(B.) Extracts from Remarks on the Treatment of Enteric Fever

By John S. Bristowe, M.D., F.R.C.P., etc., etc. (British Med. Journal, Nor. 21th, 1880.)

1. Diet. - It was formerly the custom to 'starve fevers.' During the last thirty or forty years, however, and in no small degree owing to the teachings of the late Dr. Graves, the practice of 'feeding fevers' has been very generally adopted; and few, I should think, can doubt the wisdom of the change; for not only are fevers characterised by rapid degradation of tissue, with progressive emaciation and enfeeblement of system, but experience has demonstrated that fever-patients are capable in no inconsiderable degree of assimilating nourishment, and that the specific symptoms of their diseases are seldom, if ever, aggravated by its judicious administration. These remarks are especially true of enteric fever, which is a disease of long duration, and one in which emaciation and asthenia not only are rapidly developed and apt to become extreme, but are exceptionally slow to be recovered from. But it is a fever which, probably more than any other specific fever, demands care and judgment in its dietetic management; for its incidence is mainly on the alimentary canal, and dietetic errors are likely, therefore, to be attended with immediate injurious results. I need scarcely remind you, that Peyer's patches and the solitary glands in the lower part of the small intestine are always affected in enteric fever, and the solitary glands in the large intestine in about one-third of the total number of cases; that ulceration of the diseased patches commences for the most part from the seventh to the tenth day of the fever; that cicatrisation, usually begins some time during the fourth week, but may be delayed indefinitely and indefinitely prolonged; and that the specific consequences of the intestinal lesion, against which we have especially to take precautions, are uncontrollable diarrhoea, intestinal haemorrhage, and perforation of the ileum. Under these circumstances, it is clear that the food to be administered should be easy of digestion and assimilation, and that its residue should be unirritating to the diseased bowel along which it has to pass. Dr. Murchison observes that it 'may consist of such articles as the following: milk, eggs, beef-tea, veal, or chicken-broth, to which may be added vermicelli or arrowroot, meat-essences, meat-jellies, custard, bread and milk, sago, and tea or coffee diluted freely with milk.' But this, it seems to me, is to be regarded rather as an enumeration of the articles of diet from which we may select under special circumstances, and in exceptional cases, and to which we may resort indifferently during convalescence, than as a list of foods to be administered indiscriminately during the febrile stages of the disease. Indeed, Dr. Murchison admits, what most of us know by experience, that beef-tea and other animal broths and essences not unfrequently promote diarrhoea in enteric fever; and the suppression of the salivary, and probably of the pancreatic, secretion which attends the disease interferes importantly with the digestion and assimilation of starchy matters, which thus, as Dr. Cayley especially maintains, become irritants to the alimentary canal. These facts serve to control our liberty of action in no inconsiderable degree, and reduce us to the necessity of feeding patients almost exclusively on milk and eggs. Indeed, I suppose that few physicians at the present day give anything besides milk to enteric fever patients so long as the temperature remains febrile. That is the practice which Dr. Murchison himself advocates; it is the practice recommended by Dr. Cayley; it is the practice which has prevailed at St. Thomas's Hospital for many years past; and one which, with few exceptions, I have carried out, as long as I can recollect, both in private practice and at the hospital. Very few patients are unable to take milk; and in almost all instances in which patients protest that it disagrees with them in health, they yet take to it kindly here. Even when the stomach is irritable, as it often is early in the disease, and as it may continue during the greater part of its course, it will still generally retain milk given in small quantities and, if necessary, cooled with ice or diluted with soda-water or lime-water. It should be given, in quantities determined by the circumstances of the case, every one, two, or three hours; and thus from one to three or four pints may be readily administered even in severe cases during the twenty-four hours. The feeding of patients during convalescence is a matter of considerable nicety. The presence of a clean tongue and a good appetite, and the need of restoring health and strength to the enfeebled and emaciated frame, tempt one strongly to allow the patient to give full play to his lust for food. But when it is recollected that, during early convalescence, relapses are not unfrequent; that the characteristic ulcers of the disease are not generally healed until convalescence is far advanced; and that unhealthy processes, leading to diarrhoea, haemorrhage, and perforation, may be readily re-excited in them by anything which irritates the alimentary canal, as well as by anything which causes constitutional disturbance; the need of extreme caution becomes apparent. It is the usual custom at our hospital not to give anything beyond milk until the temperature has ceased for a full week to present a febrile rise; and then to commence with bread and milk, eggs, or rice-pudding; only subsequently adding fish, and fowl, and butchers' meat to the dietary. Of course, many cases occur in which it is thought right not to adhere rigorously to this rule; but it is curious, as most of our 'sisters' know by experience, that the premature addition of solid matter to the diet, is constantly followed by exacerbation or temporary renewal of fever. 2. Alcohol. - It is impossible to discuss the subject of the treatment of fevers without referring to the question of the use of alcohol in relation to them.

I see no reason to doubt that alcohol is a food; at any rate, it contains the same elements as starch and sugar, which are undoubted foods; and the experiments of Thudichum and Dupré show that, when once taken into the system, it is in some way used up in the system, and escapes in very minute proportion through the emunctories. But we have, doubtless, many foods that are more valuable as foods than alcohol; and in milk, at any rate, we have one which is generally well suited for invalids. It is rarely necessary, therefore, to have recourse to alcohol as food; and its use in fevers depends mainly on its primary or stimulating - its medicinal - influence. I have never used alcohol indiscriminately in any kind of fever cases; and, indeed, ever since I have had the care of patients in St. Thomas's Hospital, I have been very sparing in my use of it.

Many typhoid cases, and even severe cases, have recovered under my care without having tasted a drop of alcohol. Many no doubt have had it; but the circumstances under which I have given it have been: the presence of extreme debility, indicated by a feeble heart and rapid pulse; the supervention of 'typhoid symptoms'; the occurrence of pulmonary complications; and the debility of prolonged convalescence. My friend Dr. Ord, in an interesting paper on enteric fever, in the eighth volume of the St. Thomas's Hospital Reports, based upon sixty cases (of which twenty-four were my own) received into the Hospital from the end of July, 1877, to the end of March, 1878, observes that 'twenty-four patients received no stimulants at all; six only a small quantity during convalescence: eight not any till after the tenth day of admission; twenty-two received them within the first ten days of stay in the hospital, or while the fever was in activity; but very few indeed received them till after the end of the first week of illness. The quantity of stimulants varied from a glass of wine or a glass of beer up to sixteen ounces of wine daily in one case, and eight ounces of brandy in another.' Of these cases eight were fatal, the mortality being at the rate of 13.33 per cent. The remarks above made, while they tend, on the one hand, to show that alcohol is less valuable than many persons suppose in the treatment of fever, tend, on the other hand, to demonstrate that alcohol is not injurious in fevers. Indeed, I never recollect to have seen a case in which, even under physicians who have used it largely, alcohol has clearly acted injuriously. My main reason for withholding it has not been the fear of doing mischief, but simply because I have not thought it necessary; and, not finding it necessary, I have allowed economical considerations to weigh with me. I am satisfied that there are many occasions in enteric fever when alcoholic stimulants are of the greatest value; and that whoever then neglects to have recourse to them imperils his patient's life.

In conclusion, gentlemen, let me state briefly the treatment to which I should like to be subjected myself if ever, unfortunately, I should become affected with enteric fever. I should like to be placed in a cool, well-ventilated room, and covered lightly with bedclothes; to have a skilful and attentive nurse to look after me; to be fed solely with cold milk, unless vomiting should demand the addition to the milk of medicine calculated to allay vomiting. If diarrhoea became troublesome, or ever there was much pain or tenderness in the caecal rings and in the bowels, I should like to be treated, not with laxatives, but with opium, given either by the mouth or by the rectum. If constipation were present, I should, excepting in the first week, like to have enemata only employed for its relief. In the event of intestinal hemorrhage coming on, I should like to have ice to suck or ice-cold fluids to drink, cold compresses to the belly, and cold injections into the bowels; and, though I am sceptical as to their efficacy, I should still choose to have astringents, and more especially lead, given to me at short intervals. If perforation should take place, let me have large and repeated doses of opium. Stimulants I should prefer to be without early in the disease; later, however, and during convalescence, I should like to have them in moderation. As to the cold baths, I would rather not have them; but I would, nevertheless, leave it to my physician to exercise his discretion in the matter. I would leave it also for him to decide, according to circumstances, whether alcohol should be administered to me in large quantities. I would prefer not to be treated at a temperance hospital.