Typhoid Fever. The name, though firmly rooted in popular and even in scientific usage, is an unfortunate one, as it tends to perpetuate the confusion which long existed between this disease and typhus fever. It is best called enteric (i.e. intestinal) fever; and that term will be used here. 'Gastric fever' generally means this disease, but this term has been very loosely employed, and should be given up. Enteric fever was long confounded with typhus; though it can now be traced in the records of disease with much probability as far back as the 16th century. Early in the 19th century the connection of severe fevers with intestinal lesions was recognised in France; but the credit of finally proving the non-identity of typhus and enteric fever was due to Dr (Sir William) Jenner in 1849-51.
Symptoms and Course.—Enteric fever chiefly affects children and young adults; it is rarely met with after middle life. The period of incubation (see MEASLES) is generally from ten to fourteen days, but may in rare cases be as short as two days, or as long as three weeks. The onset is generally gradual, the patient complaining of weariness, headache, sickness, or diarrhoea for some days before he is compelled to take to bed. It may, however, be quite sudden. All the usual symptoms of the feverish state succeed; the temperature generally reaches 103°, sometimes 105° or 106°, but is one or two degrees lower in the morning than at night. The pulse, except in severe cases, is less quickened than in most febrile diseases; frequently it does not exceed 90 or 100 per minute throughout. The tongue is generally coated on the dorsum, but red at the tip and edges. The digestive organs are much disturbed; sickness and vomiting are frequent at the beginning of the attack; there is almost always some discomfort and tenderness in the abdomen; and diarrhoea, though not a constant, is a very characteristic symptom. Generally during the second week the characteristic rash appears, consisting of small rose-coloured spots coming out in successive crops, so that, though each spot lasts only three or four days, some can be discovered for ten days or more. The rash is rarely copious, and sometimes altogether absent, but it bears no proportion to the severity of the case. The pupils are generally somewhat larger than normal. Some cough is very frequently present. Delirium may be absent throughout, but when present is apt to be very severe and troublesome. The feverish state usually lasts about three weeks, by the end of which time the patient is very thin and weak. Its subsidence in the great majority of cases is very gradual, and convalescence is slow, while relapses are not infrequent. Death may take place by coma, by exhaustion, in consequence of severe hemorrhage from the bowels or of perforation of their coats, or from pneumonia or some other complication; rarely from any cause before the second week. an appreciable thickness; then by firm strokes against a hard platen a number of copies may be made. A type-written document may also, if a copying ribbon (one saturated with appropriate copying-ink) be employed, be copied in the copying-press; and if lithographic ink has been employed the print may be transferred to stone. By means of Edison's Mimeograph the type-writer may also be utilised for making numerous copies in printer's
The death-rate in hospital cases has varied from 10 to 30 per cent.; usually it is between 15 and 20. It is least below the age of twenty, and increases, though not very markedly, with age. Slight and abortive cases are by no means uncommon.
Post-mortem Appearances.—The one characteristic lesion associated with enteric fever has its seat in Peyer's patches and the solitary glands of the intestine (see DIGESTION, Vol. III. p. 814), particularly at the lower part of the small intestine. They first become congested and swollen, then grayish; the swollen tissue dies and is cast off, leaving an ulcer corresponding in shape to the affected patch. All these stages may frequently be met with in a single case. These lesions explain the diarrhoea and abdominal pain, and the liability to intestinal hemorrhage and perforation which are so characteristic of the disease.
Treatment.—In no disease is careful nursing of more vital importance. The patient must be kept in bed, and saved from fatigue as far as possible. The diet must be regulated with special care, not only during the continuance of the fever, but after convalescence has set in. Milk should be the chief food, artificially digested if necessary, and supplemented with beef-tea, chicken-tea, or other animal soups. No solid food should be given, except perhaps a little dry toast if the patient can take it; solid fragments of food, such as grape-stones, or even particles of the pulp of fruits, may so irritate the ulcers as to lead to hemorrhage or perforation. Stimulants are usually necessary in severe cases. No drug is known to cut short the disease; and in many cases none is required. High temperature may often be brought down with benefit, either by cold bathing or by quinine or other antipyretic drugs. Diarrhoea should be checked by opium or astringents.
Causation.—Enteric fever is one of the most ubiquitous of diseases, being probably present in all parts of the world; but it is less frequent in tropical countries. It is now proved to depend on defective hygienic conditions, and particularly on imperfect disposal of excreta. The poison appears to be discharged in the patient's dejecta, but not to be active till it has been some time outside the body. It is rare, if proper care is taken, for nurses or others attending on cases of the disease to become infected; but the gases from drains into which the dejecta have passed are very dangerous; and still more so are drinking-water and milk which have accidentally become contaminated with them. In the great majority of instances the disease can be traced to infection from a previous case. It has long been recognised that the infective agent must be an organism, and in 1880 Eberth described a form of bacillus as the real cause of the disease. His observations were confirmed by subsequent observers. But it has since been stated that this bacillus is not constantly present in cases of enteric fever; that a very similar though not identical organism, commonly present in healthy stools, called Bacillus coli communis, is found in large quantity; and that Eberth's bacillus is merely a variety of this commoner organism, modified by its cultivation within the body. The question that had generally been regarded as definitely settled by clinical evidence in the affirmative, whether typhoid fever is a specific disease always due to infection from a previous case, is thus reopened in a new form.
See Murchison's Continued Fevers; Hirsch's Geographical and Historical Pathology; and with reference to the organisms connected with the disease, Vallet, Le Bacillus Coli Communis, &c. (Paris, 1892); also Barr, The Treatment of Typhoid Fever (1892).