Typhoid Fever in Wester~ Australia. 171

ART. u Fecer in Western Australia a~d its Ma~agementP By MICHAEL O'CONNOR, M.D.; ~ .A. Univ. Dubl. ; ]Iember of the Legislative Assembly, Western Australia ; Senior Physician Perth Public Hospital ; Medical Officer to the Perth Board of Health.

])URING the past thirteen years the most common disease I have met with has been typhoid fever, and it is in connection with the treatment of typhoid I propose to say a few words.

On account of the great influx of people to West Australia, with consequent overcrowding, neglect of sanitation, impure water, &e., a very great number of eases have occurred throughout ~he colony, especially in Perth al~d on the recent gold-fields' towns.

I t may be said that .the treatment of this disease is well defined, but my experience teaches me to the contrary, and that there is no settled plan, but that every case must be treated on its merits. The vast majority of cases will get well if they are put to bed and kept on fluid food, but there is a large minority--say 25 per cent.---that must be attended to accord- ing to circumstances. Of these 25 per cent. probably more often than in any other disease is the me'dieal at tendant able to turn the scale in favour of his patient by constant, unre- mitting care and attention, combined with skill and knowledge of the disease.

General Ma~tagement.--It is absolutely necessary that the patient should be in bed ; without this nothing, I believe, will :save the patient. This undoubtedly was the main cause of so many deaths, especially among young men, on the West Australian gold-fields, who either lived far away when they were taken ill and travelled to the nearest hospital, only in most cases to die, or else would not giv~ in that they were ill, and with the assistance of spirits tried not to give in, only to collapse in a week's time.

A well-ventilated room, sufficient sunlight, enough clothing to be comfortably warm, nothing to worry, and the absence of visitors. (I have constantly noticed in hospital serious

Being a Thesis read for the Degree of Doctor of Medicine of the University of Dublin, June, 1903.

172 Typhoid Feces is~ 1Veste)'l~ Aust~'.lio.

relapses occur in typhoid cases after visiting das"s, either caused I) 3" excitement, or more generally by well-meaning friends. who, thinking the patient is starved, bring them food not allowed bv the medical attendant.) Fresh air is most conducive to recovery, patients treated in tents out of town doing so much hetter than even in well-ventilated hospitals.

Dict.--This must vary according to the patient, but generally, 1 think, three pints of milk and one pint of beef- tea or mut ton broth per diem is sufficient, and [ generally add about equal parts of water, or preferably harley water, to the milk. which not only prevents the milk from eurdling in the stomach, but also supplies additional water, of which the patient with fever is always in need. ()u every visit the stools shouhl he examined to see if the mill~ is properly digested, also the abdomen and heart sounds.

MediciTte.~In the earl)- stages calomel gr. 5 should be givel~. so as to have the bowels well cleared out. and it prol)ahly acts in an antiseptic manner as well. A mixture of dilute h.vdrochloric acid or liquor ammonii aeetatis is sufficient for an ordinary ease.

Headache.-This occurs in the earh" stage, when a small dose of phenaz, me (antil)yvin) and sodium salievlate, with mustard to the nap6 of the neck, rarely fails. 1 believe the cases with very severe headache want the most careful watching, as such cases, whether they appear to have had an extra dose of the poison or not, are more liable to luemorrhage than others.

,~leep.--lt is not necessary in most eases to give SOl~)rifics, hut occasionally, particularly in severe cases, it is ahsolutely important tha t i)atients should not heeome exhausted frdm want of sleep. 1 find that morl)hin in small doses per rectun~ acts well, and is less liable to upset the dTgestion. In eases where there is flatulence or any other cause l)reventing sleep, this must he treated. Sponging the l)atient is also very soothing to the sufferer.

Diarrhoea.---This is generally caused hy the l)atient l)eil~g unable to digest the milk, and heef-tea certainly tends t - increase it. Barley water should be added, or lime water. and if necessary peptonised milk with lime water should be given ; beef-tea should 1)e stol)ped, and mutton hroth may be

llv I)R _~[WHAEL ()'(_'ONNOR. 17:1

tried in it.s place, if the motions are offensive very small doses of calomel or hydrargyri l)erchhnqdmn may be given. 1 have found carbonate of guaiacol and thvmol also useful, but I consider that the diet is of lnost importance.

('o~stipatiom---This is very common in West Australia. and may 1)e corrected l)y increasing the broths and reducing the milk. Enemata are necessary and effectual.

"l'ym.t~t ~tites.--This is ahvays serious when aeeoml)anied 1)v low nervous depression, and should 1)e met with bv stimulants, such as stryehnin and eaffeiu hypodernfically, with spirits (good brandy or whisky) and turpentine. I relneml)er that one case [ was called to see, who al)peared to be ahnost on the point of death, made a marvellous recovery after being put (m turl)entine with, of course, other stinmlants.

Froln the third week 1 find that turpentine is a very useful medicine in tyl)hoid fever, l)reventing the fl)rmation of gas, which stretches the already weakened intestines, and also acting ~Ls an antiset~tie. The diet., as in (liarrh(ea, must also 1)e revised. Tinct. opii 5j, and rel~ated ill three hours, with careful attention, acts beneficially in those sudden cases of tympani~s with severe depression.

H(cmorrhoge.--The stools should be constantly examined, for often ha~morrhagie clots and sloughs may be found antecedent to an attack of hwmorrhage, when turpentine may be given and attention paid to diet, and so often preventing a serious loss of bh)od. H~emorrhage may be diagnostieated 1) 5" palh)r of the face, weakness of the pulse, a fall of temperature, and, if severe, dulness on percussion over the colon. Opium by the mouth I have found the most useful ; it calms the patient, allays the peristalsis which is set u 1) by the bh)od acting as a foreign l)ody and 1)y this means allowing eh)ts to form. Sp. terebinth. 11t 15 every third hour is useful. Attend to diet, and allow the fainting condition to remain. Reduce stimulants an much as possible. Astringents i have found of little service, but I l)elieve that chloride of calcium given when the early clots appear would tend to make the blood more e)agulable, and thus prevent hlemorrhage.

Perfor(ltio~.----Th!s should be met with la,:ge doses of opium by the mouth, but the chances of reeoverv are vetLv limited. I have no experience as regards operation, but 1 cannot see

174 Typhoid Fever in Western Austral i..

how any patient is likely to recover from such a severe operation when they are ill such a low state; and it is exceedingly problematical if any good result would occur in suturing an intestine which is already so extensively diseased as to rupture.

Temperature.---This can usually be controlled by sponging, which is most grateful to the patient. In pyrexia, which cannot be controlled by sponging, wet packing and warm bath gradually cooled down with ice, watching carefully the patient at the same trine, are effective. " I ron ing" the patient all over the body and the spine with a lump of ice I have found as useful as anything else. This may have to be repeated as often as the temperature runs up. Quinine is also effectual, but as regards the so-called antipyretic drugs, such as antipyrin, antifebrin, &e., I prefer to leave ihe.n alone. They certainly reduce the temperature, but the fever as quickly recurs again, and they have a most depressing effect on the heart, which, after all, is of ,the utmost importance in typhoid fever, as in every other disease.

Stimulant.--The nmjority of cases do not require stinmlants, but even those in the convalescing state do well with a little good wine or beer. [ cannot pretend to have any sympathy with those who treat typhoid fever on strictly temperance principles. Every case nmst be judged on its merits and treated aecordingly. If the heart sounds are getting weak, more especially the first sound, with a pulse fast and of low tension, I should give alcohol; also in cases with dryness of the tongue (not occasioned by mouth breathing), nervous and muscular prostration, with twitching, low, wandering delirimn, even up to 12 oz. per diem.

I prefer brandy and whisky of good quality to any other form when the patient is able to take it ; and I th ink it is better to give it in small doses constantly repeated, but not to wake the patient from his necessary sleep. I have also found coffee useful, which can be well taken with milk. Hypodermics of stryehnin and caffein are most beneficial when the hem't is showing signs of weakness.

Convalescence.---The patient should be kept, no matter how he may complain of starvation, for eight to ten days on fluid diet. I have found that relapses constantly occur if he is

.\Tote o1~ "Couperose. '" 175.

allowed anything in the way of solid food before that time. and after that the food must be gradually increased (very gradually), the temi)erature being watched carefully all the time.

Recently the serum treatment has been introduced, but my experience of that method is nil. One cannot hel 1 ) hoping that the favour'able reports that apl)ear in the medical journals may be eventually borne out, as in the case of diphtheria and streptococcus infection.

It would be unwise to jump at a conclusion that serum treatment is a specific in typhoid fever because certain medical men have had a low death rate, for we all know, at least those who have had an extensive exl)erience, that in one year we may have a high death rate, whilst in the next year under exactly similar treatment we may have a low death rate.

ART. I X . - - N o t e o n " Co~,pe~'osc." By t[. S. PrRnON, M.D. ; Senior Physician Belfast Hospital for Diseases of the Skin, &c.

Tn~: commencing erythema of aene rosacea, called by the :French dermatologists " Couperose," is a very troublesome complaint, and a great disfigurement, especially in the case of ladies, who are more frequently affected than males. The disease, as is well known, begins with flushing of the face, often due to dyspepsia, finally leading to a congested con- dition of the skin of both cheeks and nose, shown by its reddish colour -often called St. Anthony's fire. As a re- sult of this erythematous condition acne may be developed, which still further adds to the discomfort of the patient. However, the papules ending finally in pustules of acne belong exclusively to acnc--the c o u p e r o s ~ - - c o n s t i t u t e d by dilatations of the cutaneous capillaries. I may remark that the local treatment is most important, and for some time I have been using an ointment containing 10 grains of the iodide of cadmium to one ounce of vaseline rubbed well into cheeks and nose at night, and washed off next morning with hot water and an over-fatted soap, accompanied by massage of all the affected skin. The latter I hold to be most impor- tant. Formerly I have prescribed iodide of sulphur, which, however, darkens or stains the skin. I also have tried