It has been seen above that a liberal supply of cold water to drink may be fairly considered as a necessity for the enteric patient, and that three or four pints should be the minimum allowance. The forced ingestion, however, of much larger quantities of water than this has been recommended as a systematic method of treatment, and therefore deserves separate consideration. About 14 years ago D6bove succeeded in forcing 10 to 12 pints of water daily on his patients and his results were extremely good. More recently Cushing and Clarke have given 4 oz. of water every 15 minutes during the waking hours to their patients, and in this way amounts, varying from 8 to 14 pints were comparatively easily ingested. Besides this their patients had at least 3 pints additional fluid in the form of milk and albumin water in the course of the day. The effect of such a treatment is a very marked diuresis, and by this method it is hoped that the elimination of toxins is very much increased. While I have seldom, personally, succeeded in persuading patients to take more than 8 or 9 pints of water in addition to their other fluids, I have, like Cushing and Clarke, noticed a very marked diminution and improvement in such symptoms as headache, restlessness, delirium and other toxic manifestations, and such results certainly point to a clearing out of the toxins from the blood. It was found by Cushing and Clarke that their cases, which were being treated systematically on the usual hydro-therapeutic lines, required the cold bath less frequently, and when we remember that the chief merit of systematic cold bathing is the increased diuresis which it secures, such a result was only to be expected. They state that complications under this form of treatment, generally speaking, are rare, but that meteorism appeared to occur a little more frequently than usual. The latter has not been observed by myself, but I have not succeeded in giving quite so much water to my cases as have the American physicians. A lower mortality rate was observed in those patients whose daily elimination of urine exceeded 160 oz. The ingestion of this large amount of water has the effect of increasing considerably the excretion of chlorides which are usually, in enteric fever, retained. Thus assuming the average income of chlorides, when the diet is restricted to milk, to be 36 grains, the normal individual retains 15 grains, the ordinary typhoid patient 27 grains, and the typhoid patient who is receiving large quantities of water only 11 grains. The conclusion seems justified that the polyuria is able to counteract the excessive chloride retention in fever. Thus both clinically and experimentally it would appear that this free supply of water to the patient is of real advantage.
It would be interesting to know if there was any risk of protective substances in the blood being eliminated together with the toxins under this method of treatment. Such an objection is probably only theoretical, for as we have seen, the improvement of the toxic symptoms is such as to make us doubt that the resistance of the patient to the toxins is in any way weakened. Todd, however, considers that free diuresis, which he admits to be desirable, soon exhausts the system of its salts, which are necessary to preserve the integrity of the blood plasma and for the function of the leucocytes. He considers that the exhaustion of the salts from the blood tends to cardiac arrest. He therefore advocates the use of saline beverages, 10 grains of sodium chloride with 5 grains of potassium bicarbonate being dissolved in 8 oz. of water, the whole being flavoured with a teaspoonful of lemon juice. Five pints of this mixture is given in the day. The main object of the treatment is to maintain the alkalinity of the blood. It is interesting to note that Sollmann and Hoffmann, who investigated the cases treated by Cushing and Clarke, found that in these cases any addition to the chloride income was promptly balanced by an increased chloride output, so that, after all, the added saline is promptly excreted. But this, of course, in no way invalidates Todd's contention that it is useful while it is actually in the blood. Todd also holds that sodium chloride solution is better absorbed in the stomach than water, and that the dissipation of heat is very much assisted by the elimination of large quantities of water by the skin, lungs, and urine.
I consider that the free administration of water is of very great importance in the treatment of any case of enteric fever, but I am accustomed to regard 6 pints as a satisfactory allowance, anything over that figure usually involving the employment of special nurses and considerable worry to the patient. Any patient, on the other hand, who is willing to drink more I would certainly encourage to do so, but as a rule the severe toxic cases which require fluid most are those to whom it is most difficult to administer it.
Enough has been said to show that the practitioner has a wide choice of dietaries for typhoid patients. Each system has something in its favour, and it is by the judicious application of the suggestions we gather from each to our individual cases that we are likely to obtain the most satisfactory results. Thus, while following the rule that safety usually lies in moderation, and that extremes both in the direction of starvation and of liberal feeding may be with advantage avoided, we may not infrequently be confronted with cases in which the complete stoppage of all food substances on the one hand, or the early administration of solid food on the other, may do much to secure the successful recovery of the patient. My own feeling is that a fluid diet, chiefly consisting of milk, as indicated in the first part of this section, is the safest and, in the long run, the most advantageous in the acute stage of the fever, and that this diet should be rapidly increased in the early days of convalescence, due care being exercised in watching the effect of each addition. I can see no benefit whatever in starving patients with practically normal temperatures, clean tongues, and good appetites, and in any case we learn from the good work done by the modern disciples of the famous Graves, who " fed fevers," that food may be supplied with considerable liberality and without risk in the early convalescence of enteric fever.