I402 THE ENTEROIDEA GROUP OF TROPICAL FEVERS 



3. Perforation. — ^The only chance is to perform a laparotomy, 

 and deal with the perforation surgically; but this must be done as 

 soon as possible. After the operation the Fowler-Murphy after- 

 treatment should be carried out, and the patient placed as nearly 

 in an upright sitting position as compatible with comfort. This 

 position is maintained for four days. At the same time a con- 

 tinuous administration of salt solution per rectum is carried out, 

 and so arranged that the patient obtains 2 to 6 litres per diem for 

 a week, and Wainwright's special apparatus for this purpose may 

 be employed. 



4. Diarrhoea. — This may be checked by tannalbin, 10 to 20 grains, 

 three times a day, or tannigen in the same dose. A very useful 

 adjunct is an enema containing Dover's powder, 5 grains; tannin, 

 10 grains; mucilage of gum, i ounce: and thin starch solution, 

 I ounce. Bismuth preparations should, if possible, be avoided, as 

 they are apt to obscure traces of blood, which may be valuable 

 hints of a possible haemorrhage. 



5. Cholecystitis. — This should be treated by urotropine, and when 

 chronic by antityphoidal vaccination, or a surgical treatment may 

 be advisable. 



6. Hyperpyrexia must be combated- by tepid, cool, or even iced 

 sponging, by immersion in baths of a temperature between 75° to 

 85° F. Antipyretic drugs should not be given. 



7. Delirium. — Acute mental symptoms require sedatives or relief 

 of intracranial pressure by lumbar puncture. 



8. Cardiac Failure. — This may require to be combated by hypo- 

 dermic injections of digit alin or camphor in ether, or by strychnine 

 and by saline injections. 



9. Phlebitis. — This usually occurs in one of the legs, which must 

 be wrapped in cotton-wool after applying ichthyol in lanoline 

 (2 per cent.). 



10. Bedsores. — These are usually quite preventable, but great 

 care is necessary to dry and to disinfect the back and to harden the 

 skin with spirit lotion. When the sores have developed they should 

 be disinfected twice daily with hydrogen peroxide, and a xeroform 

 or zinc oxide powder applied. In some cases a protargol ointment 

 (5 per cent.) or a balsam of Peru ointment (i to 2 per cent.) are 

 useful. 



11. Abscesses. — -Local inflammations should be treated with ice- 

 bags, and when pus has formed incisions must be made. 



12. Bone Lesions. — A stiff jacket may be necessary to relieve the 

 pain of a typhoid spine, and the osteitis or periostitis may require 

 surgical treatment. 



B. The Treatment of Convalescence. — This may be subdivided 

 into — (I.) The treatment of a simple case; (II.) the treatment of 

 sequelae; (III.) the treatment of the acute carrier. 



I. The Simple Case.— The most important factor is to keep the 

 patient in bed without any change of diet until twenty-one days 

 after the temperature has permanently reached normal, and then 



