As diet in cases of fever I recommend the prescriptions of Professor Moritz, which coincide with my own experiences, so far as a fever diet is concerned; and in addition the physiologico-chemical cell-food which I have used for many years with the greatest success (Dech-Manna Diet). The importance of the latter is due to the fact that it not only prevents the destruction of the cells, but has a general strengthening effect upon the system.
Whatever the differences in manifestation the febrile diseases may show, the febrile reduction of the digestive capacity of the stomach and the bowels is so characteristic, that it should be specially noted in this connection.
True, fever shows considerable disturbance of metabolism, since the decomposition of the albumen is increased in an abnormal way. This fact, however, does not demand any particular attention, in regard to diet. As far as possible during fever it is well to exercise an economizing influence on the decomposition of the albumen of the body through the introduction of all kinds of food that produce energy, so that it is not necessary to give preference to any one particular kind of food.
The injury to digestion during fever comprises not only the peptic functions, which manifest themselves clearly in a reduction of the excretion of hydrochloric acid, but all functions pertaining thereto, the motory as well as the resorptive.
The danger that the patient will receive too much solid food, hard to digest, is generally speaking not very great since, during acute fever, patients as a rule show a decided lack of appetite. The other extreme is the more likely to occur; that the amount of nutrition given may be less than what is requisite and helpful; too much deference being paid to the inclinations of the patient. Formerly the general belief obtained that fever would be increased, in a degree detrimental to the patient, by allowing the consumption of any considerable amount of food, and following this doctrine, the patient was permitted to go hungry. This, however, is absolutely erroneous. No one would feed a feverish person in a forcible manner, but it is absolutely imperative to take care that he receives food productive of energy in reasonable quantities.
As a rule hardly one-half, or at the most two-thirds of the normal quantity of nourishment necessary for the preservation of life, may be introduced into the organism in case of acute febrile disease. I have already indicated that there is no particular danger in such partial "inanition" (starvation) for a short period, but that, accordingly, the qualitative side of the nourishment becomes more important the longer the fever lasts. It has also been mentioned that the organism reduces its work of decomposition, gradually adapting itself to the unfavorable conditions of sustenance, and thus meets our efforts to maintain its material equilibrium.
It is important always to make use of any periods of remission and intermission, during which the patient has a better appetite and can digest more easily, to give him a good supply of food. It is also well to administer as much nourishing food as possible in the beginning of an illness, which is likely to be lengthy, provided the patient is not yet wholly under the effects of the febrile disease. The food must then be gradually reduced in the course of the illness.
As to quality, the diet must be selected from forms II and III (as below), and will consequently consist of glutinous soups, in some cases with the addition of a nutritive preparation of egg, meat jelly, milk and possibly thin gruel and milk.
The quantity of food which the patient may receive can only be given approximately, as follows:
For adults—(to constitute a sustaining diet). Soup ½ pint, milk and milk gruel ⅓ pint, meat 3 oz., farinaceous food the same, 2 eggs, potatoes, vegetables, fruit sauces 2 to 2½., pastry and bread 2 oz.
These quantities must be considered as the maximum for each portion. The quantity of beverage at each meal must also be very limited, not exceeding 3 to 6 oz., so that the stomach is not overburdened unnecessarily nor its contents too much diluted.
The reduced meals are harmonized with the object of sufficient general nourishment by eating more frequently, about five to six times a day. Patients with fever should have some food in small quantity every 2 to 3 hours. It is important that the patient be fed regularly at fixed times. This will be found advantageous both for the patient and for nursing.
Form II comprises purely liquid nourishment, "soup diet." Consommé of pigeon, chicken, veal, mutton, beef, beef-tea, meat jelly, which becomes liquid under the influence of bodily heat, strained soups or such as are prepared of the finest flour with water or bouillon, of barley, oats, rice (glutinous soup), green corn, rye flour, malted milk. All of these soups, with or without any additions such as raw eggs, either whole or the yolk only, if well mixed and not coagulated are easily digested. (Besides albumen preparations, Dech-Manna powders, dry extract of malt, etc., may be added).
Form III comprises nourishment which is not purely liquid. Milk and milk preparations (belonging to this group on account of their coagulation in the stomach):
(a)—Cow's milk, diluted and without cream, dilution with ½ to ⅔ barley water, rice water, lime water, vichy water, pure water, light tea.
(b)—Milk without cream, not diluted.
(c)—Full milk, either diluted or undiluted.
(d)—Cream, either diluted or undiluted.
(e)—All of these milk combinations with an addition of yolk of egg, well mixed, whole egg, cacao, also a combination of egg and cacao.
Milk porridge made of flour for children, arrowroot, cereal flour of every kind, especially oats, groat soups with tapioca, or sago, and potato soup.
Egg, raw, stirred, or sucked from the shell, or slightly warmed and poured into a cup; all either with or without a little sugar or salt.
Biscuit and crackers, well masticated to be taken with milk, porridge, etc.
As a rule fever is accompanied by an increased thirst, which may be satisfied without hesitation. It is unnecessary, and detrimental, for patients suffering from an increased excretion of water through the fever heat, to be subjected to thirst. Since the mucous membrane of the digestive channel is usually not very sensitive to weak chemical food irritations, the cooling drinks, which contain fruit acids, such as fruit juices and lemonades, are as a rule permissible. Fruit soups may also be given.
It is different, of course, if an acute catarrh of the stomach or of the bowels is combined with the fever. In such cases fruit acids must be avoided. Still it is not necessary to resist the desire of the patient to take whatever may be given him, at a low temperature. Even ice cream, vanilla or fruit water ice, may be used in moderate quantity.
Warning against cold drinks is necessary only in case of disease of the respiratory organs when the cold liquids would cause coughing.
The use of dietetic stimulants such as Dechmann's Tonogen, Eubiogen and Plasmogen, is the same in these cases as has been mentioned in several places previously.
As soon as the patient has made sufficient progress, he may receive more solid food.
The salivary digestion being improved, he may now be allowed several more substantial dishes of rice and groat, cooked partly in milk, partly in water and eaten with fruit juice. He may also have several kinds of green vegetables, like spinach, cauliflower, asparagus, comfrey, etc.
With additional increase in his strength, fresh fish, well prepared, is especially refreshing to a patient with light fever.
As to mental pabulum, in case of severe fever, I recommend for the patient absolute mental and physical rest; little talking, no noise, no visits, no disturbance of any kind. Within his system nature has to accomplish an enormous task to facilitate which complete quiet is essential. Just as he who has serious preoccupations needs quiet environment, so that his attention may be devoted to his thoughts, so also a patient in the throes of fever must relax all external considerations in deference to the struggle of the vital forces within. Whatever disturbance of mentality occurs has always prejudicial effects, such indeed as may in some cases cost the life all are seeking to save.
SCARLET FEVER.
Scarlet fever is an exanthematous form of disease distinguished by a scarlet eruption of the skin. It produces marked symptoms in three localities, the skin the throat and the kidneys.
It is doubtful whether it can be conveyed from one person to another; at least nothing is known concerning the "contagium," or germ of conveyance of infection,—according to the differential diagnosis of Dr. G. Kuhnemann, whose work on the subject is held to be authoritative. It is not to be denied that the disease may be carried by articles of clothing and by intermediary persons, who themselves are not suffering from it.
The incubation period—the time intervening between infection and eruption—during which the infected person is "sickening for" disease, varies from two to as much as eight days.
Chills, feverishness, headache, nausea and actual vomiting are the initial symptoms, and sore throat with difficulty in swallowing soon follow.
Inspection reveals the appearance of an acute throat inflammation, and the tip and sides of the tongue are red as a raspberry. A few hours later—or at most a day or two—the eruption appears; first in the throat, then on the face and chest. It begins with minute, bright red, scattered spots, steadily growing larger until they run together so that the entire skin becomes scarlet, being completely covered with them. Frequently the temperature in the evening ranges as high as from 103° to 105° Fahrenheit. Albumen is always found in the urine.
After two or more days the fever mounts gradually, the throat symptoms increase, the eruption fades away, and from four to eight days later the patient's condition returns to normal.
At the beginning of the second week desquamation, or scaling, begins, the skin peeling off in minute flakes. At this stage heavy sweats set in and the excretion of urine is increased.
In epidemic form the type is sometimes much more malignant, even to the degree that death occurs on the first day with typhoid and inflammatory brain symptoms, unconsciousness, convulsions, delirium, excessive temperature, and rapid pulse. This may happen even without the eruption becoming fairly recognizable. In such severe epidemics the throat symptoms are apt to take on the aspect of diphtheria. The renal discharge exhibits the conditions of a catarrh of the urinary canals originating from causes we do not understand.
Among the after effects of scarlet fever are inflammation of the ear with all its consequences, and inflammatory affections of the lungs, air passages, diaphragm and heart membrane.
The cause, I repeat again, is dysaemia—impure blood.
If the patient is predisposed to this form of disease and moreover, a weakling, the case is a dangerous one.
Every good mother should see to it that there is healthy blood in her offspring. The task is comparatively an easy one, the method, is simple and ignorance ceases to be an excuse, for my object is to place the necessary knowledge within the reach of all.
The treatment of scarlet fever varies according to which symptoms are most severe.
In the first place prophylactic efforts must be constantly employed to prevent possible contagion. Healthy children must be strictly seperated from the sick till the end of desquamation or scaling—a period of four to six weeks.
If the course of the attack is normal, the patient should be kept in bed under a light cover with a room temperature of 60° to 65°. The sick room must be well ventilated and aired daily.
The windows should be hung with transparent red curtains.
The diet may consist of milk, curds, barley soup, oatmeal gruel, flour gruel, with some cooked fruit and, of drinks, lemonade, soda water, and raspberry juice; but the most important drink from a scientific point is Dechmann's "Tonogen," as previously described.
The linen should be changed often
Sponge baths with chilled vinegar-water (1 part cider vinegar diluted with 2 parts water) are helpful when the temperature rises to 102°. If the temperature reaches 105° or over, baths must be promptly administered. The patient may be placed in a bath of 85° or 90°, and the water allowed to cool gradually down to 70° or 65°.
A sick child may stay in such a bath ten or twenty minutes, while the time in a bath practically should not be more than three or five minutes. The bath must be repeated as soon as the fever again reaches 105°.
When the first symptoms of measles, scarlet fever or chicken-pox are noticed, give the child a three-quarter pack. (See directions under "packs"). After each pack sponge the patient with cool vinegar-water.
If the fever is high during the night, apply a sponge bath every half hour or hour.
During the day give the patient ¼ teaspoonful of Dechmann's Plasmogen, dissolved in ½ pint water, a little every hour.
In the evening and during the night alternate this blood-salt solution with Tonogen.
Blood plasm contains eight different salts in different composition, and only when the actual physiological composition is employed can there be any guarantee against the decomposition of the blood-cells. Plasmogen is such a composition.
When diphtheria and Bright's disease complicate the case, they must be dealt with as under ordinary conditions and treated by a competent, Hygienic dietetic physician.
If recovery is prompt and desquamation (scaling) is in progress, warm baths may be applied for a few days.
When the temperature and urine continue normal for a few weeks, the child may be regarded as restored to health.
MEASLES.
Measles or Rubeola is an exanthematous or eruptive contagious form of children's disease.
In Measles the medium of contagion is the excretion from the air passages, mucus coughed up and air exhaled; also the saliva, tears, blood and perspiration of the patient.
In Measles also, as is the case with regard to scarlet fever, the "contagium," or germ of contagion, is unknown.
The general susceptibility to measles is extraordinarily great the poison being of a virulent nature.
If the disease attacks one of feeble constitution whose environment is unfavorable and insanitary,—dwelling in badly ventilated rooms, for instance, with little attention paid to personal cleanliness, the attack is likely to assume a malignant form.
A period of from ten to fourteen days may elapse between infection and the development of the symptoms.
During this period the patient may infect others.
This explains how easily a whole school may become infected.
During the preliminary period children feel tired, relaxed, suffer pain in the joints and headache; they have chills and are feverish at evening. Among the symptoms enumerated are catarrhal affections of the air passages, the larynx, the nose and eyes. Constant sneezing, nosebleeding, cough, watering eyes, ultra sensitiveness to strong light, are concurrent conditions. At the same time the fever becomes pronounced.
These symptoms continue for four or five days and then rapidly abate and the eruption appears. First a red rash is seen, which spreads over the surface of the face. Inside the mouth and throat a similar mottled redness is seen. In the course of a day the eruption spreads over the whole body. After continuing at their height for a day or two the symptoms gradually decline, and in a little over a week the child may be pronounced well. The skin then sheds all the superfluous cuticle left by the eruption, and in three or four weeks after inception the normal condition is again reached.
In the malignant form all the symptoms are of a severe type. Occasionally catarrhal affections of the air passages, croup or pulmonary inflammation supervene, and the patient succumbs.
Other concurrent forms of disease are whooping cough, diphtheria, pulmonary consumption, inflammation of the eyes, ear disease, and swelling of the glands.
Measles demand no distinctive treatment. The room must be well ventilated, with a temperature of about 60°, and light must be almost totally excluded. At night no lamp should be allowed.
Treatment and diet should be the same as in scarlet fever.
GERMAN MEASLES.
German Measles (Rubella or Roetheln), is an eruptive form of children's disease, much more harmless than the disturbances previously depicted. It is one which occurs in epidemics, but to which children individually are largely susceptible; the actual contagium thereof, however, is likewise unknown to science.
Eight days generally intervene between the time of infection and the breaking out of the rash.
During this period no acute symptom is noticeable. In the majority of cases the fever that precedes the eruption is not high; headache, cold and sorethroat accompany the appearances of the rash, which in this case breaks out at once, and not after several days, as in the case of actual measles. The spots are about the size of lentils, and are quite deep red, appearing first upon the face.
After the rash has been out for one or two days, it gradually becomes paler, the fever goes down, and recovery progresses rapidly, usually without any after effects.
It is not necessary for the patient to remain in bed longer than three or four days; nevertheless, the treatment should be just the same as prescribed in the case of the real measles, so as not to leave any weakness or subsequent complication.
There are many other forms of disease, besides these, which are likewise accompanied by fever and a rash, which also appear in epidemics and are evidently due to a great variety of causes. As they, however, invariably run the natural course, I shall not dwell upon them here.
CHICKEN-POX.
Chicken-pox, or Varicella, of which the contagium also remains a mystery, is another infectious eruptive form of disease, peculiar to children. It begins with the appearance of a number of little pigmented elevations on the skin which develop into vesicles and pustules. After a certain period they become encrusted with scabs, which dry up and fall off. When the pustules are deep-seated, small scars remain There is no fever, and the illness is over in about fourteen days. The contagion passes through personal contact, or through clothing and bed linen.
If symptoms are severe enough to require it, treatment should follow the directions for scarlet fever.
SMALL-POX.
As a matter of fact Chicken-pox is of congeneric origin with small-pox, with which, in a very much milder degree, it has various features in common. But small-pox itself is engendered of foul and insanitary conditions of life, impure blood and bad and insufficient nourishment and these, together with its risk under unscientific conditions and in times past of facial disfigurement, have made its name more repugnant to the layman than perhaps any other form of disease. All that need be said about it here, however, is that it is largely a terror of the past and that the sure preventative against it always, and the one reliable anti-toxin against contagion, under all circumstances, is good healthy blood and hygienic-dietetic living.
Those readers who may desire a minute description of this form of disease will find the same in chapt: XII of my greater work "Regeneration."
TYPHOID FEVER OR TYPHUS ABDOMINALIS.
This description of fever is usually termed typhus or nerve fever. It characterizes all forms of typhoid disease of which the following features constitute the prominent symptoms.
To a peculiar degree, chiefly young and strong individuals of from 15 to 30 years of age are attacked by this disease, while those in early youth and of more advanced years are much less subject to the same.
It is a complaint very dangerous to those who eat and drink to excess and without discretion. Strong excitement of the mind, such as a shock or great anguish, will undoubtedly favor the appearance of typhus. The seasons too have considerable influence upon it, most cases occurring during the Autumn months—from August to November.
It has been previously indicated to what extent the study of the hygienic conditions of life will assist in the discovery of the real causes of so-called contagious disease. One instance may show the enormous influence of dietetic movements on the outbreak of great epidemics.
It is reported in the "Journal of the Sanitary Institute," London, that the English Seaside Resort Brighton, in the period from July, 1893, to August, 1896, 238 cases of abdominal typhus were observed,—about equally divided for the different years. In 56 cases the typhus was caused by the eating of oysters (36 cases) or clams (20 cases). There was evidence that the water from which these oysters and clams were taken was badly polluted by the excrement of several thousand people, brought through sewers to the place were the shell-fish had been gathered. It was very characteristic in a number of cases that only one of a number of persons, who were otherwise living under equal conditions, fell ill with typhus, a short while after having eaten some of the shell-fish. No other points essential to the spreading of this contagious disease could be discovered. Brighton is healthily situated and built; hygienic conditions in general are favourable; much attention is paid particularly to keeping the soil clean, removing all faeces and providing good drinking water. Contamination through milk in all of the 56 cases, according to most careful investigations, was out of the question. They occurred in entirely different streets in various precincts of the town; 45 of the patients lived on 43 different streets. Besides the people attacked by typhus, many other persons fell ill from lighter disease of the intestines, after having eaten of these crustaceous bivalves, the symptoms being diarrhoea and pains in the stomach. Measures were taken to remove the noxious causes as soon as the source of infection was discovered.
The same conditions were some time ago noticed in Berlin. Out of 14 people invited to a dinner, nine fell ill—5 of them very seriously—under symptoms of typhus, after having eaten oysters from Heligoland. Part of the personnel of the kitchen and some of the servants were taken ill with the same critical symptoms.
Abdominal typhus is a general illness of the whole body, and consequently all organs of the body are more or less altered in a morbid way while the disease lasts. The main change occurs in the lymphatic glands of the intestines and in the spleen.
The following are its anatomical symptoms: With the beginning of the disease the lymphatic glands of the mucous membrane of the intestines begin to swell; they are constantly growing during the course of the disease and attain the size of a pea; extended over the level of the mucous membrane they feel firm, hard and tough. In favourable cases the swelling may go down at this stage, but generally the formation of matter begins through the dying of the cells, caused by insufficient nourishment. This is gradually thrown off, and a loss of substance remains—the typhoid ulcer. This varies in size and in depth. Light bleeding in no great quantity ensues. If the ulcer has gone very deep, the intestines may be perforated and then the faeces and part of the food enter the abdominal cavity. The result is purulent and ichorous peritonitis. As a rule, however, the ulcers are purified and heal by cicatrization. Usually the spleen is enormously enlarged (through a rapid increase in the number of its cells). The swelling of the spleen can easily be detected by external touch.
During what is termed the earlier stage, which as a rule last about two weeks and precedes the breaking out of the disease proper, the patient still feels comparatively well, or only begins to complain of headache, tired feeling, prostration in all the limbs, dizziness, lack of appetite. It is thus absolutely impossible to fix a definite date for its development. In most cases the patient complains of a chill, followed by feverishness,—symptoms which confine him to bed,—although no actual shivering takes place. It is expedient, although quite arbitrary and subject to many modifications, to divide the course of the illness into three periods:—
(1) The stage of development.
(2) The climax.
(3) The stage of healing.
During the stage of development, which usually lasts about a week, the symptoms of the disease rapidly increase. The patient gets extremely weak and faint, has severe headaches and absolutely no appetite. In consequence of the high fever, he complains of thirst; the skin is dry, the lips chapped, the tongue coated; the pulse is rapid and full; the bowels are constipated, but the abdomen is practically not inflated nor sensitive to pressure. In most cases the spleen is evidently enlarged.
Before the end of the first week the climax is reached. This in the lighter cases lasts for the second week, or in more severe cases, even until the third. The fever is constantly high, even 104° and over. The body is generally benumbed, the patient becomes delirious at night or lies absolutely indifferent to all surroundings. The abdomen is now inflated, the buttocks show small, light red spots,—the so-called "roseola,"—which are characteristic of abdominal typhus. Furthermore, in most cases, bronchial catarrh of a more or less severe nature appears. Instead of obstruction of the bowels there is diarrhoea—about two to six light yellow thin stools, occur within 24 hours. During this second stage the complications appear.
At the end of the second or the third week respectively, the fever slackens; in cases which take a favourable turn, the patient becomes less benumbed and less indifferent, his sleep is quieter; appetite gradually returns. The bronchial catarrh grows better, the stool once more becomes normal; in short, the patient enters the stage of convalescence.
This is a short sketch of the course the illness usually takes.
Of the deviations and complaints accompanying Abdominal Typhus, the following are the most important details:—
The fever takes its course in strict accordance with the described anatomical changes in the intestines. It increases gradually during the first week, and at the end of that period it reaches its maximum of about 104°. It stays at that point during the second stage, gradually sinking during the third stage.
In lighter cases the second stage may be extraordinarily short.
If perforation of the intestines, heavier bleeding or general collapse should ensue, attention is directed thereto through sudden and considerable decrease in the temperature of the body. Pneumonia, inflammation of the inner ear and other accompanying complications also cause sudden access of fever.
Effect upon the digestive organs: The tongue is generally coated while the fever lasts; the lips are dry and chapped, and look brown from bleeding. If the patient is not carefully attended to during the extreme numbness, a fungus growth appears which forms a white coating over the tongue, the cavity of the mouth and the pharynx, and may extend into the oesophagus. Later on the tongue loses this coating and becomes red as before. Few symptoms are shown by the stomach, except occasional vomiting and lack of appetite. During convalescence there is great desire for food. The anatomical changes in the intestines have already been mentioned.
While obstruction prevails during the first week, the second week is characterized by diarrhoea of a pale and thin consistency.
When general improvement sets in, the stools gradually decrease in number, they grow more solid and finally reach the normal. The abdomen is not very sensitive to pressure and is usually intensely inflated with gas.
In the region of the right groin a cooing sound is often heard, caused by a liquid substance in the intestines, which can be felt under pressure of the finger.
Bleeding from the intestines is not infrequent and happens during the third week of the illness. It usually indicates a bad complication, since the result may be fatal. The stool assumes a tar-like appearance through the mixture of the coagulated blood with the faeces. Close attention must be given to minor hemorrhages, since they often herald others of a more intense nature.
In such extreme cases of serious complications, however, a cure has nevertheless been sometimes effected. They are occasionally followed by the immediate beginning of convalescence.
The perforation of the intestines, which is caused by an ulcer eating its way through the wall of the intestines, is much more dangerous. It happens most frequently during the third or the fourth week. The patient feels a sudden, most intense pain in the abdomen; he collapses rapidly, the cheeks become hollow, the nose pointed and cool. Vomiting follows, the pulse becomes weak and extremely rapid. The abdomen is enormously inflated and painful. In the severest cases death ensues, at latest, within two or three days, the cause being purulent and ichorous (or pus-laden) peritonitis.
Such extreme developments as these, however, are infrequent, since the illness, by timely attention according to the methods herein prescribed, will, as a rule, respond to the treatment and take a favourable turn.
Respiratory Organs:—
In the course of typhus, intense bleeding of the nose is not infrequent. In the severer cases this is a sign of decomposition of the blood, but in lighter cases it merely serves to alleviate the intense headache which is a feature of the case. The throat is liable to be affected; hoarseness and coughing occur; hardly any case of typhus catarrh. This sometimes extends into the air-passes without a more or less intense bronchial cells and causes catarrhal pneumonia, which—if not promptly treated according to the instructions herein detailed—may become extremely dangerous.
Organs of Circulations:—
With the exception of a strongly accelerated action, no change is noticeable in the heart. It may, however, suddenly become paralyzed and cease entirely, owing to the general weakness of the patient and the intensity of the fever. Weakness of the heart and possible cessation occur only during the climax or convalescence.
Nervous System:—
Disturbances of the nervous system are very frequent, hence the name "nervous fever."
Consciousness is, in nearly all cases, more or less benumbed, and at times completely lost. The patient is either lying absolutely indifferent, or he is delirious, cries, rages, attempts to jump out of bed and can only be subdued by the strongest efforts.
Patients lose control of urinary and faecal movements and require feeding.
These disturbances disappear as soon as convalescence sets in and consciousness returns.
As a rule the patient, on return to consciousness, knows nothing of what he has gone through, and has no reminiscences of the immediate past.
Sometimes cramps in the masticatory muscles have been observed, which explains the grinding of teeth apparent in some instances. Convulsions in the limbs and facial muscles sometimes appear, but most of these disturbances are of short duration.
Urinary and Sexual Organs:—
With high fever albumen appears in the urine. In some instances it may lead to inflammation of the kidneys, the symptoms of which may at times completely overshadow the symptoms of typhus. Fortunately this complication is very rare. Catarrh of the bladder occurs, because the patient retains the urine too long, while in a state of unconsciousness. Inflammation of the testicles has been observed with male patients, and pregnant women have miscarried or given birth prematurely.
Bones and Joints:—
Inflammation of the joints is infrequent and in a few cases only, inflammation of the periosteum has been observed.
Skin:—
At the beginning of the second week small rose-like spots of a light rose colour appear on the buttocks (roseola typhosa), which later on are also found on the upper legs, upper arms and back. They soon disappear, however, and leave no traces.
Pustular eczema is so rare in cases of typhus, that as a rule its appearance is taken to indicate that the disease is not a case of abdominal typhus. Frequently, however, urticaria, (nettle-rash) perspiration and other pustules are to be noticed.
The great variety of symptoms indicates that innumerable peculiarities may occur in the course of typhus. In some cases it is so light and indistinct (walking typhoid) that it is extremely difficult to diagnose it. In other cases pneumonia or unconsciousness, headache or stiff neck are indicated so overwhelmingly, that it is well-nigh impossible to recognize the underlying illness as typhus. In such cases one speaks of lung and brain typhus.
Recurrence:—
In about 10% of all cases recurrence is observed, mostly caused through mistakes in diet, leaving bed too soon, and excitement. Usually in such relapses the fever takes the same course as the original attack, but is much less intense. Although such secondary attacks are not very dangerous as a rule, great caution should be observed, especially in regard to diet, which must be followed in the strictest way until all danger has passed.
Complications and Subsequent Troubles:—are very frequent and a serious menace to life.
The most important are hemorrhage of the brain, meningitis, erysipelas, gangrene of the skin and bones, wasting of the muscles, fibrinous pneumonia; pericarditis, and frequently weakness of the heart with its consequences.
Purulent inflammation of the middle ear is one which deserves special attention.
Loss of hair is a frequent occurrence during convalescence, owing to the ill-nourished condition of the skin; this, however, is but a temporary feature soon succeeded by renewed growth.
The prognosis or forecast of typhus is not altogether bad, notwithstanding the gravity of its symptoms and the dangers of its course.
Statistics show that the mortality from typhus does not exceed 7% but each complication makes the result more uncertain and the outlook less hopeful. In the event of perforation of the intestines and severe internal hemorrhage supervening, the chances of saving life are slender.
The treatment of typhus requires, in the first place, a correct judgment of the physical condition of the patient in determining the fever treatment to be applied. Success in severe cases of typhus will only be secured by those who understand the correct methods of treating the skin. Robust patients, with reserve energy and resisting power, may receive the unrelaxing application of repeated whole packs or cool full baths. There is, however, a species of endurance, which may prove unable to endure the sustained and active force of these applications. In such cases milder applications and more frequent changes are recommended. Packs, interchanged with baths, clysters or enemas which subdue fever, alternated with ablutions, and similar methods.
Extremely stout and nervous patients must be treated with the greatest caution.
As typhus cases gradually develop, care must be exercised to prevent too violent treatment in case of serious complications. In fact the physician must not be guided by fixed rules, but must be able to individualize with prompt discretion.
During the severest stage the diet must be absolutely a fever diet, prescribed in Form II, while patients suffering from lighter attacks, and convalescents, may be permitted the milder fever diet, given in Form III.
Mental Condition. Great care and observation is necessary with regard to the patient's mental state. The observance of a quiet demeanour on the part of everyone about the sick room should help to keep the patient quiet and undisturbed and may serve to preserve his consciousness.
I have treated very severe cases of typhus, with extremely high fever, during which, however, consciousness remained. Inexorable strictness in this respect is often resented and misunderstood by those surrounding the patient until they realize the far-reaching importance of the orders by comparison with other cases.
Cold ablutions on the affected parts, air and water cushions, must be employed early enough to avert any danger of bed-sores.
This strict treatment of the patient—physically and mentally, will in most cases be sufficient to render his condition endurable; otherwise the struggle against the irritation of complications becomes intense, rendering it imperative, in the first degree, that the brain symptoms should be carefully watched.
Cold compresses on the head must be used in case such symptoms appear, but absolute undisturbed rest will conduce more than anything else to their infrequent occurrence.
Collapse must be contended against with light stimulating food (light bouillon of veal or chicken with a little condensed substance). Wine with alcohol might endanger the life of the patient. If the collapse is protracted, constituting a menace to life, the addition of cold water to the lukewarm bath and similar procedure may be tried, but only by a skilled expert.
Diarrhoea must be resisted by means of diet and clysters (enemas) with rice-water, if necessary; the enemas must be given cautiously. They are dangerous on account of possible violations and consequently rupture of the ulcerated intestines. These and other points, however, such as threatening paralysis etc., are entirely in the hands of the physician.
The contest against all the complications of typhus must be directed by absolutely skilled and experienced persons only, since in this disease particularly every mistake of any importance whatsoever, may cost the life of the patient.
Besides this specific form of typhus which commands general attention, the others are of merely theoretical interest. One, however, I wish to mention in passing; namely:
This also begins with chills and shivering, and a general tired feeling, and is immediately followed by high fever, up to a temperature of 104°. The skin is covered with excretory perspiration. The brain symptoms are lacking. The illness reaches its climax very quickly; but suddenly the patient feels much better, after extremely free perspiration. He continues remarkably well for about a week, when a new attack of the illness, a relapse, occurs. There are frequently from three to four relapses of this kind, which severely tax the strength of the patient.
The number and the intensity of these relapses determines the degree of the illness.
The treatment is regulated in accordance with the principles to be applied in abdominal typhus. The relapses may be averted or at any rate reduced to a great degree, by strict observance of the methods herein prescribed, especially in regard to diet.
Typhus abdominalis is a form of disease which requires the most careful dietetic treatment, since it combines high fever, which lasts for several weeks, with a severe ulcerous process in the small and large intestines.
Nutrition is seriously hampered by the long duration of the illness, usually considerable lack of appetite and the absolute necessity of nursing the ulcerous intestines in the most studiously careful way.
In cases which develop to the highest degree, it naturally follows that the patient wastes away to a great extent.
In the first place, all solid food must be strictly avoided. Too great stress cannot be laid on this point, since the patient, especially in lighter cases, frequently shows a strong desire for food—especially fruit.
Any lack of firmness and caution in this respect may have the most disastrous consequences. Many a patient suffering from typhus has lost his life or experienced a bad relapse and hemorrhages of the intestines through a mistake in diet,—through taking too much or unsuitable food.
The most critical period for the liability to hemorrhage, which in some cases is very profuse, is the third, and in lighter cases, the second week, when the crust of the intestinal ulcers begins to scale off.
The diet list, as in cases of typhus, consists of Form II, and milk; and it should be made a rule to confine it strictly to the most simple food, bouillon, mucilaginous soups, milk, undiluted or with tea, everything prepared with a little egg. Cream will sometimes agree with the patient.
The stools will indicate the digestion or otherwise of the milk. If there are many morsels of casein apparent in the same, the quantity of milk must be reduced and given in diluted form. The use of meat juice, liquid or frozen, and meat jelly, is quite permissible. Although neither of these preparations are very strong, they must be considered as important building-stones for the nourishment of the patient, and they offer a little variety, which is often most desirable.
Drinks. For drinking, usually fresh water is used, also bread and albumen water, especially Dechmann's Plasmogen, 15 grains in one pint of water, a mouthful from time to time alternating with Dechmann's Tonogen.
Great caution must be used in regard to fruit juices and lemonade on account of the danger of irritation of the intestines.
Carbonated and other mineral waters must be strictly avoided, since they only add to the usually prevailing meteorism, or gas in the abdominal cavity.
Albumen water, which is occasionally used in case of febrile disease and intestinal catarrh of children, is prepared by mixing the white of an egg and two to four spoonfuls of sugar in a tumbler of water. This is strained and cooled before being used. It is easily understood that by this we generate new life in the patient, so to speak, through the albumen, since it contains a large quantity of tissue building material, which in turn prevents catabolism or destruction of the organism, this as contrasted with the methods of the old regime which dooms the patient to certain death by opiates,—a course frequently resorted to by inexperienced practitioners.
If, by attention and care, the treatment has succeeded in strengthening the energy of the resisting organism to a certain degree during the fever, it becomes necessary in due course to regulate the desire for food, which sometimes grows and asserts itself in a rapid and energetic manner, while the fever is receding.
The cessation of fever by no means indicates that the ulcers are completely healed, and any mistake as to quantity and quality of food may cause a relapse. Liquid diet must, therefore, be given exclusively for at least, another eight days after the fever has ceased. After this, from week to week, gradually, the use of Form III, may be employed and thereafter more solid food, as given anon, under Form IV.
These cautions must be strictly heeded, especially in case of typhus recurrens.
If in the course of typhus severe complications, such as hemorrhage of the intestines or perforation thereof, should supervene, nourishment must immediately be reduced to a minimum. In such instances it is best to confine the diet to mucilaginous soup and to forbid everything else, as long as hemorrhages have not ceased, or the other dangerous peritonitic symptoms have not disappeared. Gradually, Form V and lastly, Form VI, may be followed.
Form IV. Diet of the lightest kind, containing meat, but only in scraped or shredded form. Noodle soup, rice soup.