make no effort to rise during the sickness, and should pass urine and bowel discharges into a bedpan or urinal under cover. In case of bleeding from the bowels, the bedpan should not be used, but the discharges may be received for a time in cloths, without stirring the patient.
Diet.—This should consist chiefly of liquids until a week after the fever's complete disappearance. A cup of liquid should be given every two hours except during a portion of the sleeping hours. Milk, diluted with an equal amount of water, forms the chief food in most cases unless it disagrees, is refused, or is unobtainable.
In addition to milk, albumen water—white of raw egg, strained and diluted with an equal amount of water, and flavored with a few drops of lemon juice or with brandy—is valuable; also juice squeezed from raw beef—in doses of four tablespoonfuls—coffee, cocoa, and strained barley, rice, or oatmeal gruel, broths, unless diarrhea is marked and increased by the same. Soft custard, jellies, ice cream, milk-and-flour porridge, and eggnog may be used to increase the variety. Finely scraped raw or rare beef, very soft toast, and soft-boiled or poached eggs are allowable after the first week of normal temperature, at the end of the third or fourth week of the disease, and during the course of the disease under circumstances where the fluids are not obtainable or not well borne. An abundance of water should be supplied to the patient throughout the disease.
Bathing.—The importance of cold, through the medium of water, in typhoid fever accomplishes much, both in reducing the temperature and in stimulating the nervous system and relieving restlessness and delirium. Bathing is usually applied when the temperature rises above 102.5° F., and may be repeated every two or three hours if restlessness, delirium, and high temperature require it.
The immersion of patients in tubs of cold water, as practiced with benefit in hospitals, is out of the question for use by inexperienced laymen. The patient should have a woven-wire spring bed and soft hair mattress, over which is laid a folded blanket covered by a rubber sheet. Sponging the naked body with ice water will suffice in some cases; in others, when the temperature is over 1021/2° F., enveloping the whole body in a sheet wet in water at 65°, and either rubbing the surface with ice or cloths wet in ice-cold water, for ten or fifteen minutes, is advisable. Rubbing of the skin of the chest and sides is necessary during the application of cold to prevent shock. The use of a cold cloth on the head and hot-water bottle at the feet, during the sponging, will also prove beneficial. In children and others objecting to these cold applications, the vapor bath is effective. For this a piece of cheese cloth (single thickness) is wet with warm water—100° to 105°—and is wrapped about the naked body from shoulders to feet, and is continually wet by sprinkling with water at the temperature of 98°. The evaporation of the water will usually, in fifteen to twenty minutes, cool the body sufficiently if the patient is fanned continuously by two attendants. In warm weather the patient should only be covered with a sheet for a while after the bath, which should reduce the temperature to 3°. Hot water at the feet, and a little brandy or whisky given before the sponging if the pulse be feeble, will generally prevent a chill. Patients should be gently dried after the bath and covered with dry bedclothing. The utmost care should be taken not to agitate a feeble patient during sponging.
The long period of lying in bed favors the occurrence of bedsores. These are apt to appear about the lower part of the spine, and begin with redness of the skin, underneath which a lump may be felt. Constant cleanliness and bathing with alcohol, diluted with an equal amount of water, will tend to prevent this trouble, while moving the patient so as to take the pressure off this region and avoiding any rumpling of the bedding under his body are also serviceable, as well as the ring air cushion. Medicine is not required, except for special symptoms, and has no influence either in lessening the severity of or in shortening the disease. Brandy or whisky diluted with water are valuable in severe cases, with muttering delirium, dry tongue, and feeble pulse; it is not usually called for before the end of the second week, and not in mild cases at any time. A tablespoonful of either, once in two to four hours, is commonly sufficient. Pain and distention of the belly are relieved by applying a pad over the whole front of the belly—consisting of two layers of flannel wrung out of a little very hot water containing a teaspoonful of turpentine—and covered by a dry flannel bandage wrapped about the body. Also the use of white of egg and water, and beef juice, instead of milk, will benefit this condition.
Diarrhea—if there are more than four discharges daily—may be checked by one-quarter level teaspoonful doses of bismuth subnitrate, or teaspoonful doses of paregoric, once in three hours. Constipation is relieved by injections of warm soapsuds, once in two days. Bleeding from the bowels must be treated by securing perfect quiet on the patient's part, and by giving lumps of ice by the mouth, and cutting down the nourishment for six hours. Fifteen drops of laudanum should be given to adults, if there is restlessness, and some whisky, if the pulse becomes feeble, but it is better to reserve this until the bleeding has stopped. Patients may be permitted to sit up after a week of normal temperature, but solid food must not be resumed until two or three weeks after departure of fever, and then very gradually, avoiding all coarse and uncooked vegetables and fruit.
The greatest care must be exercised by attendants to escape contracting the disease and to prevent its communication to others. The bowel discharges must be submerged in milk of lime (one part of slaked lime to four parts of water), and remain in it one hour before being emptied. The urine should be mixed with an equal amount of the same, or solution of carbolic acid (one part in twenty parts of hot water), and the mixture should stand an hour before being thrown into privy or sewer. Clothing and linen in contact with the patient must be soaked in the carbolic solution for two hours. The patient's expectoration is to be received on old muslin pieces, which must be burned. The bedpan and eating utensils must be frequently scalded in boiling water. The attendant should wash his hands always after touching the patient, or objects which have come in contact with patient or his discharges, and thus will avoid contagion. If farm or dairy workers come in contact with the patient, the latter precaution is especially important. If there is no water-closet in the house, the disinfected discharges may be buried at least 100 feet from any well or stream. Typhoid fever is only derived from the germs escaping in the urine, and in the bowel, nose, or mouth discharges of typhoid patients.