If perforation take place, the prognosis is most grave ; but even in this strait death is not absolutely certain. If the collapse which follows the extravasation be quickly recovered from, even although considerable tympanitis, pain, and tenderness remain, we may hope that the peritonitis has been localised by intestinal adhesions, and that further improvement may take place.
Treatment.—In every case of typhoid fever, if there is any reason to suppose that the disease has been contracted in the house, the drains should be thoroughly examined at the earliest opportunity, and every care must be taken to prevent the entrance of sewer-gas into the passages. All soil-pipes should be ventilated : waste-pipes should be cut off from direct communication with the sewers ; cisterns supplying water for drinking and cooking should be entirely separated from those whose pur pose is merely sanitary ; and the water itself—unless its purity be above suspicion—should not be drunk without having previously been boiled and filtered.
The treatment of typhoid fever consists mainly in careful and judicious nursing. Sir William Jenner has insisted strongly upon the absolute necessity in this complaint of perfect rest. The child should be confined to bed at once, and if the attack has occurred at a distance from his home, it is better that he should remain where he is, than run the risk of in creasing the severity of his illness by the fatigues of a removal. Fatigue not only exhausts nerve-power, which is already reduced by the fever, but it also increases destruction of tissue at the same time that it checks elimi nation by the excretory organs. The bedroom should be a large one, and the air must be kept as pure as possible by judicious ventilation. Its temperature should not be allowed to rise above 65°. The patient should be lightly covered and not overloaded with bedclothes. There is, how ever, one precaution which it is expedient to take. As in all cases where the mucous membrane of the bowels is the seat of catarrh, flannel in the shape of a flannel bandage should be applied round the belly so as to avoid the risk of chill. All discharges from the body must be at once disinfected before being removed from the room, and linen, etc., soiled by such discharges must be subjected to the same disinfecting process before being washed. If there be reason to suspect the purity of the water-sup ply, none should be used for drinking purposes without previous boiling and filtering. This, however; the child may be allowed to drink without stint, provided too large a quantity be not taken at once. A free supply of water assists the depurating action of the skin, kidneys, and lungs ; but distention of the stomach by too much fluid is provocative of nausea and flatulence. For this reason effervescing drinks are to be avoided ; they are apt to distend the stomach and cause uneasiness.
The question of diet is a very important one. The old plan of " starving the fever " and reducing the patient has been fortunately abandoned, but we must not fly to the opposite extreme and overload the stomach with food in the hope of supporting the strength, however digestible and well selected the food may be. Farinaceous matters, on account of their ten dency to ferment and form acid, are better avoided. Fruit for the same reason is out of the question. It is better to restrict the diet to meat broths made fresh in the house, and to milk. The broths may be flavoured with vegetables, but must be carefully strained. The milk should be di luted with an equal quantity of barley-water, so as to split up the curd and prevent its coagulating in the stomach in large lumps. Masses of hard curd are a frequent source of irritation, and may excite restlessness and ab dominal pains. They may also, perhaps, increase the diarrhoea. The quantity of food to be given at one time should never be left to the dis cretion of the attendants. Nourishment should be administered in pre scribed doses at regular intervals—the quantity and the length of the in tervals to be decided by the age of the patient and the facility with which the meal can be digested. Nausea, restlessness, excitement of pulse, in crease of fever, and flushing of face, are signs that the digestive organs are being taxed beyond their powers.
The question of stimulation is closely allied to that of food. Stimu lants must not be given too early. They are useful to strengthen the ac tion of the heart and increase nerve-energy, but are seldom required before the end of the second or beginning of the third week of the disease. Even then, they should be only given in severe cases where the heart's action gives signs of failing, and there is marked delirium or great muscular pros tration with tremor. Tremor, " out of all proportion to other signs of nervous prostration," is, in the opinion of Sir William Jenner, evidence of deep destruction of the bowel. In these cases alcohol is of the utmost value. The signs connected with the heart which may be taken to indicate the necessity for stimulation are diminution or suppression of the impulse with feebleness of the first sound. The effect of stimulation should be carefully watched. If the fever diminish, the tongue and skin get or re main moist, the pulse and respiration become slower and fuller, and the mind clearer, we may know that we have benefited our patient. If, on the contrary, the temperature rise, the heart's action become feebler and more frequent, the delirium increase, and the child get restless with inability to sleep ; or if he become duller and seem sinking into a comatose state, we may conclude that alcohol is acting injuriously, and that it must be discon tinued or given in smaller quantities.