TYPHOID FEVER. Typhoid or enteric* (Gr. Ev-repov, the intestine) is a specific infectious fever characterized mainly by its insidious onset, by a peculiar course of the temperature, by marked abdominal symptoms occurring in connexion with a specific lesion of the bowels, by an eruption upon the skin, by its uncertain duration, and by a liability to relapses. This fever has received various names, such as gastric fever, abdominal typhus, infantile remit tent fever, slow fever, nervous fever, “ pathogenic fever, ” Src. The name of “ typhoid ” was given by Louis in 1829, as a derivative from typhus. Until a comparatively recent period typhoid was not distinguished from typhus. For, although it had been noticed that the course of the disease and its morbid anatomy were different from those of ordinary cases of typhus, it was believed that they merely represented a variety of that malady. The distinction between the two diseases appears to have been first accurately made in 18 36 by -Messrs Gerhard and Pennock, of Philadelphia, and valuable work was done by other American doctors, particularly Elisha Bartlett (1842). The difference between typhus and typhoid was still more fully demonstrated by Dr A. P. Stewart, of Glasgow (afterwards of London). Finally, all doubt upon the subject was removed by the careful clinical and pathological observations made by Sir William Jenner at the London fever hospital (1849-1851).
The more important phenomena of typhoid fever will be better understood by a brief reference to the principal patholo ical changes which take place during the disease. These relate for the most part to the intestines, in which the morbid processes are highly characteristic, both as to their nature and their locality. The changes (to be presently specified) are evidently the result of the action of the oontagium on the system, and they begin to show themselves from the very commencement of the fever, passing through various stages during its continuance. The portion of the bowels in which they occur most abundantly is the lower part of the small intestine (ileum), where the “ solitary glands” and “ Peyer's patches " on the mucous surface of the canal become affected by diseased action of a definite and progressive cha-racter, which stands in distinct relation to the symptoms exhibited by the patient in the course of the fever. (I) These glands, which in health are comparatively indistinct, become in the commencement of the fever enlarged and prominent by infiltration due to inflammatory action in their substance, and consequent cell proliferation. This change usually affects a large extent of the ileum, but is more marked in the lower portion near the ileo-caecal valve. It -is generally held that this is the condition of the parts during the first eight or ten days of the fever. (2) These enlarged glands next undergo a process of sloughing, the inflammatory products being cast off either in fragments or en masse. This usually takes place in the second week of the fever. (3) Ulcers are thus formed varying in size according to the gland masses which have sloughed away. They may be few or many in number, and they exhibit certain characteristic appearances. They are frequently, but not always, oblong in shape, with their long axis in that of the bowel, and they have somewhat thin and ragged edges. They may extend through the thickness of the intestine to the peritoneal coat and in their progress erode blood-vessels or perforate the bowel. This stage of ulceration exists from the second week onwards during the remaining period of the fever, and even into the stage of convalescence. (4) In most instances these ulcers heal by cicatrization, leaving, however, no contraction of the calibre of the bowel. This stage of healing occupies a considerable time, since the process does not advance at an equal rate in the case of all the ulcers, some of which have been later in forming than others. Even when convalescence has 1 The word “ enteric " has been substituted for “ typhoid” by the Royal College of Physicians in the nomenclature of diseases authorized by them, and the change was officially adopted by all departments of the British government. Its advantages are doubtful, and it has been generally ignored by those foreign countries which used the word “ typhoid." “ Enteric " is preferable in that it cannot be confounded with “ typhus ” and bears some relation to the nature of the affection, the characteristic feature of which is a specific inflammation of the small intestine; but it is not sufficiently distinctive. There are, in truth, several enteric fevers, and the appropriation of a term having a general meaning to one of them is inconvenient. Thus it is found necessary to revert to the discarded “ typhoid, " which has no real meaning in itself, but is convenient as a distinctive label, when speaking of the cause of the disease or some of its sym toms. We have the “ typhoid bacillus, " “ typhoid stools, " “ typiioid spots", “ typhoid ulcers, ” &c. The word “ enteric " cannot well be applied to these things, because of its general meaning. Consequently both words have to be used, which is awkward and confusing.
been apparently completed, some unhealed ulcers may yet remain and prove, particularly in connexion with errors in diet, a cause of relapse of some of the symptoms, and even of still more serious or fatal consequences. The mesenteric glands external to, but in functional relation with, the intestine, become enlarged duringithe progress of the fever, but usually subside after recovery. Besides these changes, which are well recognized, others more or less important are often present. Among these may be mentioned marked atrophy, thinning and softness of the coats of the intestines, even after the ulcers have healed—a condition which may not improbably be the cause of that long-continued impairment of the function of the bowels so often complained of by persons who have passed through an attack of typhoid fever. Other changes common to most fevers are also to be observed, such as softening of the muscular tissues generally, and particularly of the heart, and evidences of complications affecting chest or other organs, which not infrequently arise. The swelled leg of fever sometimes follows typhoid, as does also periosteal inflammation.
T he symptoms characterizing the onset of typhoid fever are very much less marked than those of most other fevers. The most marked of the early symptoms are headache, lassitude and discomfort, together with sleeplessness and feverishness, particularly at night; this last symptom is that by which the disease is most readily detected in its early stages. The peculiar course of the temperature is also one of the most important diagnostic evidences of this fever. During the first week it has a morning range of moderate febrile rise, but in the evening there is a marked ascent, with a fall again towards morning, each morning and evening, however, showing respectively a higher point than that of the previous day, until about the eighth day, when in an average case the highest point is attained. This varies according to the severity of the attack; but it is no unusual thing to register 104° or 105° F. in the evening and 103° or 104° in the morning. During the second week the daily range of temperature is comparatively small, a slight morning remission being all that is observed. In the third week the same condition continues more or less; but frequently a slight tendency to lowering may be discerned, particularly. in the morning temperature, and the febrile action gradually dies down as a rule between the twenty-first and the twenty-eighth days, although it is liable to recur in the form of a relapse, Although the patient may, during the earlier days of the fever, be able to move about, he feels languid and uneasy; and usually before the first week is over he has to take to bed. He is restless, hot and uncomfortable, particularly as the day advances, and his cheeks show a red Hush, especially in the evening or after taking food. The aspect, however, is different from the oppressed, stupid look which is present in typhus. The pulse in an ordinary case, although more rapid than normal, is not accelerated to an extent corresponding to the height of the temperature, and is, at least in the earlier stages of the fever, rarely above IOO. In severe and protracted cases, where there is evidence of extensive intestinal ulceration, the pulse becomes rapid and weak, with a dicrotic character indicative of cardiac feebleness. The tongue has at first a thin, whitish fur and is red at the tip, edges and central line. It tends, however, to become dry, brown or glazed lookin, and fissured transversely, while sordes may be present about time lips and teeth. There is much thirst and in some cases vomiting. Splenic and hepatic enlargement may be made out. From an early period in the disease abdominal symptoms show themselves and are frequently of hi hly diagnostic significance. The abdomen is somewhat distended or tumid, and pain accompanying some gurgling sounds may be elicited on light pressure about the lower part of the right side close to the groin-the region corresponding to that portion of the intestine in which the morbid changes already referred to are progressing. Diarrhoea is a frequent but by no means constant symptom. When present it may be slight in amount, or, on the other hand, extremely profuse, and it corresponds, as a rule, to the severity of the intestinal ulceration. The discharges are highly characteristic, being of light yellow colour resembling pea soup in appearance. Should intestinal hemorrhage occur, as is not infrequently the case during some stage of the fever, they may be dark brown or composed entirely of blood. The urine is scanty and high coloured. About the beginning, or during the course of the second week of .the fever, an eruption frequently makes its appearance on the skin. It consists of isolated spots, oval or round in shape, of a pale pink or rose colour, and of about one to one and a half lines in diameter. They are seen chiefly upon the abdomen, chest and back, and they come out in crops, which continue for four or five days and then fade away. At first they are slightly elevated, and disappear on pressure. In some cases they are very few in number, and their presence is made out with difficulty; but in others they are numerous and sometimes show themselves upon the limbs as well as upon the body. They do not appear to have anv relation to the severity of the attack, and in a very considerable proportion of cases (particularly in children) they are entirely absent. Besides this eruption there are not infrequently numerous very faint bluish patches or blotches about halfpan incli in diameter, chiefly upon the body and thighs. When present the rose-coloured spots continue to come out in crops till nearly the end of the fever, and they may reappear should a relapse
