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I have laid this emphasis upon the administration of oxygen because I believe in a large measure it was to this that his recovery was due, and because I have elsewhere expressed my doubts as to the value of oxygen in the treatment of pneumonia. I am still very doubtful as to its efficacy in the treatment of acute lobar pneumonia; but in bronchitis and secondary broncho-pneumonia, as in this case and other similar ones, I have become a convert to its utility.
The varieties of typhoid fever which I have described do not by any means exhaust the total number, but will suffice to show how great are the variations in the symptoms and course of the disease. They will make it clear how widely one case differs from another, and how essential it is to treat each case individually. It is possible--though I fear unlikely that some day a specific antidote for the disease may be discovered; it is unlikely, because no treatment is likely to benefit a patient suffering from an ailment in which the virulence of the poison may be manifest in almost every part of the body. In some cases intestinal, in others pulmonary, and in others nervous symptoms will predominate. These may occur as complications of the disease, or may be directly due to the toxins produced by bacilliary infections; they will be influenced by the antecedent history of the patient, by his age, by the sex, and by the surroundings: and there is probably no disease in which-bearing in mind always the possible development of fatal intestinal complications—it is so important to treat the individual patient irrespective of the name of his disease.
POLYURIA AS AN ELEMENT IN PROGNOSIS.
For the last eight years, with the aid of successive housephysicians, I have made repeated observations upon the amount of urine passed in cases of enteric. Polyuria is a well-known symptom at the end of nearly all febrile conditions, but I am not aware that much attention has been paid to it in connection with typhoid, in which, however, it is a very marked and conspicuous condition. Towards the beginning of the fourth week-seldom earlier, sometimes a little
later the urine increases in quantity from thirty ounces or thereabout to sixty or eighty, or even ninety ounces daily. My attention was first directed to this point by my former house-physician, Dr. Ganner, and since that time, in every case the amount has been noted daily during the course of every case of enteric. It has been found in numerous observations that this polyuria occurred not only in every case that was doing well, but even in many cases of great severity where the prognosis for a time was quite uncertain, and it was found, even in these severe cases, if polyuria was present the patients all ultimately recovered. In no case in which polyuria was noted have I known perforation to occur, and in no case has hæmorrhage of any moment ever occurred after polyuria had been established; and, furthermore, the occurrence of relapse is of the most extreme rarity when polyuria has once begun. The amount of fluid taken was greatly exceeded by the amount of fluid evacuated, and seemed to bear little or no relation to it. If my observations are correct, and can be substantiated by others, it seems probable that we have in polyuria a valuable aid to prognosis.
About this as a source of danger to the life of the patient there can be no doubt, but the opinions as to its gravity and influence on prognosis vary very widely and very curiously. Dr. Curschmann, of Leipsic, who wrote the volume on “Typhoid Fever" in Northnagel's Encyclopædia of Medicine, gave as his opinion that from 20 to 30 per cent. of those attacked die; while Trousseau, Graves, and some other English physicians look upon hæmorrhage not only without alarm, but even as a rather favourable occurrence, regarding a moderate loss of blood occurring in a robust, full-blooded patient with high fever as likely to influence the general condition favourably. Probably between these two extremes of opinion lies the happy mean of fact. So far as my own experience goes, though I have had many very alarming cases of hæmorrhage, I have never lost a patient from it, and am therefore not unnaturally inclined to agree with those
practitioners who look upon it without alarm. Certainly I have seen hæmorrhages sufficiently profuse to greatly exhaust the patient, already debilitated by an exhausting disease, but, though some of these have subsequently died. from asthenia, I have never seen one succumb within the period of time which rendered it likely that the hæmorrhage was the cause of death. This extraordinary discrepancy in the opinion of those best qualified to estimate the value of a symptom must depend upon the extraordinary difference in experience, or upon the great variations in attack of the disease. Curschmann is of opinion that nearly 50 per cent. of his cases of hæmorrhage occur during the first two weeks of the disease, 24 per cent. in the third, and 13 per cent. in the fourth weeks. My own experience has not shown this preponderance of cases early in the disease. I have seen one case in which it occurred within two or three days of the onset of malaise before the diagnosis of enteric had been confirmed; and I have seen it, as in the case which will illustrate this symptom, as late as the forty-fourth day after the disease had been established. I recognise that it is a symptom which has always to be treated very seriously, but which has to be regarded with varying gravity according to the supposed source of the bleeding. The three sources from which hæmorrhage may occur are (1) from a deep perforating ulcer of Peyer's patches, a condition which is apt to be associated with peritonitis and constipation; (2) from the soft, spongy, hyperæmic, and friable tissue of Peyer's patches which are discoloured dark-red to black; and finally and generally, from a catarrhal condition of the lining membrane of the intestines between the Peyer's patches themselves. This latter condition is generally associated with diarrhoea, and I am far more disposed to attach grave importance to hæmorrhage occurring in cases of constipation than to that which accompanies, more or less, profuse diarrhoea. For this reason I should like to repeat a point upon which I laid emphasis in my paper on the treatment of enteric, that constipation in the course of enteric is to be avoided at all hazards, and to insist upon not more than thirty-six hours transpiring without
an action of the bowels. One of my patients a nurse in the hospital, who was suffering from an acute attack of the disease contracted in the hospital, and occurring at the same time as the case of paratyphoid disease I have already recorded--had on several occasions hæmorrhage of the most alarming description; and it is noteworthy that a larger hæmorrhage always coincided with constipation, more or less marked, while slighter attacks, which seemed to influence her condition but little, occurred when the bowels were relaxed. The treatment of this condition must, of course, vary with one's conception of its cause. When I have believed it to be due to a general intestinal catarrh, I have found it influenced by the use of bismuth, which seems have no effect whatever when it is due to hyperemia of Peyer's patches, and still less when it is due to an ulcerated process extending almost to the peritoneal wall of the bowel. In these cases the first essential is to keep the bowels in a state of absolute rest, and for this purpose opium is our sheet anchor. I know of no other drugs which give one any confidence in dealing with this condition, and the only other procedure which I employ is the application of an ice coil to the abdominal surface. If the patient seems to be sinking from the amount of blood lost, I administer strychnine subcutaneously, and order large enemas of a saline solution. From lead, ergot, and other hæmorrhatic drugs I have derived no benefit.
DEATH FROM PERFORATION IN TYPHOID.
The experience in London hospitals has shown that more than 3 per cent. of all cases of typhoid die from this cause, and of all the deaths that occur from the disease, more than 25 per cent. are occasioned by this terrible accident. It was held formerly that no patient ever recovered when perforation occurred, and there are many still strongly convinced that such is the case unless surgical interference be invited.
Personally, I have had but little experience of surgery in this condition, and it is one of the particular reasons for my reading this paper that I may get the experience of those who
have been more fortunate, or perhaps more courageous than myself in obtaining the aid of surgery to avert death. I cannot, however, accede to the proposition that death must occur, for I have had several cases in which there seemed no moral doubt that perforation had occurred, and in which recovery took place without operation. Twenty years ago I saw in consultation a young man of twenty who, whilst apparently doing well after a severe attack of typhoid, became suddenly collapsed, his abdomen became greatly distended, the liver dulness was lost, and no movement of the abdomen (which was rigid) took place during respiration; his pulse became rapid and feeble and hard; the temperature fell in the course of a few hours to 97 degrees, and became subnormal; his face presented a Hippocratic expression, and no doubt was entertained that he was within measurable distance of an early death. His friends suggested further consultation, and we had the benefit of the opinion of the late Dr. Heslop, who concurred with the diagnosis of perforation, and joined us in a fatal prognosis. Opium was given-not, however, with the idea of benefiting the patient and food was almost stopped. Very gradually the distension subsided; the pulse improved in quality, while diminishing in frequency; and gradually all bad symptoms disappeared, and the patient made a good recovery.
Last year I had in the hospital a patient who also, I was satisfied, had perforation, and whose case I should like to read in some detail. He was a strong, healthy lad, aged sixteen, who six weeks before admission began to feel ill and suffered from diarrhoea for a few days, with some pain in the abdomen, whilst at the same time he complained of slight cough. A doctor who was summoned diagnosed inflammation of the bowels, and after a few days' treatment he began to improve a little, but never got rid of the feeling of illness. He kept his bed all the time. Another doctor, having been called in about a week before admission, diagnosed enteric. At this time he had no diarrhoea, but the one daily action of the bowels was copious and fluid and offensive. On admission, he was found to be very collapsed. Temperature,