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TYPHOID FEVER





Category: Infectious Diseases

Typhoid fever is an acute infectious disease caused by a
(Bacillus) germ, named after the discoverer (Eberth). This germ enters
into the system, as stated below, locates itself in different organs,
especially in the small intestine. It does its worst work in Peyer's
glands, situated in the small intestines. They enlarge, ulcerate, break
down and their structure is cast off into the bowel. This eating goes so
far, in some cases, that it eats through the tissue to the blood vessels
and other bleeding follows. Sometimes it goes through all the coats, the
peritoneal being the last one. If this occurs we have what is called
perforation of the bowel and the peritoneum around this perforation
inflames and there is the dread complication of peritonitis. This is very
fatal, as the patient is weakened from the inroads of weeks of fever and
from the effects of the poison germ. Typhoid fever is also characterized
by its slow (insidious), slyly, creeping onset, peculiar temperature,
bloating of the abdomen, diarrhea, swelling of the spleen, rose-colored
spots and a liability to complications, such as bleeding from the bowels,
peritonitis, bronchitis and pneumonia. Its average duration is three to
four weeks, often longer. In order to take this disease there must first
be the poison germ and then this enters into the system, generally through
water that contains the germ, milk, oysters and other foods, etc.

Cause. The typhoid bacillus (typhoid). This enters into the alimentary
canal usually through contaminated water or with milk directly infected by
the milk or by water used in washing cans. Also through food to which the
germs are carried from the excreta (discharges) by flies, occasionally
through oysters by freshening.

Filth, improper drainage and poor ventilation favor the preservation of
the bacillus germ and lower the power of resistance in those exposed.



Time. It occurs most frequently between August and November and in those
of from fifteen to twenty years of age. The Peyer's patches and solitary
glands of the bowel enlarge, become reddish and are somewhat raised. These
go on and ulcerate until the blood vessels may be eaten into and bleeding
sometimes results, it eats through the bowel, then there is perforation
and peritonitis. The spleen is enlarged, the liver shows changes, the
kidney functions are also deranged.

Symptoms. The symptoms are variable. The following gives the symptoms in
a typical case:

Incubation. The period of incubation lasts from eight to fourteen and
sometimes to twenty-three days. During the period the patient feels weak,
is almost unable to work, has chilly feelings, headache and tiring dreams,
does not know what is the matter with him, constipation or diarrhea, has
no appetite, may have some pain in the abdomen which is occasionally
localized in the right lower side. Soreness on deep pressure is often
found there. In some cases there is nosebleed.

First Week. After the patient is obliged to take to his bed: During the
first week there is in some cases a steady rise in the fever each evening
showing a degree or degree and one-half higher than the preceding evening,
reaching 103 to 104, and each morning showing higher fever than the
preceding morning. The pulse is characteristically low in proportion to
the temperature, being about 100 to 110, full of low tension, often having
double beat. The tongue is coated; there is constipation or diarrhea; the
abdomen is somewhat distended and a little tender to the touch in the
lower right portion. There may be some mental confusion at night.
Bronchitis is often present. The spleen becomes enlarged between the
seventh and tenth day and the eruption usually appears during this period
on the stomach and abdomen.

Second week. All the symptoms are intensified in the second week, the
fever is always high and the weakening type; the pulse is more frequent;
the headache is replaced by dullness; the bowel symptoms increase and we
have the "pea soup" discharge if there is diarrhea; there is a listless,
dull expression on the face; the tongue is coated in the center, red along
the edges and the tip, becomes dry and sometimes cracked and almost
useless. It is hard to put it out of the mouth, it sticks to the teeth or
lips and curls there, and sometimes the patient allows it to remain partly
out of the mouth. There may be bleeding from the bowels and perforation of
the bowel, producing peritonitis.



Third week. The temperature is lower in the morning with a gradual fall;
the emaciation and weakness are marked. Perforation of the bowel or
bleeding may occur. Unfavorable symptoms now include low muttering,
delirium, shakings of the muscles, twitching of the tendons, grasping at
imaginary things, lung complications and heart weakness.

Fourth week. In a favorable case: The fever gradually falls to normal,
the other symptoms disappear. Death may occur at any time after the second
week from the disease or complications. The convalescence is very gradual
and the appetite is very great.

Special symptoms and variations. It may come on with a chill sometimes it
is observed by nervous symptoms only.

Walking type. In this type the patient is able to be around and can walk.
The temperature is as high, but some of the other symptoms are not so
violent. This is a dangerous kind because the patient is able to walk and
thinks it foolish to remain quiet in bed. Walking and being around are
likely to injure the bowels, and there is then more danger of bleeding
from the bowels. A typhoid fever patient should always go to bed and
remain there until he has fully recovered.

Digestive Symptoms. The tongue is coated, white and moist at first, and
in the second week it becomes red at the tip, and at the edges. Later it
is dry, brown and cracked. The teeth and lips are covered with a brown
material, called sordes.

Diarrhea. In some cases constipation is prominent, in others diarrhea is
a prominent symptom. Bloating is frequent, and an unfavorable symptom,
when it is excessive. Bleeding from the bowel occurs usually between the
end of the second and the beginning of the fourth week. A sudden feeling
of collapse, and rapid fall of the temperature mark it. It is not always
fatal.

Perforation of the bowel is usually shown by a sudden sharp pain coming in
paroxysms generally localized in the right lower side. The death rate
varies very much; in hospitals it is seven to eight per cent. Unfavorable
symptoms are continued high fever, delirium and hemorrhage. Persons who
are hard drinkers do badly and very many of them die.

TREATMENT. Prevention. Sanitary Care. Do away with the causes. Keep your
cellars clean; do not have them damp, filthy, and filled with decaying
matter, as these all tend to weaken the system and make you more
susceptible to the poison. In the country, no drainings should come near
the wells or springs. Not all water that looks clear and nice is pure. The
"out-houses" must be kept clean, and emptied at least twice each year. In
the small cities, especially, the water should be boiled during the months
when the supply is limited and the wells are low. If more attention was
paid to our water supply to make certain that it was not contaminated, and
to our foods, especially milk, and to keeping our cellars and drains in a
good clean and dry condition, we would have little typhoid fever.
Carelessness is the real cause of this terrible disease. The milk should
be boiled as well as the water when there is an epidemic of typhoid.



Sanitary Care of the Household Articles. Dishes must be isolated, washed,
dried separately and boiled daily. Thermometers must be isolated, kept in
a corrosive sublimate solution one to one thousand, which must be removed
daily. Linen when soiled must be soaked in carbolic acid, one cup of
carbolic acid to twenty of water, for two hours before being sent to the
laundry. Stools must be thoroughly mixed with an equal amount of milk of
lime and allowed to stand for one hour. Urine must be mixed with an equal
amount of carbolic acid, one to twenty, and allowed to stand one hour. Bed
pans, urinals, must be isolated and scalded after each time of using.
Syringes and rectal tubes must be isolated, and the latter boiled after
using. (See Nursing Department). Tubs should be scrubbed daily, canvasses
changed daily and soaked in carbolic acid as the linen is. Hands must be
scrubbed and disinfected after giving tubs or rubbing over typhoid fever
patients. Blankets, mattresses, and pillows must be sterilized after use
in steam sterilizer. I know some people have not all the necessary
conveniences, especially in the country, but the greatest care must be
taken. A professional nurse was once taking care of a very severe case of
typhoid for me. I was continually cautioning her to be more careful of
herself. She did not heed it, and finally took the disease and battled
eight long weeks with it, before there was much improvement. Careful
nursing and a well regulated diet are the essentials in a majority of
cases. Put the patient in a well ventilated room, and confine him to the
bed from the beginning, and have him remain there until well. The woven
wire bed with soft hair mattress, upon which there are two folds of
blanket, combines the two great qualities of a sick bed, smoothness and
elasticity. A rubber cloth should be placed under the sheet. An
intelligent nurse should be in charge; when this is impossible, the
attending physician should write out special instructions, regarding diet,
treatment of the discharges and of the bed linen.

Much of the above on typhoid is from the world-wide authority, Dr. Osler,
and should be-followed in all cases if possible.

Diet and Nursing in Typhoid Fever. Milk is the most suitable food. Three
pints every twenty-four hours may be given when used alone, diluted with
water or lime-water.

The stools will show if the milk is digested. Peptonized milk, if not
distasteful, may be used. Curds are seen in the stools if too much milk is
given and is undigested. Mutton or chicken broth or beef juice can be
used; fresh vegetable juices can be added to these, instead of milk. The
animal broths are not so good when diarrhea is present. Some patients will
take whey, buttermilk, kumiss, when ordinary milk is distasteful. Thin
barley gruel well strained is an excellent food for this disease. Eggs may
be given, either beaten up in milk or better still, in the form of albumin
water, This is prepared by straining the whites of eggs through a cloth
and mixing them with an equal quantity of water, which may be flavored
with lemon. Water can be given freely; iced tea, barley water, or lemonade
may be used, and there is no objection to weak coffee or cocoa in moderate
quantities. Feed the patient at stated intervals. In mild cases it is well
not to arouse the patient at night. When there is stupor, the patient
should be aroused for food at the regular intervals night and day. Do not
give too much food. I once had a case in which I did not give more than
one quart of liquid food in four weeks, as it distressed her. She made a
good recovery on plenty of water.



Cold Sponging. The water may be warm, cool, or ice cold, according to the
height of the fever. A thorough sponge bath should take from fifteen to
twenty minutes. The ice cold sponging is quite as formidable as the full
cold bath, for which there is an unsuperable objection in private
practice.

The Bath. This should be given under the doctor's directions, and I will
not describe it.

Medical Treatment. Little medicine is used in hospital practice. Nursing
is the important essential in typhoid fever.

Management of the Convalescent. An authority writes, My custom has been
not to allow solid food until the temperature has been normal for ten
days. This is, I think, a safe rule, leaning perhaps to the side of
extreme caution; but after all with eggs, milk toast, milk puddings, and
jellies, the patient can take a fairly varied diet. You cannot wait too
long before you give solid foods, particularly meats, They are especially
dangerous. The patient may be allowed to sit up for a short time about the
end of the first week of convalescence, and the period may be prolonged
with a gradual return of strength. He should move about slowly, and when
the weather is favorable should be in the open air as much as possible.
Keep from all excitement. Constipation now should be treated with an
enema. A noticeable diarrhea should restrict the diet to milk and the
patient be confined to the bed. There are many who cannot have a
professional nurse. Good nursing is necessary in typhoid fever. Any
sensible person who is willing to follow directions can do well. But she
must do as the doctor directs.

These are some things you need to do: Look out for bad symptoms; twitching
of the tendons, grasping at imaginary things are bad symptoms. Inform the
doctor and soon. Never allow the patient to sit up in bed. The stool must
be passed lying flat and you must place the bed pan without the patient's
aid. Bleeding may be started by the least exertion. I knew of one woman
who lost her life through necessity of getting up and passing the stool
sitting on a chamber. Bleeding came on suddenly, and before the doctor
could get there she was nearly gone. Cough and sudden pain in the lungs
need prompt attention. I dismissed a boy on one Wednesday as convalescent.
That night it became suddenly cold and he became chilled. The mother sent
for me the next day, and we pulled him through pneumonia. Suppose she had
waited another day? She was not that kind of a mother. Your greatest trial
will come in convalescence, when the patient is so hungry. Be careful or
you will kill the patient by kindness. A minister I knew killed himself by
going against the doctor's orders and eating a hearty dinner. The doctor
was rather profane, and when he went to see the preacher, after the
relapse caused by the dinner, he relieved his mind in no gentle manner.
Again allow no visitors in the sick room or one adjacent. They are an
abomination. Many people are killed by well-intentioned ignoramuses. Do
not whisper; the Lord save the patient who has a whisperer for a nurse. I
cannot urge too strongly proper nursing in this disease. It is an absolute
necessity. A nurse to be successful must have good sense and also must
obey all directions. A diet is a necessity in this disease. The patient
must not move any more than is absolutely necessary for his comfort. He
must never try to help move himself. The muscles of the abdomen must
remain lax and quiet. The danger, I think, is in the bowels. The mucous
covering in the interior is inflamed and ulcerated, and there is always
some danger of the ulceration eating through the coating into the blood
vessels, causing more or less bleeding and even eating the bowel enough to
cause an opening (perforation) and the escape of the bowel contents into
the abdominal cavity causing inflammation of the peritoneum (peritonitis)
and almost certain death. Walking typhoid is dangerous for that reason.
The food must be of such nature that it is all digested. It must not leave
lumps to press upon the sore places in the bowels causing more trouble
there and more diarrhea.





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