CHAPTER III.

ON THE MANAGEMENT OF CONVALESCENTS FROM FEVER and

DYSENTERY.

DURING the earlier periods of convalescence, the utmost attention should be paid to the diet and regimen of patients who have been labouring under either dysentery or fever. The food at first should be chiefly farinaceous, in small quantity, and repeated somewhat often. Care should be taken never to load the stomach; for, in the majority of cases, the mucous surface of this viscus, as well as that of the bowels, is in a very sensible and irritable condition, and liable to be thrown into a state of inflammation, inducing thereby a relapse, by whatever may excite it too strongly.

Many of the relapses which follow either febrile or dysenteric attacks depend as much upon errors in diet and regimen as upon the influence of the exhalations from the soil, and vicissitudes of temperature or of weather. After the patient has been for some time supported by farinaceous articles of diet, with the addition of a little wine, when the energies of the system require such support, the lighter and less heating kinds of meat diet may be given, at first in small quantity, and its effects carefully observed. If it heat the system or accelerate the pulse, its quantity must either be diminished, or it should be entirely omitted. The animal food which may be at first tried is that least likely to heat the system, and the readiest digested. The flesh of chickens, young fowls, and of young animals generally, is to be preferred; and soup only in small quantity indulged in, for reasons already alluded to when treating on the management of disorders of the digestive organs.

When the failing energies of the system absolutely require the supporting influence of vinous liquors, they may then be taken in small quantity; but if there exist any suspicion in the mind of the practitioner of organic disease still lurking about the system, they should never be ventured upon. They are beneficial chiefly when employed to excite the exhausted energies of the frame, when exhaustion as supervened as a consequence merely of over-excitement,

and when it is quite unaccompanied with congestion or lesion of any particular organ. If we find any acceleration of pulse or heat of skin follow either the food or wine indulged in, we should immediately resort to purgatives and a stricter antiphlogistic diet. Relapses both in fevers and in dysenteries are chiefly occasioned by a too liberal indulgence of the returning appetite, together with want of a sufficient attention to the state of the bowels, and to the use of purgatives or laxatives, as circumstances require. Undue exposure, also, either to the sun, or to the night-air and dews, or a too sudden return to the habits and regimen usually followed by the patient in health, frequently occasions relapses. But one of the frequent causes of such occurrences, especially when acting conjointly with those now enumerated, is the continued operation of the exciting causes of fever and dysentery, namely, exhalations from the soil, during the progress of recovery.

This cause should be especially guarded against, both during the continuance of disease and the commencement of recovery, and the patient, if possible, removed beyond its reach, to more salubrious situations. When the distance to a more healthy situation is short, patients should be taken thither immediately upon their being taken ill: if the place be too far for immediate removal, they should be taken to it as soon as their state admits of the change; for it is often surprising to see the great rapidity of recovery in a salubrious situation, compared with what is always observed in localities abounding with the sources of disease, or in which disease is endemic. During my practice in India I have had numerous instances of these facts brought to my notice. Thus, in Java, during the expedition to that place in 1811, when in charge of the chief hospital at Weltivreeden, I remarked the very great malignancy and mortality of fever and dysentery in the hospitals of Batavia, and the entrenched camp at Cornelis, and the long duration and difficulty of recovery: whilst deaths were much fewer, and convalescence much more rapid, in the more elevated and better ventilated hospital at Weltivreeden, which was but a short distance from these very pestilential situations. In them disease of every kind, owing to the continued operation of a most noxious atmosphere, was rendered more malignant; and all disorders, whether external or internal, were stamped with the same general character. In the higher and more healthy positions to which the sick were afterwards taken, disease ran its course, in various forms, according to the circumstances of individual cases, assumed a more manageable character, and was followed by a more rapid and perfect recovery. But in

other situations, as where the troops cannot be taken to a healthy situation, immediately upon being seized by disease, the period of convalescence must be waited for, when great advantage will generally be obtained by removing them to healthy localities until they are perfectly restored. The advantages which result from carrying men at first when taken ill, or as early as convalescence will admit, to salubrious situations, for the purpose of medical treatment, and removal from the powerful causes of disease to which the neglect of such a measure might expose them, are evident not only in the occurrence of a milder or less dangerous form of disease, and a more rapid convalescence, but also in the preventing of those local congestions and fatal obstructions of internal viscera from supervening, which ultimately either prove fatal, or oblige those affected by them to leave the country.

Having thus insisted upon the propriety of taking the sick at once to hospitals or other accommodations placed beyond the sphere of operation of those causes which occasioned the disease, and particularly without the influence of the endemic source of mischief; and, if this be not practicable, of removing them, when convalescent, to such situations, observing at the same time all due precaution, both during the removal and after it has been made,— I shall offer a few remarks upon the propriety of attending closely to the state of the functions of the digestive organs, to the diet, the regimen, and the dress, for a considerable time after convalescence from fevers and dysentery, and especially when the patient is returning from India to Europe.

Attention to the actions of the stomach is important; they may be promoted by gentle tonics; but the use of these medicines should also be combined with laxatives, as the employment of the former merely, during recovery from febrile diseases, is always productive of constipation; and the functions of the bowels, as well as those of the stomach generally, require assistance for some time after all other derangements are removed. In those cases, where any of the abdominal viscera have suffered considerably during the dysenteric or febrile disorder,—and these are very numerous,―the combined operation of gentle laxatives and deobstruents with tonics is extremely necessary. Where the colon, liver, or spleen, have experienced any organic lesion, which is frequently the case, and where there is reason to believe that enlargements, obstructions, or other similar derangements, still remain, the use of purgatives and laxatives, with gentle tonics, change of air, and other internal and external remedies, and measures which I have already noticed as

requisite in chronic diseases of the organs employed in the functions of digestion and assimilation, should be put in practice.

These means, with a strict attention to clothing, should be also resorted to when the patient finds it necessary to remove from India, or any other intertropical country, to Europe. During the voyage homewards, invalids generally find it a matter of great difficulty to keep the bowels sufficiently open; and many have their complaints aggravated by want of attention to the functions of these viscera. Accumulations not unfrequently thus form in the large bowels, and occasion irritation; and if the patient have been suffering from dysenteric disease, a return of his disorder is not an unusual consequence. In other cases, where the liver has been much affected either from previous disease, or during fevers or dysentery, an attack of hepatitis may be induced by the want of due attention to the state of the bowels, conjoined with the influence of a colder atmosphere than that to which the patient had been for some time accustomed.

Attention to warm clothing, when returning to a cold climate, has been already insisted upon, when the disorders of the liver and stomach were under consideration. But although requisite in these, it is still more so in derangements of the bowels, and especially when the patient is returning to Europe in order to restore his health, after attacks of dysentery or fever. He should never dispense with flannel next his skin, on any occasion, and should be particularly careful always to preserve his feet warm, and resort to such other additional clothing as his sensations and the varying state of the seasons in Europe require. When he has returned to England, he should be still more careful both to preserve an open state of his bowels, and to keep the surface of the body and extremities comfortably warm.

When the patient has it in his power to select the period of return to this country, some attention may be paid to it. If he arrive early in the spring, he is liable to feel the effects of a very variable season for some time. If he returns in winter, the sudden transition from a warm climate to a cold one may be detrimental to the system, especially after it has become assimilated, by a long residence, to a warm country. In my opinion, the best time of arriving in England is in the months of June, July, August, and September. the invalid find the cold too severe during the winter months in some of the more easterly counties or in the metropolis, he may try the climate of Bath, and make use of the waters, which may be of service to him.

If

He should, at all times, be attentive to the first symptoms of disorder, especially of his bowels, and immediately resort to medical aid. He should also never neglect the slightest cold; for persons who have resided for any considerable time in a warm climate, are liable to pulmonary affections, and inflammatory attacks implicating both the liver and lungs, upon their arrival in Europe. Those who have suffered much from ague should also be cautious of exposing themselves to its causes when they arrive in this country; for a liability to attacks of this form of fever often continues through the greatest part of life, especially if the patient be subjected to their exciting causes in a state of predisposition to their invasion. In other respects, the invalid who is returning to Europe after attacks of dysentery or fever, should adhere to the injunctions insisted upon in the former part of this work, and there urged in respect of change of climate after diseases of the stomach and liver.