Some Extracts from a Lecture on Enteric Fever

Kai Tiaki : the journal of the nurses of New Zealand, Volume VI, Issue 2, 1 April 1913, Page 56

Some Extracts from a Lecture on Enteric Fever

Guthrie Hawkins

By

M.D., F.R.C.S., published m

"The Hospital."

The incubation period of enteric fever varies within considerable limits, but the average duration may be taken as approximately twelve days. It is not unlikely that incubation may be influenced by the degree of concentration of the poison, the violence of the germ, and the avenue by which it gains access to the economy.

Symptoms. — The disease usually comes on insidiously, and during the incubation period, little more may be complained of than lassitude, pains m the limbs, and nausea, together with headache, and insomnia, which are early symptoms of special importance. This initiation is sometimes announced by rigors. In the first week the malaise of the prodromal period becomes more pronounced, epistaxis is of frequent occurrence, and the patient becomes feverish and restless at night. The temperature steadily increases, the evening records being about 1° higher each day. The pulse is accelerated, of full volume, but low m tension and often dicrotic. The tongue is small and pointed, red at the tip and edges, with its papillae unduly prominent. There is already some distension of the abdomen, with tenderness which is specially marked m the right iliac fossa, where there is gurgling on deep pressure. The headache continues, giddiness is often complained of on sitting up, and, at night, some degree of mental wanderings may set m. The bowels are either slightly relaxed or obstinately confined, at the end of the week approaches the spleen is found to be increased m size, and the first crop of rose-coloured spots appear, usually over the lower chest and abdomen. These spots are well defined and raised above the surface, round or oval m shape from 1 to 3 millimetres m diameter and of a pinkish or rose colour, which disappears on pressure, but never becomes petechial. They may be few m number and easily overlooked, but, m some cases are so numerous as to

attract immediate attention. The eruption occurs m successive crops of spots, each crop lasting about four days, and the first usually declaring itself between the sixth and twelfth day of the disease. The urine presents the usual fibrile changes, but does not necessarily contain albumen. Bronchial catarrh is not an uncommon incident during the first week.

In the second week the symptoms of the first week are aggravated, and the temperature continues at a high level with only slight morning remissions. The headache, which rarely continues beyond the tenth day, is replaced by mental dullness and stupor, and there is a frequent accompaniment of deafness, and buzzing m one or both ears.

The tongue becomes, dry, glazed, and cracked, and sores accumulate round the teeth. The typanitis and iliac forsa tenderness increase, and there may be more or less profuse diarrhoea, though constipation continues the feature of many cases.

The stools where loose, assume the typical pea-soup colour with which we are familiar.

During the third week the temperature chart begins to show a daily variation of about 2°. Instead of remaining, as during the second week, at a fairly uniform level, it falls lower and lower each morning, while the evening record, though also declining comes down more gradually, the morning temperature may thus, m four or five days, reach ( .)S° or 99°, while m the evening it still touches 101° or 1 .02". The pulse usually ranges from 100 to 120. There is marked weakness ; more or less pronounced meteorism ; an increased number of stools if there 4 , be diarrhoea ; and a condition of general prostration — manifested by drowsiness, low muttering delirium, muscular tremors, subsultus tendinum, carphologia, and irresponsiveness to the attentions of m those

attendance — which is known as the " typhoid state." Bed-sores are apt. to form over the sacrum and other prominent parts.

Complications and Immunity. — It is during this week that the pulmonary complications, cardiac failure, haemorrhage from the bowel, and perforation arc most to be feared. In the case of haemorrhage, the blood which is evacuated will be bright if its source is an artery which has been perforated during the separation of a slough, but dark if it proceeds from a general oozing m the congested areas of the bowel. A moderate bleeding may occur without seriously disturbing the ordinary course of events, but if the amount is copious and of sudden onset, the patient becomes cold, blanched, collapsed, pulseless, and his temperature falls 2° or 3°. The most alarming feature about haemorrhage is the possibility of its being the forerunner of perforation.

In favourable cases, the fourth week is the week of convalescence. The diarrhoea previously present, subsides ; the tongue moistens, and cleans ; the temperature gradually sinks to normal ; and the appetite is restored or may become exaggerated. In severe cases the urgent symptoms of the third week continue m an aggravated degree, and convalescence may be delayed till the fifth or even the sixth week.

One attack does not confer any lasting immunity from risk of recurrence m anything like the same degree as is the rule m other infective fevers. Relapses are always to be dreaded ; they occur m from 6 to 10 per cent, of all cases and one or more may happen, they must be regarded as autogenous reinfections, and usually set m within two or three weeks after complete defervescence has been established. This sketch describes m broad outline the course of a typical case, but there are certain deviations from the usual, so important that they must be referred to.

Deviation from the Normal. — Instead of being gradual the invasion may be sudden and acute with (a) nervous manifestations — delirium, meningitis, convulsions and mania ; (b) pulmonary symptoms — bronchitis, pneumonia, pleurisy ; (c) gastrointestinal symptoms — uncontrollable vomiting, intense diarrhoea, intestinal haemorrhage, perforation : (d) renal symptom*, nephritis, suppression of urine.

A very obscure and dangerous variety of invasion is that known as the ambulatory form of the disease, when the patient fights against the minor early symptoms of his complaint and remains at work until some acute development, .or debility, compels him to take to his bed. Many ambulatory cases are responsible for the acute modes of onset which have been enumerated. When the temperature follows the usual course it climbs by a step like arrangement during the first week, the evening records being from 1° to 1.5° higher than that of the morning. Having reached its height, which may be 104° or 105° m the evening, the fever persists during the second week with but slight morning remissions. During the third week it becomes distinctly remittant. with an alternation between morning and evening of 3° or 4°. In irregular cases the initial temperature may be high — 103° or 104° or the usual curve may be reversed and show a high morning and lower evening record.

Hyperpyrexia is uncommon, but may happen before death. Dietary error, mental upset, or physical exertion may cause a temporary rise of temperature to 102° or 103° some days after normal defervescence has taken place. The behaviour of the temperature during a relapse is a repetition of the original, but it is usually lower, and rarely persists for more than two weeks. Gerhardt has described cases m which there has been no temperature disturbance. Fresh crops of the typical rose-rash are seldom met with after the beginning of the third week. Tn about one-fourth of all cases no rash is discoverable ; this is most frequently the case m children. Accidental rashes — erythema, urticaria, herpes, etc., sometimes occur m the early stages of the illness. They are probably toxaemic. Miliaria and sudamina are common m cases where there is a profuse perspiration. Oedema may occur, and is due either to anaemia, nephritis, or thrombosis. A peculiar odour is exhaled from the surface of the

body m many patients. . . Larygnitis, bronchitis, pleurisy and pneumonia may all occur as incidents m the course of an attack of enteric fever. It is important to remember that pneumonia often with obscure physical signs, may be the initial manifestation of the disease.

An early symptom m obscure cases. — When diarrhoea occurs it is most probably

more dependent upon an intestinal catarrh than upon extensive ulceration. It is generally most troublesome during and after the second week. The evacuations are then offensive, of a pea soup consistence and appearance ; and may contain m the third week, fragments of slough. There is always some flatulent distension of the abdomen, but extreme meteorism is to be regarded as an evil omen. Haemorrhage from the bowel is most frequent after the second week, when it occurs earlier it is probably due to a congested state of the mucous membranes, and not to ulceration.

The spleen is enlarged, and m the majority of cases can be felt below the costal arch, sometimes as early as the beginning of the second week. The liver may be enlarged, with an accompanying slight jaundice, but this is rare.

The most serious complications of enteric fever are intestinal haemorrhage and perforation. They may occur together and are most to be feared m the third week. Peritonitis is a common cause of death and may arise either from perforation through the floor of a Peyer's patch, or from extension through peritoneal coat or from inflamed mesenteric glands. When it occurs peritonitis is not always ushered m with severe symptoms. It may develop insidiously, and may even escape detection. This is explained by two considerations : (a) the blunted sensations of the patient ; and (b the limited area of the perforation, which allows the infecting agents to reach the peritoneum very slowly. In suspicious cases persistent hiccough is a symptom of important significance.

Further Complications. — Appendicitis may complicate the illness, either as an independent affection or as the result of a typhoid ulceration of the appendical walls. Myocarditis is responsible for many fatalities. All varieties of pulmonary and pleuritic inflammation may interrupt convalescence. Repeated rigors sometimes occur during the period of defervescence and, despite the alarm they cause, usually pass off without the development of any explanatory cause ; they are probably dependent upon a slight and passing toxaemia. Venous thrombosis is always a danger to be feared, it occurs most frequently m the femoral veins. Arteritis and phlebitis are also met

with occasionally m the course of convalescence. Periostitis or necrosis, most commonly involving the ribs., tibiae, or femurs, are well recognised complication. They occur most frequently m young patients m whom the osseous tissues have not reached then full development. Cardtitis, though infrequent, is of serious, often fatal, import. Orchitis occasionally happens, and is usually unilateral. Ulceration of the larynx occurs m a small proportion of cases, and is always a formidable incident.

A sequelae of enteric fever which is too often overlooked is cholecystitis. Its importance as regards the subsequent occurrence of gall-stones or other gall bladder conditions cannot be too strongly emphasised.

Many nervous disorders are traced back to an attack of enteric fever, but it is always difficult to be sure how far cause and effect are directly related.

The morbid changes associatied with enteric fever are, as you know, primarily situated m the lymphoid tissues of the intestine. The intestinal mucous membrane is more or less involved m a catarrhal process, upon the severity and extent of which the amount of diarrhoea m great measure depends Peyer's patches and the solitary follicles exhibit a series of changes which differ according to the period of hyperaemia, ulceration, necrosis or cicatricial repair at which they are observed. The patches and follicles near the iled-caecal valve are those most seriously involved, and the process spreads upwards. The mesenteric glands are usually hyperaemic swollen and hard, especially m the neighbourhood of the intestinal lesions. The spleen is always enlarged ; the liver and kidneys are congested ; the heart is frequently soft and flabby, and the lungs may be cedemalous or congested at their bases. The bone marrowshows changes similar to those m the eymphoid tissues of the bowel.

There is perhaps no disease m which the ultimate issue so much depends on the careful and judicious management of the patient, and there is none other, m which death threatens from so many quarters. The older the patient the more serious the outlook. The disease is always more serious m hot, Ml 7

than m cool weather. Hyperpyrexia is a very unfavourable symptom.

Fat subjects never stand enteric fever well. The mortality m women is greater than m men. An abundant diuresis throughout the illness is a good prognostic feature. In cases where there is copious and repeated haemorrhage, the ultimate issue is specially uncertain. The occurrence of perforation makes a fatal issue almost certain unless surgical measures can be adopted effectively and at once. Heart failure is the most serious risk of all m uncomplicated cases. A small and irregulaf pulse is ominous and should always give rise to anxiety, if it reaches or exceeds 140. Patients whose constitutions are undermined by the abuse of alcohol are especially liable to succumb to the disease.

Aiming at the Diagnosis. — The diagnosis m a well marked ease, is very simple, especially after the first week, but a mild attack may make a firm diagnosis difficult. When enteric fever is prevalent m a neighbourhood its occurrence of persistent headache, anorexia, insomnia, general feebleness, and epistaxis should excite supsicion that the sufferer is smitten with the disease. If to these early manifestations there becomes added a remittent temperature a soft dicrotic pulse and a slight hectic flush over the malar prominences, strength is given to the original misgivings, and these are finally confirmed by the occurrence of tympeinitis, tenderness and gurgling m the right iliac forsa. the characteristic rose-rash and a positive widal reaction. The agglutination test of widal is not usually obtainable before the sixth or seventh day of the disease and may be much later

A blood examination sometimes enables a definite conclusion to be arrived at earlier than by any other method of investigation.

From 5 to 10 c.c. of blood should be withdrawn from the median basilic vein by means of a fine syringe and forthwith incubated m nutrient solution. In positive cases a growth is usuall obtained m from 24 to 48 hours.

Treatment. — There is no specific treatment for enteric fever Careful nursing and a suitable dietary are the essentials of management. The patient should be put to bed at the earliest possible moment, m a large well -ventilated room, and m a house beyond suspicion of sanitary fault.

This is important m private practice, because if the drainage system or the water supply of the house where the patient was first taken ill is suspected bis removal is imperative.

Milk should be the mainstay of the dietary m the large proportion of cases. Three pints distributed over the hourly and four hours and given m repeated small quantities serves all the requirements of most cases. The milk may be scalded, or peptonised, or mixed with barley water, according to indications. These are to be obtained from c ireful and repeated examinations of the stools. If masses of curd are found means must be taken to provide for the better digestion of the milk. The weak point m an all-milk dietary is that it falls somewhat short m carbo-hydrates, this may be provided for by adding one tcaspoonful of maltine to the milk three or four times a day. If after a time the milk becomes distasteful, it may be made more palatable by flavouring with tea, coffee, orange, or lemon. In those eases where it cannot be tolerated, no matter how disguised, recourse must be had to whey, mutton, or chicken broth, and jellies prepared from mutton, veal or fowl. Eggs may be given m the form of albumen water. Cold water or ice to quench thirst should be permitted freely, indeed, the patient should be encouraged to drink water to the extent of two or three pints m the 24 hours. Alcohol is not necessary until there is delirium, subsultus tendinum inclinations of cardiac trouble. It has recently become the custom with certain physicians to advocate a much more liberal dietary, and some go to the length of recommending solid food, particularly meat, whenever a genuine desire is expressed for it by the patient, and when his physical condition is such as to interpose no reasonable objections.

It is very likely that the milk alone dietary is more spartan than is absolutely necessary but it answers extremely well m this hospital, and we must not forget that the experience of many men go to prove that relapse appears to be directly due, m many instances, to the too early administration of solid food.

In favourable cases, though solid food may be of doubtful advantage, the gradual addition of soluble and easily assimilable substances to the milk, such as custards, jellies.

Blanc manges, junkets, bread jelly, potatocream, pounded fish, tea, coffee, cocoa, etc., is m our experience here not only justified, but desirable. Two conditions, mmy own practice, guide me to these additions : A normal morning temperature, and an expression on the part of the patient of a desi re for more food.

The Danger of Pyrexia. — Pyrexia is one of the phenomena of enteric fever which demands careful watching .Its persistence is not without danger and it ought m every case to be controlled by the local application of cold m one form or another. A bath is the best means of adoption, and when available should be had recourse to whenever the temperature reaches 102° and 103°. The patient ought to be completely immersed m water of 85° to 70° F. When taken from the bath he should be wrapped m a dry sheet and put back to bed under a light blanket. It is often wise to administer a small quantity of brandy and hot water, and to apply hot bottles to the feet, so as to promote the circulation and overcome any depression produced by the cold. The number of baths must be regulated by the patient's condition, and the behaviour of his temperature. They may be repeated every six or eight hours if necessary. The only decided contra- indications to this bath plan of treatment are haemorrhage or peritonitis. When, for any reason the cold water is objected to, the bath may be made luke warm — at first 90° to 80° F., and gradually cooled 10° or 12° by the addition of cold water. Failing the bath the patient may be packed over the chest and abdomen with tepid or cold water clothes, or he may be surround by an ice cradle. Antipyretics are of no use m reducing temperature, unless m extreme cases where the application of cold produces no lasting effects on the pyrexia, where they are thus indicated quinine, being germicidal to the typhoid bacillus, is probably the best to choose and should be given m two doses of ten grains at six, and again at ten m the evening. With a view to limiting the activities of the bacillus, many intestinal antiseptics have been recommended. A few of the more popular are chlorine water and quinine, perchloride of mercury with perchloride of iron, repeated small doses of calomel, carbolic acid, salol, salicylate of bismuth, napthol, essentia] oil of cinnamon, and so on. The weak point m all such forms

of medication is that the bacilli do not multiply m the intestinal canal alone, but grow as well m the blood, spleen mesenteric glands and intestinal walls. For these wards, salol is the antiseptic chosen m all cases, except those associated with copious diarrhce'a, when it is replaced by small doses of Dover's powder with salicytate of bismuth If the urine is found to contain bacilli urotropine m ten grain doses may be com bined with salol.

Abdomenal distension, when excessive, is relieved by the administration of charcoal, or by local application of turpentine stupes, or by enamata of valerian, or turpentine, or by the passage of a long rectal tube. A moderate diarrhoea may be left alone, but if the evacuations exceed four or five daily they should be controlled by the B.P. pill of lead and opium, or by enemata of starch and laudanum. Constipation on the other hand, must be combated by a simple enema given every alternate morning, with an occasional small dose of calomel at night followed by a morning saline draught. Haemorrhage of moderate amount need not excite alarm, but when copious it must be controlled by opium m full doses, combined with chalk mixture, gallic acid hamamelis ergotine, or adrenolin chloride. The occurrence of haemorrhage is an indication for the addition to each pint of milk of twenty grains of calcium chloride. In cases where the haemorrhage is so copious as to induce collapse, the subcutaneous or intravenous injection of saline solution must never he omitted. The occurrence of perforation demands surgical interference as the only hope of saving life.

Threatened cardiac failure is the indication for the free administration of alcohol, accompanied, if need be, by the hypodermic injection of strychnine digitalin, ether or caffein. Where there is persistent insomnia paraldehyde, chloralamide, bromural, or trional may be given at bed time.

A serum prepared from the horse is now used m some cases, and is stated to influence favourably the course of the disease. The usual dose is 10 c.c. Chantemesse combines serum injections with cold baths and claims to have achieved encouraging results, especially m patients to whom the serum has been administered during the first week of illness.

Bed-sores must be guarded against, and, m most cases, it is wise to put the patient on a water bed early m the course of his illness. When convalescence is established an ordinary mixed diet may be gradually resumed and recovery of strength will be promoted by suitable tonics and change of air.

Infection and Sanitation. — Prophylactic measures of sanitation, and not least among them compulsory notification, have done much to reduce the prevalence of enteric fever. The disease according to Collies' statement, " does not spread any great distance when the ventilation is good, the cubic space abundant, and the general sanitary arrangements satisfactory. When enteric fever is prevalent m a neighbourhood, drinking water and milk should be boiled before use and the skin should be entirely removed from raw fruit before eating. Food supplies from suspected quarters of contamination are to be avoided, and all varieties of mineral water should be forbidden until it is ascertained that the water used m the manufacture has been boiled or condensed and that the bottles and corks have been properly sterilised.

Persons exposed to special risks of infection should be inoculated with anti-typhoid vaccine at the earliest opportunity.

It is abundantly proved that persons who have suffered from enteric fever may convey infection to others for many years after they themselves have recovered. When it happens that one or more cases, otherwise unexplained, occur among those who are m close association with such a person, he should be suspected, and if the typhoid bacillus is found m the faeces or urine, or if Widal's agglutination test is positive he must be isolated. He is what is known as a typhoid carrier and may unconsciously infect milk water or other articles of diet, even if he is not directly a source of danger. His treatment is a matter of great difficulty, but he must be kept under observation and every effort made by the use of vaccines, w w ith intestinal and urinary antiseptics, to free him

from the presence of the offending organisms. When by such measure this freedom is not obtained, the question of draining the gall bladder and bile ducts may be entertained.

Preventive Measures. — The following preventive precautions should be adopted m the conduct of every case : —

1. The mattresses and pillows, or such of them as are likely to become soiled with discharges, should be protected with rubber covers.

2. The bed and body linen should be changed daily.

3. All linen, etc., removed from the patient must be wrapped immediately m a sheet wrung out of carbolic solution 1-20 or 2 per cent, lysol, allowed to soak for six hours and then boiled.

4. Feeding utensils, after use, must be washed at once m boiling water.

5. The evacuations, both of bowel and bladder, should be received into a bed-pan containing half a pint of carbolic acid or lysol solution, and after they are passed-, a further and larger quantity of the antiseptic solution should be added.

6. When death occurs, burial should follow without undue delay, the body being freely sprinkled with strong carbolic acid and coffined within a few hours of death. When consent can be obtained cremation should always be preferred to burial.

7. When recovery takes place the room occupied by the patient and all its contents must be subjected to the most thorough disinfection, according to approved methods.

8. The nurses m attendance should wear overalls and rubber gloves when their duties demand contact with the patient. The hands should be repeatedly washed m an antiseptic solution, and it is a safe precaution from time to time to rinse out the mouth and throat with a similar fluid of suitable strength.

9. Every care must be taken that the patient after convalescence, or those who have been m attendance upon him, do not unwittingly become, though apparently well, carriers of infection.