_(A) General Description._
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.
_B. Essentials._
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.
_(C) Symptoms and Course._
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.
_D. Treatment._
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:
_E. Relapsing Fever (Typhus Recurrens)._
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.
_F. Diet in Cases of Typhus._
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.
Mashed boiled brains or sweetbread, or puree of white or red
roasted meat, in soup.
Brains and sweetbread boiled.