Previous Page      Full Application Library 

Typhoid Fever

Bryan Applications, T

An acute infectious disease in which the small intestine is specially affected, typhoid or enteric fever is caused by an organism known as the typhoid bacillus, or bacillus typhosus, or Eberth (after Karl Joseph Eberth of Wiirzburg, professor of pathology at Halle). This is a rod-shaped organism with a number of whip-like processes, or flagella, projecting from all round its body. By the lashing of these flagella it makes its way through any liquid in which it occurs.

The bacillus is found in the blood and in numerous organs of persons suffering from the disease. It is also found in the feces and urine, and may persist in those discharges for many years after recovery from the disease. A person who harbors the bacilli in this way is called a typhoid carrier, and a common place for the bacilli to persist and multiply is in the gall bladder.

The chief source of infection is water that has been polluted with the discharges of a typhoid patient or carrier. If polluted water is used to wash milk containers or utensils, the bacilli multiply readily in the milk; this becomes highly infectious and also the cream or cheese made from such milk. Freezing does not kill the typhoid bacillus, and ice-cream made with infected milk or cream can readily communicate the disease. Salads polluted by sewage or washed with infected water are also dangerous.

Another common source of typhoid infection is the oyster, as these mollusks are sometimes bred in water which is polluted with sewage. For the same reason mussels are sometimes implicated. Flies and other insects may like-wise be agents of infection by feeding on sewage or excreta and afterwards visiting food or food utensils.

Persons who handle typhoid patients or their clothing may have their hands contaminated or may inhale the germs in the dust of excrement which has dried on bedding or utensils.

Symptoms of the infection:

After infection has occurred there is an incubation period of from seven to twenty-eight days; usually it is about twelve days. Fever then begins; occasionally it is high from the onset, but usually it is not very high for the first few days though it is progressively increasing, the temperature each evening being higher than on the preceding one. During this time the patient probably keeps getting about, but suffers from loss of appetite, headache, vague abdominal pain and slight diarrhea or, perhaps, constipation. Frequently there is epistaxis or bleeding from the nose, and bronchitis is not uncommon.

The temperature reaches its acme on the fifth to the seventh day, when it may be 103° to 105° F., and, if he has not done so before, the patient now feels compelled to take to his bed. For the next ten to fourteen days the temperature, beyond dropping a little in the mornings, does not vary very much, but after this in favorable cases, it begins to come down gradually day by day, or, in other words, it ends by lysis. Sometimes, however, the high level of temperature is maintained for several weeks.

When the patient takes to his bed, diarrhea is generally established, with thin stools, which, from their appearance, are described as pea-soup stools. Sometimes the character changes to what is called the chopped parsley stool. In any case these are usually very foul. There is some distension of the abdomen and pain. The tongue is covered with a yellowish fur in the center, but is red at the lip and edges. The eye is clear, and the mind is usually alert, though sometimes headache is severe, or there is dullness and apathy.

Frequently sleep is disturbed and the patient tends to be wakeful at night. The rate of the pulse and respirations corresponds as a rule with the elevation of temperature. The spleen is enlarged.

Characteristic appearance of the rash:

On the seventh or eighth day a characteristic rash usually appears, first on the abdomen, chest and back, but later it may be found on the limbs and face. It consists of small rose spots, slightly elevated above the level of the skin, and these appear in crops, the older spots beginning to disappear as the new ones come out.

By the end of the second week the patient is beginning to feel exhausted. The tongue is probably dry. The pulse is rapid and weak. The abdomen is more distended, sometimes very much, a condition described as meteorism or tympanites. This may cause embarrassment to the heart and lungs. There has been considerable loss of flesh, and the face is thin.

If the temperature begins to decline, there is a gradual improvement in other respects also, but if the fever continues, the patient tends to develop what is called the typhoid state.

In typhoid fever there is inflammation of Peyer, patches (after the Swiss anatomist, Johann Conrad Peyer), the collections of lymphoid tissue in the lining of the small intestine, particularly towards its lower end. These become swollen, and project above the surface of the bowel. Then the superficial part of a patch dies, forming a slough which is thrown off and leaves an ulcerated surface. The ulcer becomes deeper and may reach the peritoneal lining. Blood vessels in the bowel wall are also liable to be opened by the ulcerative process. There is a general catarrhal condition along the lining of the bowel.

From the end of the second week there is a possibility of two serious complications occurring. One of these is severe hemorrhage from the bowel. Should this happen, the temperature drops to subnormal, and there are signs of collapse. The other is perforation of the bowel. This also causes signs of collapse, and probably pain, though sometimes pain is absent, and after a short time signs of peritonitis appear.

Among other possible complications are pneumonia, pleurisy, meningitis, parotitis, and inflammation of joints or bones. A stiff or painful condition in the back-bone, sometimes referred to as typhoid spine, is caused by inflammation of the inter-vertebral disks. Thrombosis (q.v.) in a vein, usually in one of those of the lower limb, sometimes occurs, but generally during convalescence. Typhoid fever may be followed by prolonged physical weakness and sometimes by mental derangement.

Illnesses resembling typhoid fever, but generally of less severity, are caused by bacilli which are akin to the typhoid bacillus. These illnesses are described as paratyphoid fever A, paratyphoid fever B. Relapses occasionally occur in typhoid fever, being more frequent in some epidemics than in others; they are fairly common in paratyphola A.

There may be some difficulty in diagnosing typhoid fever in its early stages, and it is sometimes mistaken for pneumonia, acute tuberculosis, appendicitis and other disorders. After a few days, however, it may be possible to cultivate the typhoid bacillus from a sample of the blood, and after ten days the Widal test (after the French physician, Femand Widal), which is based on the agglutination of the bacilli, is generally found to be positive. Other tests may be applied.

How to prevent the disease:

The main method of preventing typhoid fever is to provide a supply of pure water for households, and now that this has been pretty well accomplished, at any rate for the towns, typhoid fever is a relatively uncommon disease. There is always a danger, however, when water is drawn from shallow wells or in a casual way from streams. Considerable attention is also being given to the oyster and mussel industries, and dangers from these sources are being lessened. Another method of lessening the prevalence of typhoid fever is the control of flies. An important preventive measure is to discover human carriers of the disease and sterilize them, if possible.

This can sometimes be done by removing the gall bladder. In any case, such persons should not be allowed to have anything to do with preparing or handling food. Also, during an epidemic, a watch must be maintained for instances in which the disease is so mild that the patient can get about all the time. This type is called ambulant typhoid.

When typhoid fever is prevalent, all water used for drinking or for washing kitchen utensils, and all milk, should be boiled. Protection is afforded by inoculation with anti-typhoid vaccine, and preferably one which deals not only with typhoid but paratyphoid also; this is usually referred to as the T.A.B. vaccine. This gives protection for about two years and if, in spite of inoculation, the disease is contracted, it is likely to follow a milder course.

The issue of typhoid fever depends to a large extent on the quality of the nursing and in most cases it is desirable that a patient suffering from this disease should be treated in an institution, as the accommodation and wealth of appliances provided in such a place make nursing easier and more efficient.

The treatment is in general that described under the headings Fever and Infectious Disease. As typhoid is such a protracted disease, however, special care is necessary in keeping the mouth clean, and in preventing bed sores.

The patient should be encouraged to drink a large quantity of water, and some of this may usefully be in the form of home-made lemonade. At the same time sufficient food should be taken, mainly milk but also eggs, beaten up or as albumen water, sugar, butter, bread and corn-flour, or arrowroot. A watch should be kept on the stools, and if large, or many, milk-curds appear, the milk should be citrated or even peptonized.

Typhoid is one of the diseases in which the control of the temperature by cold or cool baths is much practiced in some parts of the world.

Drugs, with the exception of intestinal antiseptics, such as betalnaphthol and oil of cinnamon, are little used in uncomplicated typhoid. For hemorrhage styptics are employed, but for perforation the only useful treatment is immediate operation. Tympanites, or distension of the bowels with gas, is treated by giving oil of cinnamon, 2 to 5 minims in capsules, and by applying turpentine stupes to the abdomen. Constipation occurring during the course of the disease, or in early convalescence, should be corrected by enemata and not purgatives.

Stimulants should not be given as a matter of routine, but only when they appear to be necessary.

Application and treatment:

The laboratory results show the M.O.R for the typhoid bacillus to be, 1865 Hz. Treat typhoid as infectious disease. Standard treatment regimen via water pans is recommended. Space sessions at 72 hour intervals. Drink lots of clean water.