feet of rubber hose.
The sponge hath is indicated when the temperature is hardly high enough
to warrant the more drastic tub bath and yet is sufl&ciently elevated to cause
discomfort. In any case the patient should receive two sponges daily for the
sake of cleanliness. The method is as follows : The water may be of various
temperatures as indicated; often the addition to it of a little alcohol is grateful to
the patient. An ice cloth should be applied to the head and a sponge or soft
cloth wet just sufl&ciently to leave a thin film of moisture on the skin is used;
this cools the patient by rapid evaporation and does not wet the bed clothing
and with it he is thoroughly rubbed, while the other hand is performing
friction, and then dried, one part at a time. Care should be observed to
keep the portions of the body not being sponged, covered. Particular
attention should be given the back for here the tissues retain heat longest.
Proper reaction is evidenced by redness of the skin. No such effect is pro-
duced upon the temperatiure by sponging as by tubbing.
The sprinkle hath as a method for the reduction of temperature may be
considered to rival the tub bath. It is better borne by many patients and is
of peculiar adaptation to private practice.
The technique is as follows: The head of the bed should be raised about lo
inches from the floor, and, to keep the mattress from sagging, crosswise under
it should be placed several boards as long as the width of the bed. The mattress
should be covered with a rubber sheet upon which a pillow and ordinary sheet
are adjusted. The patient should be stripped and sprinkled with water of
the desired temperature from a watering pot or from an irrigating apparatus
to the tube of which a sprinkling nozzle is fitted. The water as it flows from
the foot of the bed is received in any large vessel and may be used over and
over, the proper temperature being maintained by the addition of ice. The
water should not be poured from too great a height and should be applied
chiefly to the abdomen and legs. Rubbing with the hands should be con-
tinued throughout the procedure, otherwise the patient should be dealt with
exactly as in tub bathing.
The wet pack is another useful hydrotherapeutic procedure less unpleasant
lo the patient than the tub. The body from the axillae to the groins is
ENTERIC FEVER. 1 7
wrapped in a sheet which is kept cool enough by repeated wettings to con-
trol the temperature.
Antipyretic Drugs. Certain drugs of this class, such as antipyrine, acetphe-
netidin, acetanilide. pyramidon, etc., may be used in excessively high tempera-
tures but they are not to be recommended because of the possibility of their
causing cardiac depression. Neither do they, although they may bring about
a fall in temperature, act favorably upon the other symptoms of the disease.
Lactophenine, in daily dosage of 60 to 75 grains (4.0 to 5.0) m^ay cause a
prompt fall in temperature, quiets the nervous system and induces sleep.
Quinine and euquinine also cause the temperature to drop, but none of this
class of drugs affects the course of the disease and they are not to be recom-
mended save as adjuncts to other forms of treatment.
Treatment by intestinal antiseptics other than chlorine has been frequently
advocated. Among the drugs discussed in this connection may be mentioned:
Phenyl salicylate (salol) in doses of from 5 to 10 grains (0.33 to 0.66) four
to five times a day. The possibility of injuring the kidneys more than over-
balances any possible good effect that this drug can accomplish.
Thymol in the same dosage is open to the same objections.
Calomel as an intestinal antiseptic is practically inert and the good effects
reported from its use have doubtless been due to the free purgation in the
early period of the disease which its exhibition induces.
Betanaphthol in 5 to 10 grain (0.33 to 0.66) doses three or four times daily,
is claimed to be capable of causing intestinal antisepsis without toxic symp-
toms. Its use is recommended in combination with bismuth salicylate when
there is diarrhoea, with magnesium sulphate when there is constipation. It
is asserted that under the influence of this drug there is less tendency to ab-
dominal pain and tympanites, the tongue becomes clear, the stools odorless,
convalescence advances rapidly and there is a diminished tendency to com-
pUcations.
Phenol and iodine, one part to two in doses of one to three minims (0.065
to 0.2) well diluted, three to six times a day have been recommended.
Naphthalene is objectionable on account of its large dosage, unplea,sant taste
and liabiUty to cause strangury. Beer yeast, three teaspoonsful (12.0) in milk
per day, has been given in the hope that its micro-organisms might inhibit
the growth of the typhoid bacilli in the intestine, but little is to be accom-
pHshed by this agent save a checking of the diarrhoea.
Acetozone is the commercial name given to a mixture of benzoyl-acetyl
peroxide, an inert absorbent substance. It is administered as an intes-
tinal antiseptic, the daily dosage being 10 to 20 grains (0.66 to 1.33) dissolved
in a quart of water. Various observers have reported favorably upon this
preparation, claiming that when taken early in the disease and in large
amounts the course is shortened to 10 to 12 days. Also under its influence
l8 THE INTECTIOUS DISEASES.
the abdominal, nervous and other symptoms are less marked than usual.
There is much difficulty in inducing patients to take sufficient amounts for
long enough periods of time.
Treatments by Means of Intestinal Antiseptics and Free Elimination. The
object of these methods is to render the alimentary tract as aseptic as possible
and to remove without delay the cause and products of the infection. As
far as the antiseptic part of the treatment is concerned it differs in no way
from the methods hitherto described, but added to these is the free exhibition
of purgatives, which are given to carry off the fascal accumulations, the
patients being encouraged to drink large quantities of fluid to replace that
removed by purgation.
The simplest of these forms of treatment is as follows: This consists of
the daily administration of calomel in ^ to J grain (0.016 to 0.032) every
half hour up to six doses; two or three hours later one-half ounce (15.0) of
Epsom or Rochelle salts is given. The object is to bring about three to four
free movements per day. Phenyl salicylate (salol) in five grain (0.33) doses,
every three hours, is the antiseptic used in connection with this treatment.
The claims are not excessively extravagant, but it is believed that under this
treatment haemorrhage and perforation are rendered less frequent. The possi-
bility of salivation from the calomel must be considered, but it is not likely to
take place, probably because of the frequent movements from the bowels.
Another method of treatment which at one time created a considerable
amount of discussion is as follows : Tablets consisting of podophyllum resin
1-960 grain (0.00067), calomel 1-16 grain (0.004), guaiacol carbonate 1-16 grain
(0.004), menthol 1-16 grain (0.004), eucalj-ptol, q.s. were ordered. One of these
tablets was given every 15 minutes during the first 24 hours and in larger
doses during the second day, if necessary, until at least five or six free defse-
cations had taken place during the second and third day. On the third or
fourth day tablets containing podophyllum resin 1-960 grain (0.00067), calomel
1-16 grain (0.004), guaiacol carbonate J grain (0.016), menthol 1-16 grain
(0.004), thymol 1-16 grain (0.004), eucalyptol q.s. were prescribed; one every
two or three hours. Both these tablets were given at longer intervals if there
was a faU in temperature. On the fourth or fifth day guaiacol carbonate
three grains (0.2), thymol one grain (0.065), menthol J grain (0.033), eucal-
yptol five minims (0.33) were administered in capsules, one every three
hours alternating with the tablets. This plan of treatment in some instances
failed to accomplish the result claimed for it and is now in little vogue.
Treatment of Special Conditions and Symptoms. The mouth and tongue
should be kept clean by the employment of regular and frequent washings
with diluted liquor antisepticus, tincture of myrrh, etc. A very useful mouth
wash consists of equal parts of liquor antisepticus, hydrogen dioxide solution,
lime water and water. The mouth should be cleansed after every administra-
ENTERIC EEVER.
19
tion of food and there is no contraindication to the use of the tooth brush.
Sordes and coating upon the tongue may be removed by cotton swabs wet
in one of the above mentioned solutions. A convenient tongue-scraper may be
constructed of a piece of whale bone bent into a loop. In cases where the
tongue is extremely dry the " tongue-bath " often affords much relief. This
consists simply in holding the mouth full of fluid for several moments. In
this way considerable moisture is absorbed by the mucous membranes.
Heart Weakness. In this condition it is better not to use alcohol unless
the patient has been accustomed to the stimulant in health. In such a case
it may be employed (brandy or whiskey) in doses necessary to produce the
desired effect. As a heart stimulant strychnine — 1-60 to 1-15 of a grain
(0.00 1 to 0.004) depending upon the condition to be met — is the stimulant
of choice. Extreme heart weakness may necessitate the additional employ-
ment of digitaHs — the tincture 5 to 10 minims (0.33 to 0.66) — glyceryl nitrate
— i-ioo to 1-50 of a grain (0.0006 to 0.0012) — or aromatic spirit of ammonia —
one to two drachms (4.0 to 8.0.) Collapse may be treated by hypodermatic
injections of camphor — one grain (0.065) — ^^^ olive oil or «ther — 15 minims
(i.o). Marked asthenia may necessitate the intravenous infusion or hypo-
dermatic injection of normal (0.9 percent.) sodium chloride solution.
Symptoms Referable to the Nervous System. The headache and general
pains of the onset may be mitigated by antipyrine salicylate in 10 grain (0.66)
doses every two hours, and by hot or cold applications. The delirium may
be controlled by the use of the ice cap, and various sedatives, sodium bromide
^ to I drachm (2.0 to 4.0), sulphonmethane (sulphonal) 15 to 20 grains
(i.o to 1.33); chloralformamide 20 to 30 grains (1.33 to 2.0), sulphonethyl-
methane (trional), 10 to 15 grains (0.66 to 1.0); hydrated chloral or
morphine may be employed as a last resort, the latter best hypodermatically
as Magendie's solution, 10 drops (0.66).
Tympanites may be lessened by the very careful introduction of a rectal
tube, through which large quantities of gas are often voided, and by the
internal administration of oleum terebinthinse, 5 to 10 minims (0.33 to
0.66) in capsule. The food should be diminished in quantity as the meteor-
ism is the result of fermentative processes. High rectal irrigations of nor-
mal saline are also useful in this connection.
Diarrhxa, if obstinate, may usually be controlled by the use of bismuth,
with the addition of opium if necessary.
Constipation is best treated by the use of saline enemata, though certain
observers, as will have been noticed in the foregoing sections, have no objection
to the use of calomel and other purgatives.
Bed sores should never be allowed to occur and may be prevented by atten-
tion to the points where they are likely to appear. The strictest cleanliness
must be maintained about the back of the heels and over the buttocks and
20 THE INFECTIOUS DISEASES.
sacrum. The sheets must be kept smooth and the bed thoroughly clean
and free from crumbs, moisture and contamination from the rectal or vesical
discharges. In addition to the maintenance of careful cleanliness, measures
should be taken to harden the skin of the susceptible parts. To insure a good
blood supply to these the patient should be turned upon his side several times
a day and the skin of the back thoroughly rubbed with a dry towel and dusted
with powdered talc. Applications rubbed into the skin to harden it, such as
salt, two drachms (8.0), to whiskey, one pint (^ litre), or a dilute solution of lead
subacetate may be employed. When the skin becomes red and irritated but is
still unbroken it should be painted with a solution of silver nitrate, 20 grains
(1.33) to one ounce (30.0) of water. When the bed sore has appeared, with
the object of preventing its spread and of accelerating its cure, the patient
must be so placed as to take all weight from the affected part, this may be
accomplished by the use of a rubber bed ring. The sore itself must be kept
clean by swabbing with i to 5000 mercury bichloride solution and dusted with
iodoform. A dressing of zinc oxide ointment spread upon gauze may be
apphed. In marked cases the use of the water bed may become necessary.
If the sore spreads or burrows through the surrounding parts free opening
and thorough irrigation are indicated.
Complications should, in general, be treated as when occurring independ-
ently, but the treatment of intestinal haemorrhage, peritonitis and perfora-
tion needs special consideration.
Upon the appearance of any symptom suggestive of hemorrhage all hydro-
therapeutic measures should be stopped immediately and absolute quiet
insisted upon. An ice coil should be applied to the abdomen and the food
should be of the most non-irritating character; it is often wise to stop feeding
entirely for six or eight hours. If the hsemorrhage is extreme a hypodermatic
injection of from ^ to ^ of a grain (0.016 to 0.022) of morphine should be given
and the foot of the bed should be elevated. The administration of morphine
or opium has the disadvantage that it may mask the symptoms of a concur-
rent perforation of the intestine and on this ground certain clinicians con-
sider it better omitted. If symptoms of collapse are present hypodermatic
stimulation by means of aether or camphor with sterile oil is necessary. In
this connection hypodermatoclysis of hot normal saline solution or direct
infusion into a vein is also useful. The most efl&cient drug in the control of
the haemorrhage is calcium lactate in doses of 20 grains (1.33) three times
daily. Calcium chloride is also effective, both these substances having a
decided influence in increasing the coagulabihty of the blood. Their use
should not be continued for more than three or four days for their more pro-
tracted administration is likely to result in a diminution of the blood's coagu-
lability. Gelatin in doses of 75 to 120 grains (5.0 to 8.0) has been recom-
mended in the treatment of haemorrhage, and ergot — | drachm (2.0) of the
ENTERIC FEVER. 21
fluid extract — also has its advocates. Internal styptics such as tannic and
gallic acids, lead subacetate, etc., may be employed but their effect is prob-
lematical.
Perforation of the intestine and peritonitis necessitate early operative treat-
ment and by this means many patients are now saved who under less radical
treatment would formerly have died. The earlier the operation is under-
taken after the establishment of the diagnosis the better are the chances of
recovery. Operation should be performed even in desperate instances and
when the condition is obscure an exploratory incision is advisable, the resis-
tance to the shock of operation being usually good in typhoid patients.
Such surgical complications as periostitis and cholecystitis often recover
without operation but when the presence of pus is clearly demonstrable
radical treatment should be undertaken.
Nevu-itis following enteric fever is frequently characterized by paralysis
and although its symptoms may persist for months, as a rule recovery takes
place under the influence of massage, electricity and general tonic treat-
ment.
The so-called typhoid spine may prove an obstinate sequel of the disease;
it is usually accompanied by a nemrotic condition of the patient and requires
practically the same treatment as neurasthenia, namely, rest in an institution
where anxious and sympathetic friends are not given access to the patient,
hydrotherapeutic measvires, massage and proper exercises. The application
of the acutal cautery may prove effective.
During convalescence the patient should be guarded against recrudescences
and relapses, the treatment of which, should they occur, is practically the
same as that of the original attack.
With regard to diet it may be stated that if the patient's nutrition remains
good it is best to allow no solid food before the 7th to the loth day after the
return of the temperature to normal; solid food may be permitted earlier than
this to patients who are weak and much emaciated and in certain instances
a persistent slight afternoon fever has been known to subside upon giving
the patient simple solid food. The danger of inducing perforation by the
too early administration of solids, however, must not be forgotten and the
same is true of too early muscular exertion. The first solid foods usually
allowed are scraped raw beef sandwiches, soft boiled eggs, milk toast, boiled
rice and other cereals. These should be given tentatively and with caution
at first and if no ill-effects follow, their quantity may be increased and a gradual
return to ordinary diet permitted.
As stated, muscular exertion should be undertaken with great care and
any excess of this as well as of emotional excitement should be studiously
guarded against upon the ground that recrudescence may follow.
Protracted diarrhoea is often due to the presence of an unhealed ulceration
22 THE INFECTIOUS DISEASES.
and in view of possible perforation the patient should be kept in bed and on
a fluid diet until there is evidence that the lesion has disappeared which will
usually take place if bismuth naphtholate or tetraiodophenolphthaleinate is
prescribed in doses of about 5 grains (0.33) three or four times daily in con-
nection with astringent injections such as those advised for the treatment
of ulcerative colitis.
Obstinate constipation is better treated by simple enemata than by
drugs.
With regard to the time when the patient should be first allowed to sit up,
in general it may be said that by the end of the first week after the return of
the temperatiire to normal he may be moved to a chair for a gradually increased
time each day and after a few days he may venture upon his feet and walk
about slowly. Little by little he may resume his ordinary mode of life.
PARATYPHOID FEVER.
This is a term applied to a group of diseases which in clinical course closely
resemble true enteric fever.
jEtiology. The cause of these affections is a micro-organism intermediate
between the bacillus typhosus and the bacillus coli, and closely simulates or is
identical with the paracolon bacillus. The modes of infection are probably
similar to those of enteric fever.
Pathology. The morbid changes found in these affections consist of
constant splenic enlargement and intestinal ulcerations resembling those
of dysentery rather than those of enteric fever. The solitary and agminated
follicles and the mesenteric glands are not involved. Rose spots have been
observed.
Symptoms. The incubation period is shorter than that of enteric fever
and the onset, which may be preceded for several days by prodromata such as
malaise, headache and torpor, is usually more sudden. The lethargy appears
earlier and this symptom as well as the headache is, as a rule, more marked.
The temperature rises more rapidly than in enteric fever; an initial temperature
as high as 104° F. (40° C.) has been noted. Splenic enlargement and rose
spots occur. The course of the disease varies; it may be short or, in other
instances, prolonged; convalescence is usually shorter than in enteric fever;
relapses may occur.
The differentiation from enteric fever is based upon the absence of the
Widal reaction and the causative micro-organism may be cultivated from
the faeces, urine, the blood and from the rose spots.
The disease may result fatally, but most patients recover.
The prevention of paratyphoid infections is identical with that of enteric
fever.
MOUNTAIN FEVER. 23
Treatment is essentially the same as that of enteric fever with the excep-
tion that serum employed in specific treatment must of necessity be a product
of the growth of the paracolon bacillus.
MOUNTAIN FEVER.
Synonyms. Rocky Mountain Fever; Spotted Fever.
Definition. An acute infectious disease characterized by a typical skin
eruption, a chill and high fever.
.Etiology. The disease occm-s in the Rocky Mountain region of Idaho,
Montana, Wyoming and Nevada; it is especially common in the Bitter Root
valley. It is most likely to prevail in the spring and early summer, being
very rarely observed at other seasons. Males are more commonly affected
than females and the disease attacks individuals in early or mature adult
life. It occurs less frequently in children. Persons who live in farming or
grazing districts and who spend most of the time in the open air are most
prone to infection.
Observers residing in regions where the disease is common have con-
sidered its specific cause to be the pyroplasma hominis, an organism nearly
related to the pyrosoma bigeminum (the cause of Texas cattle fever) ; this
parasite is found within the body of the red blood cells and is transmitted to
the patient through the bite of a tick, the dermacentor reticulatus.
Symptoms. The period of incubation is from 3 to 10 days, being char-
acterized by prodromal symptoms consisting of malaise, nausea and sen-
sations of cold. The invasion of the disease is marked by a distinct chill
followed by an abrupt rise of temperature which by the second day reaches
103° to 104° F. (39.5°-4o° C.) and by the 8th to the loth day may increase
.0 an afternoon maximum of 105° to 107° F. (4o.5°-4i.6° C.).. The morning
temperature is slightly lower than that of the evening. About the middle of
the 2d Week the temperature falls by lysis, usually reaching normal by the 14th
day. With the initial rise in temperature there is general pain in the body
and limbs; during the 2d week nose-bleed, more or less severe in character
occurs; the tongue is coated down the middle, red at the tip and edges; nausea
and vomiting and usually constipation are present. The urine is scanty,
dark, and contains an increased amount of urates; albumin and casts may be
present. The spleen and liver are increased in size and the conjunctivas
may be of subicteroid hue. The pulse is weak and rapid; the respirations
are rapid and regular but shallow. They may reach 60 per minute but are
usually about 40. Bronchitis may develop at the end of the istweek. In
severely infected patients the mental condition may resemble that of enteric
fever. The leucocytes may be slightly increased, there is destruction of the
red cells and diminution in the amount of haemoglobin.
24 THE INFECTIOUS DISEASES.
The eruption appears from the 3d to the 5th day, first upon the wrists, ankles
or back, thence it spreads to the arms, legs, forehead and body, the abdomen
being last involved. The spots may appear so rapidly as to cover all the
skin within 12 hours, but usually two to three days pass before the height is
reached. The rash first consists of bright red circular spots from the size of
a pin point to that of a pea; they are not elevated and in the beginning dis-
appear on pressure; they may be tender and in severe types of the disease are
dark blue or purplish in color and increase in size until the skin assumes a
mottled appearance. They begin to fade at the end of the first week and
lose their petechial character as the fever declines. Desquamation begins
during the third week but the spots may not wholly disappear for weeks or
months. The skin may become jaundiced or gangrenous over the elbows,
fingers, toes or scrotum.
The prognosis in the severer types of the affection is bad; in the Bitter
Root valley the disease is particularly fatal, 84 deaths out of 121 instances
of the disease having been reported. In other regions the mortality is less
great. Death usually occvirs during the 3d week, in some instances com-
phcations, especially pneumonia, being responsible.
Prevention. The districts in which the disease is common should be
avoided during the months in which mountain fever is prevalent. Measures
to avoid tick bites should be taken and when these have taken place the insect
should be at once removed by the application of kerosene, ammonia or tur-
pentine and the wound cauterized by pure phenol.
Treatment. This is in general symptomatic. The employment of