Typhoid Fever

Death in typhoid fever usually takes place from one of the following causes. (I) Exhaustion, in the second or third weeks, or later. Sometimes sinking is sudden, from heart failure. (2) Haemorrhage from the intestines. The evidence of this is ex hibited not only in the evacuations, but in the sudden fall of temperature and rise in pulse-rate, together with great pallor, faintness and rapid sinking. Sometimes haemorrhage, to a danger ous and even fatal extent, takes place from the nose. (3) Perfora tion of an intestinal ulcer. This gives rise, as a rule, to sudden and intense abdominal pain, together with vomiting and signs of collapse, viz., a rapid flickering pulse, cold clammy skin, and the marked fall of temperature. Symptoms of peritonitis quickly supervene and death usually takes place within 24 hours. (4) Occasionally, but rarely, hyperpyrexia (excessive fever). (5) Complications, such as pulmonary or cerebral inflammation.

Certain sequelae are sometimes observed, the most important being phlebitis (q.v.), periostitis affecting long bones, general ill health and anaemia, with digestive difficulties, often lasting for a long time, and sometimes issuing in pulmonary tuberculosis. Occasionally, after severe cases, mental weakness is noticed, but it is usually of comparatively short duration. The prognosis of typhoid varies widely and is greatly influenced by the quality of the nursing. Nevertheless it is distinctly worse in tropical than in temperate climates and is one of the most feared diseases among Europeans in India. • The susceptibility of individuals to the typhoid bacillus varies greatly. Some persons appear to be quite immune. The most susceptible age is adolescence and early adult life; the greatest incidence, both among males and females, is between the ages of 15 and 35. The aged rarely contract it. Men suffer con siderably more than women, and they carry the period of marked susceptibility to a later age.

Dissemination.

The sick, from whose persons the germs of the disease are discharged, are always an immediate source of danger to those about them. There is evidence that this is the case with armies in the field, e.g., the conclusions of the commis sion appointed to inquire into the origin and spread of enteric fever in the military encampments of the United States in the Cuban campaign of 1898. Out of 1,608 cases most thoroughly investigated, more than half were found to be due to direct and indirect infection in and from the tents (Childs: Sanitary Con gress, Manchester, 1902). A similar but perhaps less direct mode of infection was shown to account for a large number of cases under more ordinary conditions of life in the remarkable outbreak at Maidstone in 1897 (see below), which was also subjected to very thorough investigation. It was undoubtedly caused in the

first instance by contaminated water, but 280 of the later cases were attributed to secondary infection, either direct or indirect, from the sick. A good deal of evidence to the same effect by medical officers of health in England has been collected by Dr. Goodall, who has also pointed out that the attendants on typhoid patients in hospital are much more frequently attacked than is commonly supposed (Trans. Epidem. Soc. vol. xix.).

Discoveries as to the part played in the dissemination of typhoid fever by "typhoid carriers" (see CARRIERS) have thrown light upon the subject of personal infection. The subject was first investi gated by German hygienists in 1907, and it was found that a considerable number of persons who have recovered from typhoid fever continue to excrete typhoid bacilli in their faeces and urine (typhoid bacilluria). The liability of a patient to continue this excretion bears a direct relation to the severity of his illness, and it is probable that the bacilli multiply in the gall bladder, from which they are discharged into the intestine with the bile. The condition in a small number of persons may persist indefinitely. In 101 cases investigated, Kayser found three still excreting bacilli two years after the illness, and George Deane has recorded a case in which bacilli continued to be excreted 29 years afterwards.

Many outbreaks have in recent times been traced to typhoid carriers, one of the first being the Strassburg outbreak. The owner of a bakehouse had had typhoid fever ten years previously, and it was noticed that every fresh employe entering her service de veloped the disease. She prepared the meals of the men. On her exclusion from the kitchen the cases ceased. In Brentry reform atory, near Bristol, an outbreak numbering 28 cases was traced to a woman employed as cook and dairymaid who had had typhoid fever six years previously. Before entering the reformatory she had been cook to an institution for boarded-out girls, and during her year's residence there 25 cases had occurred. Numerous cases of contamination of milk supplies by a "carrier" have been investi gated, and in outbreaks traced to dairies it is wise to submit the blood of all employes to the agglutination test.