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Enteric Fever

typhoid, disease, glands, poison, doubt, conditions and children

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fever is common in children. A large proportion of the cases formerly described as "Infantile Remittent Fever " were no doubt cases of this disease. Fortunately in young subjects typhoid fever usually runs a mild course. It would be, no doubt, too much to say that, properly treated and nursed, no child should die of typhoid ; but certainly when placed from the beginning under favourable conditions for recovery, death in the child from such a cause is very rare.

Infants and children clurin,g- the first four or five years of life seem less susceptible to the typhoid poison than at a later age. Perhaps, however, it is difficult to recognize the disease in such young subjects ; and it is not impossible that many cases of febrile diarrhoea in the young child may be cases of typhoid fever which have escaped recognition. Boys are more commonly affected than girls ; and the fever seems to attack by preference previously healthy children. At any rate the patients who are brought suffering frdm the disease to the Children's Hospitals are generally well nourished, strong-looking little persons, with exceptionally good histories.

Causation.—It is now well known that enteric fever arises as the con sequence of absorption into the system of a specific poison which is gen erated by the decomposing discharges of typhoid patients. It is therefore largely distributed by the emanations from cesspools and faulty drains. Warm weather, which encourages putrefaction, increases the prevalence of the fever. Dr. Murchison has shown, from the records of the London Fever Hospital, that cases of enteric fever become more numerous after the warmth of summer, and diminish in number after the cold of the winter months. Thus, in August, September, October, and November, the fever prevails. largely ; while in February, March, April, and May, it is much less frequently seen. Whether the poison can be generated de novo is a question which has been often debated and on which opposite opinions are held. It seems certain that the decomposition of ordinary fecal matter under ordinary conditions of atmosphere cannot produce it ; but it is probable that the specific poison may be generated from non-specific ordure under extraordinary conditions. At least, it is difficult under any other hypothesis to explain outbreaks of the fever in country villages where the strictest search fails to discover any means by which the disease can have been imported from without, and in which the same insanitary state has existed unchanged for years. There is no doubt that the dis

charges from the patient are highly contagious. The disease cannot, how ever, be communicated by the breath or by emanations from the skin. It is held by some that the discharges at first comparatively innocuous, and only become hurtful after putrefaction has begun.

The poison enters the system by the mucous membrane of the lungs or of the alimentary canal. In most cases, no doubt, contaminated water is the means by which it is conveyed. Several epidemics of typhoid fever in London, of late years, have been traced to milk to which water contain ing typhoid matter had been added. It is also probable that or faulty drains, allowing the effluvia of cesspools charged with the specific poison to penetrate into a house, may be another means of imparting the disease.

One attack of typhoid fever does not necessarily protect against anoth er ; and relapses are very common.

Morbid Anatomy.—The characteristic lesion in typhoid fever consists in a swelling of the solitary glands of the small intestine, of the agminated glands constituting Peyer's patches, and of the mesenteric glands in con nection with them. The swelling is a pure proliferation of the cellular elements, which are seen by the microscope to be much increased in num ber. Some corpuscles become enlarged and develop smaller cells within their walls. The hypertrophic change in the glands begins early, prob ably at the beginning of the disease, and proceeds rapidly. It involves a certain number of Peyer's patches. These are fully developed by the ninth or tenth clay, and form thick oval plates with abrupt edges and an uneven, mammilated surface. Their consistence is softer than natural, and more friable. The solitary glands may be unaffected ; but they also often swell and form small projections from the surface of the mucous mem brane. After reaching their full size the glands, in mild cases, begin slowly to shrink. The newly proliferated cells undergo a fatty degeneration and are absorbed. The mesenteric glands also diminish in size by the same process of fatty degeneration, and gradually resume their former dimensions.

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