Farinaceous Gruels

I have alluded to the occasional advantage of giving farinaceous gruels, for, despite the fact that many writers are opposed to them on the ground that they may excite tympany, I believe them to be at times of great service. Stromeyer feeds his patients largely upon oaten grits boiled for three hours without sugar.

Da Costa recommended giving three pints of milk and one pint of broth every twenty-four hours, with a midday allowance of some gruel, such as arrowroot. There is a variety of enteric fever in which without any noticeable complications, and even without a very high temperature curve, emaciation is rapid and extreme. In such cases especially the use of farinaceous gruels is indicated. They must not be given too sweet, and a little cream or lemon juice may be added in lieu of sugar. It is often advisable to add a table-spoonful of malt extract, or one of the "prepared foods," such as Mellin's, Horlick's, Ridge's, or malted milk may be given in milk.

Sleep And Food

In all cases of typhoid fever the question arises in regard to waking the patient at night for nourishment, or to take the temperature.

Some patients awaken easily, are fed, and drop off to sleep again almost immediately. They may be.fed every two hours day and night. Others, if awakened, do not readily fall asleep again, and lose half the night's rest or more, and this may considerably retard their recovery. It is sometimes best to let them sleep for three, or even four, hours without being aroused, for the rest may be of more value to them than food. So much depends upon the temperature, pulse, and general condition of each case that no rigid rule should be formulated, but it is best never to let four hours pass while the fever lasts without giving food. If patients are told that they have a little longer interval than usual in which to rest undisturbed, they will sometimes go to sleep at once. Of course, if they sleep during the day there is less need of postponing feeding by night. Constant drowsiness may indicate a need of more food. The nurse should always furnish a daily record of the exact amount of milk or broths actually given in twenty-four hours, making allowance for dilution, and this should be compared with the quantity of urine voided.

Thirst

Thirst is a prominent symptom in typhoid fever, and cool water should be given in abundance by the nurse, without waiting for the patient to ask for it. Water favours nutrition and the elimination of waste. If diarrhoea is absent it is well to acidulate the water with a little dilute phosphoric or hydrochloric acid, ten or fifteen drops to the tumblerful, or water flavoured with infusion of orange or serpentaria. Hoppe-Seyler has washed out the stomach in cases of typhoid fever, and shown that while the temperature remains high there is little or no acid contained in the gastric juice, and a mildly acidulated beverage may prove serviceable by aiding digestion as well as by relieving thirst.

Relief of the latter symptom is sometimes sought by painting the tongue with glycerin, which is used to prevent evaporation from the surface and not because of any special virtue in the glycerin itself, which, in fact, is hygroscopic and tends to abstract water from the mucous surface unless it is already very much diluted, and it cannot protect it sufficiently from the evaporation which occurs in mouth breathing. The use of cracked ice in excess aggravates thirst rather than relieves it, and it is better to sip cool water at a temperature of 500 to 6o° F. rather than ice. The juice of a sweet orange or a lemon is often very acceptable, and in the absence of serious complications it can do no harm. Iced tea may prove agreeable. As a rule, it is well to restrict the use of effervescent drinks for the control of thirst on account of the danger of increasing flatulency, and stretching the ulcerated intestinal wall.

In addition to the need of water for relieving thirst, it is of great service as a diluent for washing out the waste products of the febrile action from the system through the kidneys. Many clinicians, as Henry, Meigs, and Beverley Robinson, make it a special feature of their treatment to give large draughts of water. Henry advises giving each patient eighty ounces of water (including that contained in fluid food) per diem, and Meigs has given as much as one hundred and thirty ounces with benefit, including from thirty to fifty ounces of free water. Debove gives six ounces every two hours. It should not be drunk too soon after the fluid food, but in the intervals, so as not to dilute the gastric juice too much. In mild cases a little coffee or a cup of cocoa may be drunk in the morning.

Alcohol

The question of how far alcohol serves the purpose of a food and a "force regulator" in typhoid fever is very important. The employment of it in excess as a routine treatment is greatly to be deplored. It is seldom required at all in the first fortnight. Later the heart is enervated and its muscular tissue is enfeebled. In all complications which threaten life, such as severe haemorrhage, sudden cardiac dilatation, hyperpyrexia (1070 F.), pneumonia, or uncontrollable diarrhoea, alcohol must be given without stint. When the complication is passed the dosage should be gradually reduced.

Patients above forty years of age usually require stimulation early.

It was formerly customary to prescribe whisky in typhoid fever at the rate of twenty or twenty-four ounces per diem, and in some chronic alcoholic patients large quantities of alcohol may be needed to prevent collapse. Sometimes delirium will disappear when excessive dosage of alcohol is discontinued, and I am inclined to prescribe very much less alcohol than formerly, especially for young and robust patients. Undoubtedly there are cases of greatly weakened circulation in which its use must be pushed rapidly, and in which it quiets restlessness, insomnia, and delirium better than opium or other narcotics, but it is not to be forgotten that there are other valuable cardiac stimulants. By giving small doses of digitalis or strophanthus, or the two in combination, by the use of caffeine, camphor, small doses of morphine, and other remedies in combination with alcohol, much less of the latter will be required, and there is far less danger of inducing the alcohol habit. Strong whisky often intensifies the stomach catarrh and interferes with the natural absorption of food.

One very noticeable feature of the Brand cold-bath treatment is that the patients do well with so little alcohol, many of them requiring none at all in the intervals between the baths.

The kind of alcoholic stimulant prescribed must depend upon the circumstances of the case. Brandy and whisky possess the advantage that the dosage is more uniform and the bulk is not great. It is a matter of routine hospital practice, founded largely on economical reasons, to give whisky or brandy as the only form of alcoholic stimulation, but in private practice, especially among women, liquors may be distasteful, and equally good results can be obtained by ordering some good strong wine which is more agreeable to the taste, such as one of the Hungarian wines, Malaga, port, sherry, claret, etc. In Germany patients are often allowed beer, but this beverage is open to the same objection as the effervescent drinks, for there is more or less gastric catarrh usually present. It is not much prescribed in this country. It serves better during convalescence than while the fever is present. Brandy in milk or soda or Seltzer water is best for diarrhoea, and dry champagne is good if there is vomiting. As the latter is used in small doses - an ounce or less at a time - it is economical to place a patent cork with a faucet in the bottle, so that a little may be drawn at a time without losing all the effervescence.

In any case in which alcohol is given the best guides for the proper quantity are found, as in pneumonia, in the breath, delirium, tongue, and pulse. If the breath has no odour of alcohol an hour or two after the dose has been taken, if delirium has subsided, if the tongue becomes more moist, and the pulse becomes more full and slow, the alcohol is doing good.

During convalescence a little alcohol - two ounces of whisky or four or five of Burgundy a day, for example - may be needed as a tonic, but should be given only with food.