THE HISTORY, ETIOLOGY AND MODE OF

INFECTION OF TYPHOID FEVER.

W. S. RANDALL, M.D.,

SHELTON.

In the short space of time allotted to me for the presentation of this paper on the History, Etiology and Mode of Infection of Typhoid Fever, it is my privilege and pleasure to present for your consideration such data as I trust will be found of practical value to us as practitioners.

There appears to have been no definite understanding of this disease previous to the seventeenth century when Spigelius observed the malady, and in a number of postmortem examinations found what were undoubtedly typhoid lesions in the intestinal tract. Among others who gained a knowledge of the disease we find recorded the names of Sydenham, Hoffman, Willis and Bartholin.

In the following century we find Morgani, Huxam, Gilchrist and others writing in a manner indicating some knowledge of this disease. Up to this time, however, success had not crowned the efforts of these pioneers in isolating the disease from its associate-typhus fever— and not until the year 1837 did we obtain a sharp line of distinction between the two diseases through the valuable researches of Pennock and Gerhard of Philadelphia. This dreaded disease which has existed for so many ages and still exists by virtue of its germ-the bacillus typhosus holds within its relentless grasp thousands of cases yearly, the fatality of which runs from seven to fifteen per cent. Wilson states that Delafield collected 1,305 cases of typhoid fever in the New York hospitals in five years with a mortality in 1879 of 21% and in 1880 of 30%. In 18,612 cases in the British and Continental

hospitals the statistics of Murchison show 18.62 per cent. of deaths. These statistics, authentic as they are, make one stop and ponder and ask himself if in all the realm of medicine and sanitary science there will not some day be a means of forever exterminating this germ from our midst.

A word as to the clinical history: Typhoid fever is an acute infectious disease, self-limited whose chief characteristic is an inflammation and ulceration of Peyer's patches and the solitary glands of the large and small intestine.

Enteric fever has been largely used as a term designating this disease and properly so inasmuch as the lesions. are found in such a large proportion of the cases along the intestinal tract, yet it is recorded that autopsies have shown in some cases that the intestines were nearly or quite in a normal condition and that the lesions were found in other parts of the body. Different varieties of this disease occur, among which should be mentioned the abortive, severe, hemorrhagic, renal, ambulatory and pneumonic types.

The period of incubation varies from four days to three weeks, although the usual time is from two to three weeks.

The patient complains of feeling weary, loss of appetite with general malaise, some headache and symptoms simulating and at first not infrequently mistaken for a malarial cachexia.

The onset is apt to be gradual and frequently a patient will keep about for several days before consulting his physician when the above symptoms become apparent. Inquiry shows one or more chills to have occurred. The temperature is often found on first visit to be from 101.5° to 103°, tongue coated, diarrhea may be present or absent and epistaxis to a mild degree in a certain proportion of cases.

Let us direct our attention for a few moments to some

of the more common complications, those which may, for a time at least, obscure our diagnosis. Headache is apt to be of a severe type and is usually present, leading one to think of meningitis. Pain may be severe in the back of the neck with some tenderness, also making the dif ferential diagnosis from cerebrospinal meningitis somewhat obscure.

Delirium is sometimes an early symptom, but it has not been my experience to find much delirium during the first two weeks.

In case of pneumonic complication the onset may be similar to that of pneumonia, in which case the typhoid symptoms may not show themselves until after one week, when the fever, instead of terminating by crisis, continues on and the typhoid phase of the case shows itself.

Symptoms of an acute nephritis may be the first to hold our attention. Again bronchitis, especially in the very young, is a stumbling block to an early diagnosis, but continued high temperature and increasing typhoid symptoms soon clear up the doubt.

The duration of the disease varies largely in proportion to complications, but usually runs its course in a typical case in from four to six weeks.

Toward the end of the first week or the first of the second week, a few rose-colored spots may show themselves, mostly over the abdomen, although the eruption is not constant in all cases but when present is considered a valuable diagnostic sign.

The tongue gradually becomes more thickly coated and dry, there is a considerable thirst and loss of appetite, although fluid diet is usually taken with avidity. Diarrhea is, perhaps, in the majority of cases present, although constipation may exist.

The temperature rises a fraction of a degree each day with moving recessions. During the second and third weeks the foregoing symptoms become more severe and the general strength of the patient becomes reduced; the

face is flushed and nervous symptoms present themselves. The abdomen becomes tympanitic, delirium and great restlessness appear.

Diarrhea now becomes a more prominent symptom, and even hemorrhages take place. The pulse is inclined to be more feeble and the temperature somewhat higher. Considerable emaciation and weakness make their ap pearance together with subsultus tendinum and a condition of wakefulness known as coma vigil. All these symptoms present a picture with which we are only too familiar and force the attendant to express grave fears for the recovery of his patient.

During the fourth week or even earlier the temperature may fall to normal, the above mentioned symptoms become less severe and convalescence set up or the disease may continue from two to four weeks longer, if the patient's powers of resistance are equal to the strain imposed upon him.

I recently saw a case of typhoid fever in consultation with Dr. Loomis, of Derby, where the fever had been running continuously for twelve weeks, with no apparent sign of abatement. Throughout all this time there had been no delirium, and when I saw her, her mind was very clear, yet she was greatly emaciated and anemic. Multiple abscesses of the scalp were visible, with good drainage, yet these did not seem sufficient to account for the high temperature. Our diagnosis was that of a deepseated abscess not clearly defined. The doctor has since informed me that the temperature has subsided and convalescence is established. I mention this very interesting case in this connection to show that we sometimes get a post-complication in this disease which accounts for the prolonged high temperature rather than the specific glandular inflammation itself.

ETIOLOGY:-Typhoid fever is caused by the introduetion into the system not immune to the disease of the specific germ known as the bacillus typhosus. How

truly thankful should we be that the nineteenth century placed in our hands the key to this typhoid situation and discovered the microscopic organism which is the root of so much evil. To Eberth is due the credit of discovery and isolation of this baccillus, which consists of a short, thick, straight or moderately curved, rod-like body. whose ends are rounded. It is found especially in the intestinal and mesenteric glands as well as in the spleen and other organs of the body and also in the blood. According to Sajou's latest work age seems to exert an important predisposing influence, typhoid being rarely found under the age of two years and not often after fifty. According to Northrop in the Archives of Pediatrics for January, 1896, an analysis of 254 cases of ty phoid fever in childhood showed, up to five years of age, one per cent., five to ten years of age, twenty-seven per cent., and ten to fifteen years of age, seventy-two per cent.

Morse, in an article in the Boston Medical and Surgical Journal for February, 1896, states that Vogel in 1,017 cases found 412 between five and ten years of age and 393 between ten and fifteen.

This disease prevails principally in the temperate zone, although all climates are subject to it.

With us the fall and late summer months appear to be prolific periods for the disease, although winter and spring record many victims. It is rather apt to occur after a dry, hot summer with low water level, although this does not always or necessarily follow. The late Dr. William Pepper, whom we all learned to admire not only for his intrinsic worth as a physician but as a writer of rare ability, states in an elaborate article on Typhoid that "according to Murchison out of 5,988 cases seen in the London Fever Hospital during twenty-three years, 2,461 occurred in autumn, 1,490 in summer, 1,278 in winter, and 759 in spring." Also "according to Osler over 50 per cent. of the 1,889 cases in the Montreal Gen