In a typical case the chief symptoms are (1) a fever of a peculiar character, (2) looseness of the bowels, and (3) a rash of rose-coloured spots on the skin. In such a typical case the fever begins to abate in the third week of the disease, and has disappeared about the twenty-eighth day. Its peculiarity is that it is always a degree or two lower in the morning than in the even ing. During the first week the temperatAire, as taken by the thermometer (p. 38), is each day higher than the preceding, that is, it rises to a greater height each succeeding evening and falls less each morning; during the second week it keeps each day about the same level, though showing the morning fall and evening rise, and during the third week it shows a daily descent. If the temperatures be marked on a chart, the first week shows a series of ascending steps, the second week shows a series of daily rise and fall at the same general level, and the third week shows a series of descending steps. This behaviour of the temperature in typhoid fever is the most characteristic feature of the disease, and serves to mark it off from other diseases though every other symptom fails. The rash conies out in the second week of the disease. It consists of rose-coloured spots about the size of a pin's head, raised above the skin, found principally on the chest, belly, and back. (They are represented on Plate XXVII.) They conic, out, only two or three at a time, in crops, and they fade in three or four days. But one crop succeeds another, till the end of the third week. At this period (the second week) the tenderness of the belly and looseness of bowels are more marked. The motions may be very frequent and resembling pea-soup. The other symptoms continue, and the tongue is dry and tends to crack on the surface. Towards the end of the second week the tongue is more dry and brown, pulse faster and more feeble, the person grows dull and listless, is very prostrate, and there is delirium. The delirium may be violent., or simply rambling, or muttering. In the course of the third week the weakness becomes ex cessive, and bed-sores are apt to form. The patient tends to slip down in bed. The body is wasted, the lips trembling, the pulse is ex tremely feeble and quick. Irregular starting of the limbs occurs, and the hands wander aim lessly about, picking at die bed-clothes. Blood is frequently passed in the stools. If the case is going to end in death, the starting of the limbs and wandering of the hands are marked, the motions and water are passed unconsciously in bed, and stupor comes on. A favourable turn is indicated by a gradual fall in the fever, a less frequent and more distinct pulse, a passing off of delirium, cleaning of tongue, and stoppage of looseness of the bowels. Recovery is always gradual and very slow. Many months may occur before strength is re - established. Relapses are not uncommon, attended by rash and all the other symptoms of the disease. They occur usually about ten days after the disappearance ih the fever of the first attack.
While the symptoms that have been de scribed are those of a typical case of typhoid fever, it must be observed that cases are very numerous where the symptoms are very ob scure, and where, in consequence, the disease is apt to be overlooked. A patient, for example, may complain of chilliness and feverishness, of headache and unaccountable weariedness, of loss of appetite, and sleeplessness at night, and may exhibit no marked looseness of bowels, no spots on the skin, and no symptom pointing out typhoid fever with any certainty, while it is this disease which is attacking him. Constipa tion in typhoid fever is not so uucommon as is supposed. He may fight against his feelings of illness for seven or eight days, and then speedily succumb to the disease. Perhaps some great and sudden discharge of blood from the bowels occurs, or other grave sign of the mischief going on in the bowels. In all such cases the vague ness of the symptoms must not be allowed to make one indifferent. If the temperature is taken as advised (p. 507) it will probably give such warning as ought to lead to the person being sent to bed and being carefully nursed and watched. Such difficulties of diagnosis are now got over by testing the blood in a par ticular way for the presence of the typhoid organism—Widal's reaction.
The complications of typhoid fever are numerous. The looseness of bowel indicates serious mischief there. The bowels are the
seat of patches of ulceration occurring in the position of the glands of Peyer (p. 199). In the process of ulceration a blood-vessel may be opened and fatal loss of blood may occur. The bursting of the vessel may be due also to im proper exertion or to the taking of some hard food. In severe cases the blood is passed un altered or in clots. Usually it is altered and makes the motions black, tarry-looking, and offensive. Where the loss is sudden and great it is known by the sudden paleness of the patient, failure of the pulse, and fainting (Plate XXIX.). Bleeding may occur between the middle of the second and the end of the fourth weeks. Another danger is that the ulceration may eat through the bowel wall into the cavity of the belly, and there set up fatal inflammation (peritonitis, p. 265). It is indicated by rapid swelling of the belly, violent pain, vomiting, great anxiety of the patient, and extreme frequency and feebleness of pulse. This occurrence is most common in the third, fourth, and fifth weeks of the disease.
Congestion and inflammation of the lungs are also exceedingly common.
Treatment. — Many cases of typhoid fever present no marked symptoms. Nevertheless every suspicious case must be treated with watchfulness, and the mild cases with the same care as the severe. The patient should be put to bed and kept there. Often a person feels so comparatively well in the morning that he wishes to get up for a little. This must on no account be permitted. The patient should be daily sponged with lukewarm water, and the body and must be kept clean and dry and frequently renewed.
Perhaps the most important thing in the treatment of the case is the dieting. Milk should be the only diet, given raw, or boiled &there is diarrhoea, and with the addition of ice or lime-water or aerated water, and where there is digestive difficulty it should be pep tonized (see p. 137, Vol. From 1 to 3 or 4 pints daily, according to age, is 'a suitable quantity. If white, curdy pieces appear in the motions, the milk should be reduced in amount or peptonized, as those pieces will irritate the bowel. It is always best not to permit the patient to have much at one time, but to give small quantities often. Thirst afflicts the patient, and ordinary water in moderate quantities is not to be refused. Barley-water may also be given, and water made slightly acid with dilute sulphuric acid or ordinary vinegar.
As regards drugs, opening medicines must be cautiously given. At the very beginning a good dose of castor-oil should be administered. The ulceration going on in the bowel must be re membered, and if, later, the bowels require relief, it is best to give an injection of soapy or plain water. Looseness of the bowels, if excessive, is to be checked by the catechu and chalk mixture, with the addition of laudanum, if necessary, to a grown-up person. (See PRE SCRIPTIONS-CHALK Bleeding from the bowels is restrained by a half to one tea spoonful of liquid extract of ergot (spurred rye) if it is obtainable, to be given every two or three hours, as long as required. Failing that, 10 to 15 drops of turpentine every three or four hours, for several doses, may be given in a little olive-oil. Turpentine, indeed, is an excellent drug given all through the disease, 2 to 5 drops in a half to one tea-spoonful of olive-oil thrice daily. It corrects the fetor of the motions, and tends to prevent bleeding. Dilute sulphuric acid (10-15 drops) may also be given instead of these. If pain and swell ing of the belly occur, the remedy is laudanum, 10 drops in water, repeated every two or three hours, to keep down pain. As to stimulants, they are never to be given as a matter of course. They are valuable only in the later stages of the disease when weakness is exces sive, the pulse exceedingly feeble, &c. In such a case whisky or brandy is the best. It should be given in the following way: — A wine-glassful of whisky is mixed with a break fast-cupful of milk. Three or four tea-spoonfuls of the mixture are given at such intervals that the total quantity is not all used up for twenty four hours. In extreme cases double this quantity may be necessary. But it should always be given in the way described, as thus one knows exactly how much is being given. The vessel containing the whisky and milk should, of course, be kept covered.