CAUSE.– The poison of Enteric fever does not originate in decomposing sewage, but is transmitted buy the specific poison contained in the discharges from the bowels of the person infected with the fever, by percolating the soil into the wells which furnish drinking-water. It has been traced to the presence of a micro-organism called Eberth’s Bacillus, after its discover. Modern research has identifies other bacilli which can produce symptoms resembling those of typhoid (so-called Para- Typhoid), but Eberth’s bacillus (Bacillus Typhosus) is by far the most important agent. The question that most concerns us is of sewage, since the poison of Enteric fever is propagated by sewage and by sewage only, through the contaminations of water supplies or through contaminations of articles of diet eaten raw, like watercress of oysters, which may come into contact with infected sewage. That the poison is thus conveyed all are agreed, and therefore all alike concur in the necessity for eliminating the poison from our water, and our milk.
The problem of controlling and eliminating Enteric therefore is a problem of drainage and of water-supply. Drainage by cesspools is most unsatisfactory as the contents may leak into surrounding soil and there maintain possibilities of infection. Earth closets are safer and better in every way, when a system of water borne drainage, such as now exists in most towns, is impossible. The system of treatment of sewage by anaerobic bacteria in a septic tank can also be applied to house drainage in the country. As to water supply, water from surface wells should always be regarded as suspect, and if no other is available, it should be boiled before use. Surface wells are obviously liable to contamination from cesspools or leaking drains. When cisterns exist in a house they nee regular attention and cleaning, and the cistern overflow is still sometimes allowed (Wrongly) to communicate with a drain. This may permit sewage gases to ascend to the cistern water. It is doubtful it germs can be thus conveyed, as they do not seem to rise into air from a wet surface, but the poisoning by the gases is highly undesirable. Water closets too, still exist of dangerous patterns where the trapping is quite ineffective, and follows sewage air to enter the house.
Enteric fever shows a certain seasonal prevalence, the autumn being the most dangerous period of the year. It does not often attack persons above forty years of age.
SYMPTOMS.– These may be divided into (1) those of the accession, and (2) those of the three weekly periods.
Unless the poison is very concentrated, there is a p;period of incubation, varying from ten to twenty-one days, after which the disease sets in slowly and insidiously. The patient becomes languid and indisposed to exertion; is chilly and unwilling to leave the fire; the back aches and the legs tremble; the appetite fails, and there are even nausea and sickness; the tongue is white, the breath offensive, and often the throat is sore; the bowels are generally relaxed; the pulse is quickened, and the sleep disturbed. These symptoms gradually increasing, the patient has probably rigors, succeeded by heightened temperature, severe headache and such muscular debility that he takes to his bed. This is the accession. The course of the fever may now be divided into three weekly periods.
IST WEEK.– The prominent symptoms are — a gradual rise of temperature from day to day, with vascular excitement and nervous oppression, including a bounding pulse, 90 per minute or more, great heat of skin, thirst, and obscured mental facilities; the patient cannot give a coherent account of himself, complains of little except his head, and is usually delirious at night. The abdomen enlarges, is resonant on percussion, and there is tenderness or even pain on firm pressure, especially in the right iliac fossa, near the termination of the small intestine, where a peculiar gurgling sensation is conveyed to the fingers on pressure, As this is the site of most severe ulceration, the less the parts are handled here the better. During this week the patient may suffer from nose bleeding or deafness. The rose spots (Generally few in number) begin to appear on the body about the sixth day.
2ND WEEK.– Debility and emaciation become very marked, the muscles wasting as well as the fat; the urine is scanty and heavy, being loaded with urea from wasting of the nitrogenized tissues. During the second week there is also frequently diarrhoea, which often begins in the first week, and generally increases to five, six, or even more evacuations in twenty four hours. The specific characters of the evacuations are the following– Fluidity; pale ochre or drab colour; sickly putrid odour; absence of bile; a flocculent debris. This debris may be discovered by washing the discharges. It is also worth notice often before a patient takes to his bed, or looseness of the bowels sets in the faeces are of a light ochre colour, and furnish the most marked of the early signs of Enteric fever. in about a quarter of all cases there is constipation throughout. During the second week the so called Widal Reaction of the blood becomes manifest. It requires the expert, but is an admirable help in diagnosis of doubtful cases.
3RD WEEK.– The debility and emaciation become extreme; the patient lies extended on his back, sinking towards the foot of the bed, without making an effort to change or preserve his position. There is a bright and pinkish flush of the cheeks, which strongly contrasts with the surrounding pale skin; sordes occur on the mucous membrane of the mouth and lips; the tongue is dry and brown, or red and glazed, and often rough and stiff, like old leather; the urine is frequently retained from inaction of the bladder; the faeces pass without control; the tendons start from irregular, feeble contractions of the muscles; the patient picks vacantly at the bed-clothes, or grasps at black spots, like flies on the wing (Muscae volitantes), which appear before his eyes; he becomes deaf, no longer knows his friends, and on recovery will have little or no remembrance of anything that has at this time occurred, and in all probability his intellectual powers will be impaired for some time after convalescence.
In the majority of fatal cases; death about the end of the third week; and it is a notable fact that there seems to be no relation between the general symptoms and the ultimate issue, rendering the disease one of great uncertainty and perplexity.
THE ERUPTION.– From the seventh to the fourteenth day the characteristic eruption generally begins to show itself, chiefly on the sternum and epigastrium, in the form of rose-coloured dots, which are few in number, round, scarcely elevated, and insensibly fade into the natural hue of the surrounding skin. The quantity of the rash bears no proportion to the severity of the disease. This successive daily eruption, disappearing on pressure, each spot continuing visible for three or four days only, is peculiar to, and absolutely diagnostic of, Typhoid fever, (Aitken). The first crop of the eruption is rarely fully conclusive, but successive crops, even of not more than two or three spots each, remove all doubt. Although the rose coloured rash is never met with in any other disease, yet we have treated cases of Enteric fever without being able to detect a single spot. Occasionally, also very minute vesicles appear, looking like drops of sweat (sudamina), chiefly on the neck, chest, or abdomen.
TEMPERATURE.– The information afforded by the clinical thermometer in the diagnosis of Enteric fever is very important. In all the acute specific fevers the temperature is abnormally raised; in this, elevations is gradual, while in most others it is abrupt. During the first three or four days we have scarcely any symptoms to indicate the invasion of so serious a disease, except a gradual elevation of the temperature; but if, on the fourth or fifth day, the maximum temperature attained during the twenty-four hours be not 103C5* or 104*, the disease is most probably not Enteric fever. And, further, if on the first or second day the maximum temperature reaches 104*, the disease is some other acute fever, as the temperature only gradually attains such a degree in Enteric fever. At the commencement, the diagnosis is difficult, in asmuch as the characteristic rash does not usually appear before the sixth, sometimes not till the twelfth, day of the disease; and, indeed, in children, cannot sometimes be observed at any stage. Temperature is also an important element in the prognosis. Thus we have great variations in the temperature in Enteric fever, being low in the morning, and attaining its maximum degree in the evening. The greater these fluctuations at the end of the second week, the more favourable is the attack, and the shorter will be its duration. If the temperature falls considerably in the morning, even though the evening rise is considerable, the prognosis is favourable. On the other hand, should the temperature during the second week remain continuously high, we may predicate a severe and prolonged attack. Again, probably the first indication of improvement in cases of persistent elevation of the temperature is a decline in the morning temperature. When such a decline occurs, especially if it be repeated on subsequent days, even though the maximum temperature reached in the evening remain the same, we may be certain that the fever has begun to abate. It is true a sudden fall in the temperature may be consequent on Diarrhoea and Haemorrhage probably the latter when it takes place suddenly; but, usually, other symptoms would indicate such an occurrence. Unlike Typhus, the decline of the temperature is generally gradual.
LICENTIATE OF THE ROYAL COLLEGE OF PHYSICIANS; MEMBER OF THE ROYAL COLLEGE OF SURGEONS; LICENTIATE IN MIDWIFERY, LONDON AND EDINBURGH, ETC. PHYSICIAN TO THE READING AND BERKSHIRE HOMOEOPATHIC DISPENSARY.
Author of "The Stepping Stone to Homeopathy and Health,"
"Manual of Homoeopathic Treatment". Editor of "The Homoeopathic World."