Typhoid Fever.

The onset of typhoid fever, unlike that of the eruptive fevers
and of most infectious diseases, is gradual and insidious. In a large
number of cases, patients are unable to fix definitely the date at
which their ailment commenced, since the beginning of the disease
is so imperceptible. It is, therefore, impossible to say just how
long the stage of incubation endures, though the average seems to
be from three to ten days.

During this premonitory stage the patient, while usually able
to continue his avocation, is nevertheless not in his usual state of
health. He experiences chilly sensations, shivering, perhaps even pro-
nounced chills occurring at irregular intervals, perhaps often repeated
At the same time he suffers from headache, usually in the forehead,
his mental faculties seem enfeebled, he is unable to concentrate his
attention with the usual vigor, and feels generally prostrated and
languid. Impairment of appetite, nausea, and even vomiting are
not unusual symptoms. There is usually a tendency to diarrhea,
which is aggravated if the patient incautiously takes a laxative. A
frequent symptom is bleeding at the nose without apparent cause.
After these symptoms have endured perhaps a week, the individual
is compelled to give up his occupation and take to his bed.
The recognition of typhoid fever depends not so much upon
any one special symptom as upon the grouping of numerous
features after a certain arrangement. It is therefore desirable, in
discussing the symptoms of the disease, to refer in detai! to the
changes presented by different parts of the system.

Symptoms.—During the first few days there is no especial
change in the countenance, unless it be a persistent, dull red flush­
ing of face. As the disease progresses, usually by the time the
patient takes to his bed, there is an unusual lack of expression, a
degree of listlessness and even of stupidity, which attract? atten­
tion. There are cases, indeed, in which the severity of the attack
seems to be expended upon the nervous system, so that one is
inclined to overlook the other symptoms in the evidence of mental
derangement. In such cases the patient, even before taking’ to his
bed, may seem half deranged, taking no notice of questions until
repeatedly addressed to him, and then muttering incoherent replies.
The skin is usually somewhat reddened, espe^ally on the face; and
this redness, while disappearing upon pressure of the finger, returns
in a sluggish way never observed during health. This same appear­
ance of the skin may be found, also, upon the abdomen and upon
the arms, indicating a feebleness of the circulation.

During the first week in bed the patient, if not too stupid and
listless, complains of a dull, aching pain in the head. His com­
plaints become less frequent toward the beginning of the second
week, probably not because the pain is less severe, but because the
patient’s ability to perceive pain is less acute. For about the begin­
ning of the second week the symptoms of mental derangement
usually become prominent ; in the majority of cases delirium occurs
—not the violent, active delirium which we are accustomed to asso­
ciate with that name, but a low, muttering delirium quite in accord
with the physical debility of the patient. The first evidence of this
is often given by the patient upon awakening from sleep ; he is evi­
dently confused, cannot recall where he is, and answers questions
incoherently. At a later period he talks constantly in a low, feeble
tone, usually repeating frequently that he wants to go home, and
often accompanying this wish by feeble efforts to get out of bed.
No mental restraint is possible, since so soon as one effort to rise
has been defeated the patient makes another attempt. If not care­
fully watched, the individual will leave his bed, if physically able to
do so, walk out of the house, usually in his night clothes, and may
even wander a considerable distance away until he falls exhausted.

There is no apparent coherence of ideas ; the patient’s thoughts
seem merely a succession of dreams which have no relation to his
actual condition. There are exceptions to this type of delirium, in
which the patient is active and boisterous, shouts, makes forcible
efforts to rise, and may even display a belligerent spirit for his
attendants, requiring forcible restraint. Then again his delirium,
instead of being a mere succession of disjointed ideas, may take the
shape of a fixed delusion, the patient imagining himself extremely
rich or powerful. It is usually the case that, while the patient talks
somewhat coherently, he has no idea of the meaning of his words,
on wrhich account no reliance can be placed upon his answers. This
fact should be borne in mind, in endeavoring to elicit information
from the patient as to his own feelings of pain, etc. In exceptional
cases there may be no evidence of delirium throughout the entire
illness, though the patient even then rarely has, after convalescence,
any distinct recollection of what occurred during his sickness.
Associated with the delirium is an utter indifference to every­
thing in the shape of physical comfort and welfare. The patient
asks for nothing to eat or drink, though the mouth may be dry and
parched and the unfortunate person be constantly endeavoring to
moisten his lips with his tongue; flies are allowed to creep over his
face without any indication of annoyance on his part; he will/lie
listlessly in one position in the bed until the skin becomes sore. In
grave cases it often happens that the patient will evacuate the bowels
and bladder in the bed, apparently from simple indifference. Sight
and hearing are usually impaired; at any rate, light and noise of
unusual intensity are required to attract even the slightest attention.
One of the features of this disease, which must never be forgotten in
its treatment, is the patient’s inability to sleep. During the first few
days, before his mind becomes benumbed, he usually complains of
this exhausting lack of sleep; but later he is as indifferent to this as
to everything else, and lies in a condition which may seem to the
bystander sleep, but which is practically a condition of wakefulness.
He is easily aroused, but lapses at once into this semi-unconscious
state. Doubtless this lack of sleep contributed largely to the
exhaustion which constitutes one of the greatest dangers. One
of the features of this condition is a twitching of the tendons or
“ sinews,” in the wrist especially, though there may be a similar
appearance in the muscles of the face and limbs. In grave cases
there may be general convulsions, which usually shortly precede
death.

There is usually no appetite; indeed, the patient can sometimes
be fed only by force; yet in exceptional cases food is readily taken
throughout the entire illness. Thirst seems always prominent as a
symptom ; even when the patient’s mind is so blunted that he does
not ask for a drink, he may take it with avidity when administered.
The teeth become covered during the second week with dark
brown or black matter, called sordes; this is especially abundant in
unusually severe cases; the gums may be swollen, and bleed readily
upon pressure ; the tongue presents characteristic appearances. At
the beginning, that is, before the patient assumed the recumbent
posture, the tongue is heavily coated white, yellow or brown, and
indicates an unusual lack of moisture. During the first week of
the disease proper, the surface of the tongue usually’becomes brown,
hard, dry and glazed; it seems divided into small sections, like
mosaic work, and may be deeply cracked. When asked to pro­
trude the tongue, even in the early stage of the affection, the patient
complies with apparent difficulty, the tongue refuses prompt obedi­
ence, and when finally protruded is very tremulous. Having put
out his tongue, the patient sometimes forgets to withdraw it until
reminded of it—another indication of the tardy and uncertain
character of his mental acts.

Another usual symptom is diarrhea ; the stools are usually
very thin, watery and of a yellow color, though these characters are
not invariable or necessary. The abdomen usually becomes some­
what distended with gas, and a gurgling sensation may be felt by
pressure with the hand just above the right groin. In the earlier
weeks of the disease, pressure upon this spot often causes the patient
to wince ; indeed, there may be tenderness over a considerable part
of the abdomen. This is to be explained by the fact that typhoid
fever usually causes ulceration in the intestine just at that point
which lies in the right groin. This ulceration explains several of
the unfortunately frequent and dangerous incidents of the disease.
The first of these is hemorrhage from the bowels. This may occur
at any time in the latter part of the disease, and even during con­
valescence. Without any warning or premonitory pain the patient
passes a large quantity of blood from the bowels, the hemorrhage
sometimes continuing until the individual faints. Notwithstanding
the alarming appearance from this accident, the result is not
necessarily fatal. Another and almost invariably fatal result of this
ulceration in the bowels, is perforation of the intestine ; that is, the
ulceration extends through the wall of the intestine, permitting the
contents to escape into the abdominal cavity. The result is a fatal
inflammation of this cavity, termed peritonitis. This accident, too,
may occur without especial cause or warning, at any time during
or after the third week ; it sometimes happens while the patient is
convalescent.

During many cases of typhoid fever an eruption is observed on
the skin of the abdomen and chest, sometimes also on the back ;
this rash consists of a few scattered red pimples, an eighth of an
inch or less in diameter. This eruption, if it appear at all, becomes
visible during the second week. In this, as in other severe affec­
tions, there are often observed minute watery blisters scattered over
the neck and chest particularly. The patient not infrequently has
a short dry cough, and may even raise a nttle mucus. An occa­
sional complication usually involving a fatal result is an inflamma­
tion of the lungs, pneumonia.

Cause.—Typhoid fever is another of the infectious diseases
which is to be ascribed to a specific virus or poison. Yet the
present state of our knowledge would indicate that the disease is
not directly communicated by contact of the sick with the well
individual. The disease seems capable of manifesting itself with­
out previous exposure to this disease ; yet it is unquestionable that
the excretions — the stools — of a typhoid fever patient may be the
means of disseminating the disease among healthy people. The
contagion is conveyed in the water of wells and cisterns, as has
been amply demonstrated by observations upon the German and
Austrian soldiery, as well as by cases in civil life. City physicians
are well aware that typhoid fever is specially apt to occur in those
dwellings in which, however elegant the general appointments, the
sewerage is defective, as indicated by the odor from the traps.
Typhoid fever, while occurring during all seasons of the year, is
especially frequent in the fall, at which time it may amount almost
to an epidemic. The average mortality varies extremely, being
of course greater during epidemics; at these times there may be
one fatal result in three or four. At other times, however, the
average mortality is rarely more than one in six or seven.

Treatment.—The object here, as in other infectious diseases,
is simply to assist the patient to bear the ravages of the disease;
hence the chief measures will consist in such food, medicine and
hygienic arrangements as will conduce to the preservation of the
patient’s energies. It is impossible to cut short the disease.
Nowhere in medicine is there more imperative demand for
good nursing. This constitutes indeed the most important part of
the treatment of typhoid fever. It is not necessary to repeat in
detail directions which have been already several times given as to the
management of other fevers; it is sufficient to say, in brief, that fresh
air, frequent lukewarm baths, or the use of the wet pack every day,
when the fever is high, an abundance of nourishing food — liquid
food — with a liberal allowance of alcoholic stimulants. In the early
weeks of the disease the headache may be so severe as to require
treatment. This may be relieved by the application of ice water,
alcohol and water, or cologne water to the head, or by the use of
the ice cap. It will genzr.Aybe found advisable to shave the head
so soon as the disease is definitely recognized as typhoid fever. In
order to break up the distressing inability to sleep, it will be desir­
able to give an opiate, say 20 drops of laudanum. The diarrhea
requires no checking unless the stools are extremely thin and
watery, and are passed more than four times a day. In this case
we may administer ten drops of laudanum every four hours for one
day. It is not advisable for the non-professional to attempt to
control the bowels, since the source of great danger lies in the in­
testines, and the peril may be aggravated rather than diminished
by the remedies used. Instead of laudanum, ten drops of the oil of
turpentine may be administered in a teaspoonful of simple mucilage
four times a day. The energy of the household can be better
directed to the preparation of the diet. One thing should never be
forgotten, that no solid food should be given to a typhoid fever
patient until his convalescence is complete ; for the passage of
undigested particles along the intestine may not only aggravate
the ulceration, but also provoke hemorrhage or perforation of the
intestine — those especially dreaded accidents. As early as the
second week it will be necessary, in the greater number of cases, to
administer wine or whisky, which may be best given in the shape
of milk punch. If the pain and distension of the abdomen are
considerable, benefit maybe derived from the use of flannels wrung
out in hot water and sprinkled with turpentine over the abdomen.
So long as the patient’s mental condition permits, pieces of ice may
be held in the mouth, and after that cold drinks may be administered.
Care should be taken to keep the mouth and teeth free from sordes.

During the convalesence from typhoid fever, especial care must
be taken to avoid violent effort, since such effort favors perforation
of the intestine and hemorrhage — accidents which have been known
to happen weeks after the symptoms of the fever had subsided.
The patient should be taken into the open air early and often, but
not permitted to walk or strain in any way until he has recovered a
fair degree of strength.

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