TYPHOID FEVER (TYPHUS ADBOMINALIS, ILEOTYPHUS)

TYPHOID FEVER (TYPHUS ADBOMINALIS, ILEOTYPHUS)- QR

INFECTIOUS DISEASES : - etiology, pathogenesis, symptoms and course of, recognition, prediction and prevention

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What is the TYPHOID FEVER (TYPHUS ADBOMINALIS, ILEOTYPHUS) and how it is treated?

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Etiology and pathogenesis TYPHOID FEVER (TYPHUS ADBOMINALIS, ILEOTYPHUS)

Etiology. Pathogen - bruchnotifozna wand Ebert.

Epidemiology. Man is the only source of infection (the virus reservoir). Sick with typhoid fever begins abundantly to isolate the pathogen from the excrement from the end of the first or beginning of the second week of illness. On the 3rd week joins baculoviridae with urine. Fecal baculoviridae lasts longer: in the convalescence period, sometimes up to 3 months (temporary), and in more rare cases, for many years (continuous). Germ-carriers may and in people who have had light and not promptly recognized disease. In contrast to these active baillonella continuously produce a large number of pathogens, passive ballooneval (not ill with typhoid fever) are short and not abundant bellovedere.

Epidemiological risk patients depends on the length of their isolation and conducting current disinfection. The danger of baillonella largely depends on their professional sign (food industry), the level of sanitary improvement, living conditions, individual culture. The greatest risk of infection is exposed to the inner circle of bazillionaires in everyday life. Negligibly small amounts of stool, which is easily contaminated hands, or patient bazillionaires when urinating, mechanically transferred hands on various items and food products.

Distribution of fecal infection at a considerable distance contribute flies, which is a major factor in the spread of typhoid fever during periods of seasonal increases in morbidity. Water factor may play a greater role in the emergence of epidemic outbreaks. Water pollution by faecal masses can be lengthy, systematic (descent sewage, contamination of surrounding soil, close location primitive latrine) or accidental, temporary (breakthrough sewage, runoff in ponds of melt water with faecal contamination of snow). Water factor may have an indirect impact on the incidence of typhoid fever due to insufficient water supply. When infection products microbe gets often very favorable living conditions, ensuring its reproduction (meat, dairy and some vegetables). Of special importance in dairy products. Contamination of milk can cause large epidemics of different the same rapid rise in the incidence, as with water epidemics. The food contamination occurs or through baillonella participating in any phase of cooking, storage and sale of finished products, or through the flies that land on food and infecting them, or mechanical, or by regurgitation and defecation. Of great importance outbreaks associated with movement of the masses, For the disease is not enough of infection; it is necessary, in addition to the infection penetrated in sufficient quantities in the susceptible organism; however, the level of susceptibility even for every individual is not constant and depends on a number of factors (fatigue, overheating, poor sanitary conditions, and other diseases, alcoholism, and so on). Under unfavorable sanitary conditions of gradually increasing concentrations of baillonella due to the disease leads to the formation in some places endemic foci.

The pathogenesis. Depending on the method of infection in the human body penetrates not equivalent in quantitative and qualitative terms the infection. Water infection: the number of microbes is relatively small; quality - microbes significantly deviated from the main pathogenic type; the time required for animalization and reproduction of microbes, large, i.e., incubation greatest time; slow onset. Food infection: the number of germs is very large, the quality is almost not changed - incubation of short, rapid start. Contact infection occupies a middle position and gives small variations in incubation in the other direction, depending on the direct or indirect contamination and storage conditions bruchnotifosny sticks out of the human body. On average, the incubation can be expressed by formula 15"+-"6, i.e. from 9 to 21 days. When food infections it is shortened to 2 to 3 days, when water may take up to 26 - 28 days. Bruchnotifozna wand has clearly expressed lymphotropism. Multiplying in the gut, she immediately fixed in lymph apparatus of the intestinal wall. Favorable conditions for initial breeding she finds only in the lower part of the small intestine (the stagnation of food mass and the decrease in the intensity of digestion compared with the upper intestine), why later and pathological changes are mainly concentrated in this Department. In the early stages of incubation solitary follicles and Peyer's plaques sencibilisiruet decay products bruchnotifosny sticks. The further path of the germ - lymphatic vessels of the mesentery and mesenteric lymph nodes, where the mass reproduction of sticks Ebert in the incubation period (the primary source of infection). From this center the accumulation of microbes in the lymph paths through the ductus thoracicus begin to enter the bloodstream (the beginning of the prodromov). When the number of penetrating the blood of microbes reaches a certain threshold, it starts total temperature, gradually increasing the reaction. Bacteremia characteristic of the first period of typhoid fever, is the basis of generalization of infection with the electoral defeat of the lymphatic system, the reaction of the reticulo-endothelial system (swelling of the liver and spleen), the formation of powerful secondary breeding of microbes (liver) and early General intoxication. In biliary passages and liver in the gallbladder sticks Ebert are elective nutrient medium and skopljajutsja in large quantities. From here they can enter the intestinal tract with bile and again to go back into the bloodstream. Since that time, begin a parallel flow of two main processes:

1) specific changes in the intestinal wall,

2) the overall toxicity of the breakdown products bruchnotifosny sticks - endotoxin.

Pathological changes in the intestine. Mass penetration of microbes in the intestine occurs at the beginning of the 2nd week and coincides with the beginning of heavy bucillamine. Stage moshaweng swelling at this time is replaced allergic necrotic reaction. Necrotic sores gradually rejected (the beginning of the 3rd week), the bottom of the ulcer begins to be cleaned from the remnants of necrotic masses (3rd week), and sores begin to roblematic (4th week). Mesenteric lymph nodes increase very early, reach the value of the forest and even walnut, and they are sometimes formed foci of necrosis (judging by the sectional materials). With the defeat of the intestine is closely related two severe complications gastrointestinal bleeding and perforation. Recorded in various organs bruchnotifozna coli causes a number of focal reactions on the part of these bodies. In the initial period of this cellular response. In rare cases, from the first days of the disease is obtained by pronounced but relatively short overall reaction to released in the decay of microbial endotoxin, and 8 - 9-th day (at the time of formation of antibodies) disease breaks - abortive form. Usually phagocytosis is weak, the response of the lymphatic system leads to the stagnation of lymph, to abahlali bronchial mucosa is typical bronchitis, thickening of the tongue, broncho - and polyadenium.

The intoxication. The largest value in the pathogenesis of typhoid fever has the effect of endotoxin on the nervous system, heart muscle and parenchymatous organs. The defeat of the cerebral cortex manifests itself in impaired consciousness and Bregovo condition; the presence of these signs are observed in about 80 - 85% of patients. The most serious morphological changes detected in the layer of small and medium-sized pyramidal cells of the cerebral cortex, in the nerve cells of the striatum and brain stem (red nucleus, reticular substance and the nucleus of the glossopharyngeal and the vagus nerve). On the severity of the nerve cells of the autonomic nodes in the first place is occupied by the nerve cells of the nodes, ileum, second - nervous knots of the heart, the third solar plexus and fourth - sympathetic trunk. Circulatory disorders associated with direct effects of endotoxin on the heart muscle and impaired innervation of the heart and abdominal vessels (the flow of blood in the abdominal cavity). Bacteremia usually terminated earlier than intoxication, but the heavier the course of typhoid fever, the longer and harder bacteremia. Elimination of infection in the tissues occurs by phagocytosis with strong participation of the lymphatic system. Indicator is the transition temperature reaction type continua to remitting amphibolic, close to the so-called "glandular fever". Complete sterilization of the body does not always work. Accumulated in the gall bladder germs can survive for a long time after recovery and stand out together with bile into the intestine, i.e., to determine long-term presence of bacilli.

Symptoms and course TYPHOID FEVER (TYPHUS ADBOMINALIS, ILEOTYPHUS)

Symptoms appear with great continuity. During the prodromal period, General malaise, decrease of appetite, weakness, sluggishness, fatigue. With the onset temperature gradually increases, except massive foodborne infection. High numbers the temperature reaches to a 5 - to 7-th day. Headache from the first days of the disease. The white furred tongue, wet, thickened, with imprints of teeth on the sides. To shed a little blood and abahlali tonsils. Pulmones phenomena bronchitis. Abdomen slightly swollen.The liver and spleen are increasing by 3 - 4-th day of the disease. In the right iliac region palpation long rumbling and weak pain. With the 8 - 9th day on the skin of the abdomen appear roseola; skin, especially on the abdomen, acquires a special color - ivory; the hands icteric coloration. Status typhosus develops gradually. The pulse is relatively slow, dacrotized. Naturalnie phenomena from the side of the upper respiratory tract usually absent; bronchitis, on the contrary, very often. The disease is often accompanied by constipation. When diarrhea stools specific pea color.

The course is divided into three periods:

1) a period of growth phenomena (status incrementi) - 1st week

2) the heyday of diseases (status acme) - 2nd and 3rd week,

3) the period of gradual temperature reduction (status decrementi) - 4th week.

The growth temperature for the first 5 to 6 days followed a long febris continua, which in reality consists of cyclic thermal waves 4 to 6-day duration, separated by a small remissions. These waves are clearer when the 4-hour thermometry. Daily and cyclic temperature variations associated with the receipt of the decay products of the pathogen in the blood. From the middle of the 3rd week begin significant morning remission high standing as the evening temperature (amphibolic stage). The morning temperature is normal, the evening also gradually reduced; the magnitude of the curve decreases, and the temperature is normal. The sudden drop in temperature to normal and subnormal numbers by increased heart rate, drop in blood pressure and the clarification of consciousness of the patient are indicators starting intestinal bleeding. The Central nervous system is affected due to the impact of the toxin and circulatory disorders (congestive hyperemia). From the middle of the 2nd week begins with a night of delirium and insomnia at night with daytime sleepiness; then the patient is delirious and day. Suddenly brad can take violent forms with attempts to escape, jumping out of the window, etc., Sometimes in the initial period of the disease Bacillus of typhoid crosses the blood-brain barrier and picture turns meningitis (meningotyphus)that disappears in a few days. In severe forms of typhoid patient falls into unconsciousness, appear fibrillar twitching fingers and facial muscles. Status typhosus considerably complicates treatment and care and is a source of accidents in poor care and lack of supervision. In many cases of typhoid fever flows and without delirium (children, asthenics, most women).

Circulatory disorders associated with degenerative changes in the heart muscle, reaching in severe cases, the degree centrestage rebirth. Cardiac asthenia begins with the weaker of the right ventricle, which leads to stagnation in a small circle and in the liver. With the weakening and expansion of the heart comes a decrease in blood pressure and congestion in the Central nervous system and internal organs. Vascular tone decreases, resulting in a characteristic for typhoid dicrotism. The lag pulse rate of temperature level is associated with reflex irritation of nerve endings in the intestinal ulcers (no children). Long pulse frequency in General condition worsens the prognosis. From blood vessels relatively frequent thrombophlebitis and endarteritis. The blood in the first few days and if there are complications may be leukocytosis, but with a 5 - to 6-th day of the disease is usually leukopenia with neutropenia, limfotsitoz, aneo - sinophilia. Appetite is lost. Thirst strengthened. In severe cases, the salivation is reduced, and due to mouth breathing dries out the tongue and the oral mucosa. With poor care possible somatogenic mumps. The secretion of gastric juice is oppressed to the point of complete ahilii and only at the end of 3 weeks followed by hypersecretion. When the formation of ulcers on bauhinias the valve and in the colon appear persistent diarrhea, worsening the prognosis, as in this form (withlotyphus) is particularly frequent intestinal bleeding and perforation. Enhancing fermentative and putrefactive processes in the intestine leads to flatulence.

Bronchitis can be observed in almost all cases.

Pneumonia often develops due to stagnation in a small circle (hypostatic pneumonia); localization her zadanija departments, especially in the right lung (pressure liver). Shallow breathing contributes to the development of small-focus aspirazione-telematicheskoy pneumonia, the occurrence of which is facilitated by the presence of diffuse bronchitis. When necrotic decays bronchial and peribronchial lymph nodes can be formed interlobar empyema reassess in the lungs. With increasing heart weakness, razvivaetsy pulmonary edema.

Rare lesions include laryngitis with the formation of ulcers in nicecarolina space. The amount of urine usually reduced, appear albuminuria and cylindruria. The high proportion with a large amount of urine (1 ml) and only traces of protein give a good prognosis. Low specific weight by reducing the amount of urine and significant albuminuria is a bad forecast. In the midst of illness is zadergka urine in the bladder. In the renal pelvis may be formed a strong focus bruchnotifozhnykh sticks that support their secretion of urine. It is usually short-term - within 3 weeks, but in some cases it is very long. In some cases, observed the development of pelita. Skin of typhoid fever severely affected due to the reduced inflow of nutrients from the blood and trophic disorders. On the skin, in addition to reseal, there may be erythema (food infection), and with abundant sweats - prickly heat. Appearing at the end of typhoid small peeling is an indicator of malnutrition of the skin. Due to pressure on the skin covering bony prominences, are easily formed decubitus weeks). By reducing the resistance of the connective tissue can form abscesses in places subcutaneous injection.

Special forms:

Wavy typhoid fever occur new for temperature rise: or following its fall comes recrudescence (exacerbation), or after an 8 - to 14-day period of normal temperature - relapse. When multiple relapses or recrudescence disease may last several months. At relapse all the symptoms appear quickly and the temperature rise is steeper than the primary disease. For relapse is usually shorter but the severity and complications are often heavier than the first wave. Relapses occur due to insufficient production of humoral immunity and revenues in the blood of new portions of microbes. Severe relapse is observed for the sensitization of the organism at the time of the underlying disease. To predict relapse is possible on the basis of the following characteristics:

a) rapid pulse after the fall of the temperature,

b) the duration of the enlarged spleen,

in the absence of increase of the weight of the patient,

g) oliguria with high specific gravity of urine.

Outpatient typhoid fever differs from the above abortifacient forms (see Pathogenesis) and in its mechanism and clinical course; both forms are immunoreactive. When abortive form quickly mobilized General and local immunity and disease breaks after 7 - 8 days rapid temperature and the total reaction (roseola, enlarged spleen). Outpatient form humoral immunity has since the beginning of the disease, but cellular immunity of the intestinal wall is missing; therefore, the overall clinical phenomena are expressed very weakly (low grade fever, dizziness, enlarged liver and spleen, roseola), but ulcerative process in the intestine is quite developed; frequent intestinal bleeding and perforation, and when external influences, bringing the body of unstable equilibrium, any outbreak typical of the disease and relapse. The reaction Vidal positive in the early days.

Children typhoid fever is much shorter and easier than adults. The contrast mechanism: combat bruchnotifosny wand is deployed in mesenteric glands by phagocytosis (the power of children's reticulo-endothelial system). Receipt of microbes in the blood is negligible, the intoxication is weak, ulcerative process in the intestine is absent or very limited. Clinically: temperature remitting nature, the mind clear, slow pulse is absent, weak spleen enlarged and palpable later; late appearance or absence of rosea. Disease duration is shortened to 10 to 14 days. The reaction Vidal delayed. Due to the weak development of the immune tel frequent relapses.

Typhoid immunized flows by type of abortifacient (see above), and, due to the reaction of the lymphatic system the respiratory organs, often accompanied by bronchitis and hoarseness that allows you to mix it with the flu (influenza-like shape).

Typhoid elderly differs severity and high realnosti. Very frequent complications are pneumonia, thrombophlebitis and endarteritis with gangrene. The protracted nature of the flow, frequent relapse, recovery is slow.

Bruchnotifosny sepsis. Relatively rare reactiona form, flowing at a constant circulation of microbes in the blood with no local reactions in the gut. The condition of patients heavy, rash abundant, often hemorrhagic, as in typhus; the spleen is enlarged, soft, section flabby, with a severe hyperplasia of the pulp. In the intestine or absence of specific typhoid changes, or small swollen plaques (later manifestation of the reaction). For a very heavy; very high mortality.

Complications of typhoid fever are often more dangerous than the underlying disease with severe intoxication. The vast majority of deaths depends on the complications. Gastrointestinal bleeding occurs in the heyday of diseases (3rd week) and less recurrence. Blood in the stool (tarry stool or coffee grounds when bleeding in the small intestine and unchanged blood when colotyphus) appears after 3 to 12 hours after the onset of bleeding. Early symptoms are identical to the signs of collapse: a sharp drop in temperature, the clarification of consciousness (change congestive hyperemia of the brain anemia), weak pulse, falling blood pressure, the dullness of percussion sound in the ileocecal region. Need urgent therapeutic intervention, because the patient's life in danger.

Intestinal perforation occurs in the presence of deep ulcers on 3rd and even 4th week. Possible mechanical causes of perforation (nutritional errors, nestorone palpation, riot in delirium), but more often the perforation is due to the depth of the necrotic lesions of the intestinal wall. Symptoms sovpadats early signs of intussusception - a sharp pain and stomach (symptom dagger), flattening of the abdominal wall (navicular belly) with a sharp defense right; the reduction, and then the disappearance of hepatic dullness; the drop in temperature and blood pressure and clearing the mind. If perforation is slow or blocked gland, you can heal yourself with the development of peritoneal adhesions. In the vast majority need surgical intervention within the first few hours.

Thrombophlebitis often develops in v. femoralis at the exit of the femoral canal, at least - in the fifth. saphena magna or v. poplitea - on the 4th week. Initially, there is pain under papatowai ligament and palpation of enlarged lymph nodes near the external opening of the canalis femoralis (periferic), then densified wall of the vein in the form of painful strand. Limb moderately swollen, public figure on it increases. Predisposing moments: early rising from bed, long walks soon after rising. In some cases, a blood clot develops so quickly and with so little spivaetsya with the wall of the vessel, without any complaint from the patient and insignificant movements (putting the vessel) in sudden death from embolism.

Disease is a rare complication peculiar to old age. Complaints on strong solasia pain (ischemic neuritis), cooling of the diseased limb, the weakening and disappearance of the pulse on a. tibialis posterior and a. dorsalis pedis: at the end of the thumb appears purplish-bluish spot, increasing in the Central direction.

Mumps can be somatogenic and hematogenous origin. The first is a consequence of poor care for the oral cavity of the patient; inflammation begins with the parenchyma of the gland. In the second case begins peripatetic - inflamed lymph nodes around the gl. parotis. The most frequent outcome in suppuration.

There is often cholecystitis - at the end of illness or convalescence period. Starts with pain in the right upper quadrant, radiating under the right scapula and the sternum area. Temperature increases up to 39 - 39,5 ° , appears interesest sclera, probed the speaker of beef liver is enlarged, tense gallbladder spherical shape.

Recognition TYPHOID FEVER (TYPHUS ADBOMINALIS, ILEOTYPHUS)

To differentsirovat have the following diseases: from miliary tuberculosis (see), tuberculous meningitis, especially in children (see), of typhoid (see), recurrent typhus (see), malaria in tropical or mixed form with febris continua and depression of consciousness (see), Central pneumonia (see), sepsis (see) and influenza (see). Epidemiological considerations require isolation of the patient in the first week of the disease, i.e. before the appearance of reseal and reactions Vidal. Clinical diagnosis based on symptom: a steady increase in temperature and all of the pain, a headache, a common language, enlarged liver and spleen, rumbling. Addition to clinical symptoms are laboratory symptoms: vasoreactive, leukopenia with neutropenia, limfotsitoz and aneosinophilia. Especially important for early diagnosis blood cultures (hemoculture) and the reaction Vidal. C 8 - a 9-th day of the disease on the skin of the abdomen appear roseola. Serum from the same time agglutinated bruchnotifosny wand.

Prevention TYPHOID FEVER (TYPHUS ADBOMINALIS, ILEOTYPHUS)

1. The attending physician must recognize typhoid fever during the first days of the disease, to register the disease and isolate the patient in a hospital, or (with permission of the epidemiologist) at home.

2. Came into contact with the patient in the food industry karantininis to check on the carrier.

3. After hospitalization, the patient all clothing and bed linen soaked in 1% solution of soda and boiled before washing; pot, vessel, latrine toilet seat processed 5 - 10% solution of bleach; ware patient, knives, forks, spoons boil.

4. About each registered patient is sent an alert at his place of work or teaching. The occupants of the apartments and the superintendent also will be notified about the disease. Among the population is health education.

5. Clarifying the source of the disease is made by filling a standard card epidobstanovke with accurate responses on all items. In the hospital and at home should strictly carry out the current disinfection of faeces patient double the amount of 20% solution of bleach, 5% Lysol or 3% chloramine. Extract recovered is not earlier than the 12th day of normal temperature (not to forget about the possibility of relapse) after two studies of stool or duodenal contents in the presence of bacilli.

The fight against typhoid fever is mainly in the following areas:

1. The earliest possible and the complete isolation of patients with overt and atypical forms. Mandatory current disinfection of faeces and urine (see relax.). Thorough hand washing and disinfection of 0.2% chlorine solution.

2. Accounting reservoir of the virus (baillonella) is carried out by routine inspections of food on the carriage (all incoming and periodically - all enterprises) and re-examination had been ill with typhoid fever after 3 months after discharge (more efficient way).

3. Suppression pathways of infection:

a) protection of soil and water device latrines, decontamination and sewage disposal, sewage;

b) supply and water quality is good (protection of water sources, control of sampling locations, filters, chlorination, boiling, strict supervision of technical water supply);

C) fighting flies - the destruction of the larvae of the PA in breeding sites (10% bleach at least 1 time per week), saatciane boxes of food items, hospitals, dormitories, schools, kindergartens and so on;

g) destruction winged flies (toxic and sticky paper, 1% formalin solution, flycatchers). To protect from flies of both patients and their faeces, urine and dirty linen should be paid special attention. Food should be stored under the nets in glass display cases, cabinets. In the hospital wards nothing should attract flies; especially it is necessary to monitor the sealing of food waste;

d) control of fecal contamination of supplying enough water collective laundries, promotion of clean hands and simplest methods of disinfection (0.2% chlorine solution);

(e) sanitary and public oversight of food facilities (slaughterhouses, meat processing plants, drain dairy items, commercial kitchen, food establishments, retail outlets, kiosks with soft drinks).

4. Specific prevention with proper organization leads to a sharp decrease morbidity. Instructions about the time of vaccination, on the extent of coverage and the choice of the drug are given to the governing bodies of health and the epidemiologic situation, having in mind not only Tivo-partyphone, but some other infections (use of polyvalent drugs). The most convenient time to produce the planned vaccination is April - may (based on preserving immunity for the entire period of the seasonal rise). Immunization coverage should be broad enough; great importance is the coverage of children's ages, especially when combined tipsdating vaccines. The abundance of quite effective polyvalent vaccine restricts the use of only one of Tivo-partyfotos travaglini; better to use combination: Tivo-paratifizna triacsin+tetanus toxoid (see Tetanus), pentavitin (typhoid, paratyphoid a and b, Shiga dysentery and Flexner; dysenteric components in the form of anabasine - see Dysentery); the possible combinations and cholera vaccine. Vaccinations usually held three times with an interval of 10 days; usual dose of 0.5 - 1.0 to 1.0. Each vaccine is supplied with instruction on its application, specifying the components, the dosages, intervals between doses, name izgotovlenie her Institute, series and date of manufacture. These data must be fixed in the documentation of vaccination for proper consideration of the reactivity and effectiveness of the drug. Very convenient polio, niece containing seven antigens: typhoid, partyphone a and B, cholera, dysentery Shiga and Flexner and tetanus toxoid. Unlike corpuscular vaccine polio, niece consists of complete antigens adsorbed calcium phosphate. The drug is highly turbid, is easily formed precipitate; constant agitation even in the syringe. The drug is absorbed slowly and long-term (depot)that makes it possible to achieve immunity after a single injection; dose 2 ml In the production of vaccines should monitor local and General reactions and produce their records. Vaccination should be preceded by a medical examination of persons subject to immunization, and removal from inoculations with contraindications. Vaccination is contraindicated:

a) febrile and infectious patients until they have fully recovered;

b) patients with nephritis;

C) tuberculous with active forms at the conclusion of TB clinics;

g) persons with heart defects in the period of decompensation;

d) pregnant and lactating within maternity leave. When immunization of malarial need to consider provoking action shots (to assign anti-relapse treatment) (see Malaria).

Treatment.

Specific therapy is still limited to certain attempts have not received General acceptance. Serotherapy not applicable; use of blood serum of convalescents meets practical obstacles (doses up to 300 - 400 ml of serum).

Vaccine therapy: a) subcutaneous no effect;

b) intravenously, 15 to 30 million microbial cells+serum of convalescents, a single injection; the reaction is very rapid with symptoms of shock; described isolated deaths;

C) oral tablets under Besredka or liquid vaccine - method little effective, but safe;

g) by intradermal Alisova vaccine is introduced into the thickness of the skin of the anterior surface of the forearm in increasing doses, starting with the 0.1 ml; with each subsequent dose increases, the number of injections also increased (to use a well-tested tuberculin syringe); this method is safe, according to the author and his collaborators, it shortens the duration of the disease, especially at early stages of treatment.

Phage therapy for early application facilitates and shortens the course of illness; you must re - (5 to 6 days in a row) to apply large doses (at least 50 ml per os to influence the contents of the intestine and the primary focus of infection in the mesenteric lymph nodes and at the same time the same dose intramuscularly to influence vtorichniye foci of infection in the organs. Intravenous normal stock preparations of phage entails a risk of shock; perhaps the cautious use of drugs isotonic (very slow introduction of 10 - 15 ml of warmed up to 38º preparation). The unreliability of the methods specific treatment poses a doctor difficult task to ensure the patient's body the most favorable conditions for infection control.

Hemotherapy as a method of increasing reactivity of the organism, recommended N. And. rugosa (50 - 100 ml of blood donor intramuscularly 5 to 6 days in a row). In the early days of the disease can help autohemotherapy (5 - 10 ml). The most important thing in therapy is care, hydrotherapy, dietetics and symptomatic treatment is directed toward relief of the General condition, regulation of blood circulation and prevent complications.

Care. Soft bed, rubber circle under the pelvis, every 1 - 2 hours, turning from side to side. Tongue cleaning, rinsing, or washing of the mouth of the container after every meal. Lubrication lips But. Cacao, language - glycerine. Rubbing the skin in places pressure camphor alcohol. Head on ice for 1 hour with half-hour break (not to be overcooled water); enlargement of the heart - the ice for half an hour on the region of the heart with an hour break (move from head to heart). Often drink from the drinking bowl for a few SIPS of homemade lemonade, weak Morse, Borjomi, Narzan. To monitor the activity of the intestine; with constipation - enema with flatulence - gas discharge tube, the inside of the salol, methenamine, bensonetta. When urinary retention is a heating pad on the lower abdomen and only in extreme cases - catheterization. When cold weather foot - warmer. At high temperatures carefully antipyretic (not aspirin) - piramidon. For wannabe sick to watch; soft bakovici on the bed, and the upper floors to move the bed from the window, inseparable personal care; to pay attention to the number of input camphor (to cut), to appoint a small dose of luminal at night.

Dietetics. Feeding is done every 3 - 4 hours slowly; after a meal - cottage natural gastric juice or hydrochloric acid with pepsin. The calculation of the diet is not less than 50 calories per 1 kg of body weight, on average, about 3,000 calories. In the daily diet includes: milk - 700 - 1 000 ml, cream - 250 ml (fresh or whipped), butter - 50 g sugar - not less than 50 g dried white bread - 100 g Vitamins: berry, carrot or cabbage juice, organic grape juice, applesauce, orange, tangerine juice, vitamin cranberry jelly. Dishes: meat broth, chicken, fish soup, vegetarian soup of pureed vegetables with sour cream or egg yolk jelly fish or jellied veal, boiled chicken or fish (whitefish. pike), meatballs, scrambled eggs, pate from liver, brain, vegetable puree, cauliflower, pureed oatmeal with fruit syrups and sweet egg gravy, creams, Musa, fruit puree, fruit jellies, ice cream. With such a wide range can be varied menu of high-value and easily absorbed in the upper intestine dishes. If the patient is unconscious, to prevent acidosis and improve the nutrition of the heart muscle - intravenous or drip enema 25% glucose solution is 20 to 40 ml with simultaneous introduction into the skin 1 to 2 units of insulin. Systematic introduction, along with glucose, 200 - 300 mg of ascorbic acid (optional).

Drug therapy is only used when direct testimony (to avoid multiple assignments). With the expansion of the heart - camphor, strychnine, caffeine; acute fall of cardiac activity - strophanthin 0,0005 intravenous glucose (to avoid massive infusions). For pneumonia, depending on the microflora, sulfa drugs (pneumococcus), or penicillin (Streptococcus); autohemotherapy (5 ml) again 2 to 3 days in a row, camphor, banks or mustard wraps. Acute enlargement of the right ventricle and atrium with the threat of pulmonary edema - blood-blowing. Intestinal bleeding is at rest, under the head just a little pad to lift the foot end of the bed to tie his feet with a towel over your abdomen to hang the bag with ice, starvation diet. To reduce abdominal vessels - strychnine under the skin, adrenaline intramuscularly, arguin. To increase the coagulability of the blood, calcium chloride, sodium chloride intravenously, plasma human blood or fresh horse serum intramuscularly. For relaxation peristalsis - atropine (not opium). If the blood loss is too large, the transfusion of blood (200 ml). At the beginning of the perforation (the cry of the patient) immediately under the skin atropine (relaxation of spasm) and pantopon (painless response); the systematic application of penicillin. The mode of the patient, as if bleeding. The issue of surgical intervention is necessary to solve for 5 to 6 hours. Throm - supine, immobilization, and elevation of the limb splints, rolls of blankets, splint). Thrombosis of artery - painkillers (omnopon), constant warming of the peripheral portion of the limb. With rapidly progressive gangrene - amputation.

Other complications are treated by the usual rules.

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