A Treatise on Fever

by Southwood Smith

34th. Convalescent, but still very weak. Cerevis. lbj. Pt. alia.

45th. Has been gradually, though very slowly gaining strength; tongue now clean; appetite good; bowels regular (Low Diet); 2 ozs. meat daily.

52d. Dismissed cured.

II. Treatment during the Convalescence.

The management of the convalescence is one of the most difficult parts of the treatment and one of the most unsuccessful, not because there is any thing which requires to be done, nor because there is any disease which prevents recovery, but because the patient is considered as well when he is only convalescent. Of the great tendency there is to relapse during the whole of this period few medical men are sufficiently aware, and the unprofessional attendants on the sick are totally ignorant of it. For a long time the brain, the bronchi, and the intestines remain so irritable that the slightest excitement is capable of renewing the diseased action which has recently subsided; but without excitement of some kind, that renewal never takes place. It is the duty of the physician and the nurse to guard the patient from such excitement, which they may always do completely; so that whenever there is a relapse, the physician, or the nurse, or both must be in fault: as long as they perform their duty with judgment and firmness there is no such thing; but this part of their duty which is extremely simple, they cannot be induced to believe to be of importance: no one who has not seen death happen over and over again from the neglect of it will believe it, and even those upon whom melancholy experience has impressed the truth most strongly, constantly allow themselves to be surprised at the slightness of the excitement by which, and the advanced period of the convalescence at which relapse may happen. It is not easy for a nurse to resist incessant importunity and even reproach; and there are suspicions to which a physician is subjected, which, when he sees that they are entertained, it requires some moral courage to enable him to bear. Without doubt he deserves the worst that can attach to him if he allow the caprice, or the impatience, or the injustice of his patient, or any earthly consideration to induce him to swerve from the faithful discharge of the duty he has undertaken. The unreasonableness of the convalescent, should be considered and treated as the delirium of the preceding stage.

The mismanagement of the convalescence consists chiefly in allowing the patient to rise too early from bed, and to take solid food too soon and in too large a quantity; and these are by far the most frequent causes of relapse. Were I to place on record all the instances I have seen of fatal relapse from these two causes alone, the list would be frightful. Many patients, the very day they become convalescent, think they ought to be allowed to get up. They feel well, they think they are so; they earnestly declare that they are so. They are impatient of bed; they imagine it keeps them weak: “if you would but allow me to rise how thankful I should be; how much more it would refresh and strengthen me than any thing that can now be done.” Such is the language which is constantly addressed to the physician in the early period of convalescence, and if he be weak enough to yield to it and allow his patient to rise, it is a chance if he ever rise again. The most cautious and experienced physician sometimes finds himself deceived, falling into the same error with his patient, and thinking him stronger than he is. Whenever this happens, the physician has great reason for self-reproach, because he ought to allow no risk to be run. Often, however, in private practice, the physician is allowed to have no control whatever over the management of the convalescence—he is dismissed as soon as the patient is out of apparent and urgent danger; dismissed hastily, often to be more hastily recalled to witness the death of him whom every one thought to be well.

But if merely rising from bed at too early a period occasion the death of great numbers, eating heartily of solid food is a still more frequent and certain cause of it. The appetite is generally keen immediately after fever has subsided: if animal food be allowed as soon as the appetite craves for it relapse is sure to be produced. Often and often have I seen fatal cerebral and abdominal inflammation excited in a few hours after the commission of this error. I do not expect, by any language at my command, to communicate to others my own conviction of its danger. I know that such a conviction can be produced in no one who has not an opportunity of observing the convalescence of large numbers; and I know that no one who has such an opportunity can be without it.

There are three conditions under which this danger is peculiarly imminent. First, when the disease has been unusually severe and protracted. The more intense the fever and the longer it has lasted, the more are all the organs enfeebled, and the longer do they retain the irritability of weakness, In this state, anything beyond the gentlest stimulus will induce vascular excitement, which will rapidly pass into inflammation.

Secondly, when the disease was severe in the commencement, and has been promptly subdued by active treatment. Whenever copious bleeding brings on a precocious convalescence, that convalescence is invariably uncertain and infirm. It is always steady as long as it is properly protected, but it has not strength equal to its apparent health: it is as tender and fragile as it is sensitive: the least noxious agent impresses it; the least stimulus overpowers it. The patient is suddenly relieved from a load that oppressed him; the organs react with preternatural vigor; they have enough to do to sustain the reaction of the system: stimulate them still further by animal food and wine, and they will be sure to be over done; and this artificial excitement will be as fatal as the excitement of disease. It can be of little consequence to the patient whether he die of malaria or of chicken.

Thirdly, when the disease was slight in the commencement and through its subsequent progress, but the convalescence proved tardy and imperfect. In this case, animal food and wine are pernicious and highly dangerous, and often prove more fatal than a severe form of fever. Nothing is advantageous or safe for such a patient but perfect rest and quiet and the blandest farinaceous diet.