TYPHOID TEVEK. 599 TYPHOID FEVER. day the patient presents the typical appearance of enteric fever, lie is dull, listless, and apa- thetic, the eyes are lirijihl. the ])U|)ils dilated, the face pale, with Hushed cheeks and dark lips. The tongue is dry and red, with a hand of white fur on each side. At the end of the lirst week a rose-pink rash appears on the abdomen. It con- sists of from ten to thirty raised circular spots, which fade on pressure. These spots last only two or three days, but successive crops appear. The abdomen is distended and tender, and several ollcnsive yellow stools may 1)C passed daily. Death may occur at the end of the second week, from hemorrhage or ])crforation of the bowel. The third week is marked by great weakness, muscular tremors, delirium, and failing heart, although the fever is slowly dropping, and death may take place from exhaustion. Hemorrhage of the bowel is heralded by a rapid collapse. Convalescence in the average case sets in during the fourth week. The fever abates and appetite and strength gradually return. In a certain num- ber of eases relapses occur ; these are, as a rule, shorter and milder than the original attack, but are similar in character. One attack of enteric fever confers iuunnnity from others. The mortal- ity ranges from 10 to 30 per cent. There are several clinical varieties of typhoid fever. Mild and abortirc forms are characterized by a shorter course and speedy recovery (S to 10 days), although the onset may be sudden and severe and the symptoms similar in kind to the graver attacks. In the latent or ainbiilafon/ type the onset is mild and the patient does not take to his bed until the disease is well advanced. Hem- orrhage or perforation of the bowel may be the first marked symptom of this type; in other in- -stances delirium sets in and the patient goes through a very severe attack. This form is very fatal. Beiiwrrhag-ic typhoid is a rare form char- acterized by cutaneous or mucous hemorrhages. Kxeoptionally. typhoid runs its course ^^'ithout elevation of temperature (the nfcbrile type). To prevent the spread of typhoid the following precautions are observed. The stools and urine of patients are thoroughly disinfected by im- mersion in strong solutions of corrosive sub- limate, carbolic acid, or chlorinated lime. In districts having a defective drainage system the dejecta may finally be disposed of by mixing with sawdust and burning or burying in trenches after satiiration with chloride of lime. Bed pans, rec- tal thermometers, syringes, tubes, and all other utensils coming in contact with the patient's dis- charges are disinfected by boiling and immersion in antiseptic solutions. Bedclothes and linen are similarly disinfected. During epidemics drinking water and milk should be boiled and raw vege- tables such as lettuce and celery avoided. Careful nursing and regulated diet are of first importance in the treatment. The patient is strictly confined to bed from the beginning of the disease until the temperature has been normal for at least a week. A liquid diet has been found best throughout the course of the attack. The best food is milk, to which may be added lime water or vichy : or it may be pe]itonized. Broths, con- somme, albumen water, or beef juice are giv- en where milk disagrees or to vary the diet. The patient is urged to take plenty of cool water, and the juice of an orange or lemon may be given at intervals. Food is taken about everv three hours during the day, and once or twice at night if there is great exhaustion. Control of the fever is the most important ele- ment in the direct treatment of typhoid, and this is best accomplished by means of cold water, by sponging, the wet pack, and bathing. Sponging is valuable when a full bath cannot be given and for children and delicate persons. The cold pack consists in ttrap])ing the patient in a sheet w rung out of water at (10° or 0.5° and sprinkling cold water over the body with an ordinary watering |)ot or similar device. The full bath, or "cold tubbing.' was introduced by Brand of Ciermany, and this treatment is now almost universally followed in hospitals. By its use the fever is re- <luced, sleep is obtained, all the symptoms are rendered less intense, and the mortality greatly lowered. In giving the Brand bath the entire body except the head is inuncrsed in w-ater, be- ginning at a temperature of 70°, which is grad- ually lowered by adding pieces of ice. The bath lasts 15 or 20 minutes and is given whenever the fever rises above I02li>° F., or on an average of once in three hours. Vigorous rubbing of the trunk (with the exception of the abdomen) and extremities in oi'der to prevent chilling and to increase the stimulating etl'ect of the bath is kept up while the patient is immersed. After tubbing the patient is wrapped in bkinkets and hot-water bottles put to the feet. This pro- cedure is usuall.v followed by a refreshing sleep. The drug treatment of typhoid is symptomatic. Bathing renders febrifuges unnecessary. Antipy- rine and phenacetin are sometimes given, but they tend to depress the heart. Intestinal anti- septics, such as turpentine, salol, and carbolic acid, render the stools less offensive and prevent the i)ioduction of gas. Return to solid food must be gradual on account of the danger of perfora- tion through intestinal ulcers. WiD.^^L's Te.st for Typhoio Fever. This is a com- paratively newly discovered method of diagnosis. It depends upon the fact that the blood of ty- phoid-fever patients acquires the property of causing a reaction when brought into contact with active typhoid bacilli. In the actual test a small amount of blood or serum (either fresh or dried), diluted, is mixed with a fresh pure culture of the typhoid bacillus. The result may be watched in a hanging drop with a high-power lens. It con- sists in a destruction of the motility of the bacilli and their agglutination, that is their collection into larger or smaller chnnps. The reaction may not occur in the first stages of the disease. A positive result with quite dilute serum makes the diagnosis of typhoid almo.st certain, al- though the reaction does sometimes occur in other diseases, especially in the one often most difficult to differentiate clinically from typhoid fever, namely acute miliary tidicrculosis. Serum inoculations for the prevention of t.v- phoid fever have been recently introduced. The method is known as Hafn<ine's. The fluid in- jected is an emulsion of the typhoid hacilljis after the bacilli have been killed by heat. Fa- vorable results from the use of this serum have been reported. See Serim Therapy. Consult Curschmann. "Typhus and Typhoid Fevers." in yothnufirl'.i Enciirlnpcdia ( Kng. trans., Philadelphia, 1 901 ) : Osier, fifudirs in Typhoid Ferers (Baltimore, 18051 and Pro6- lems of Typhoid Fever in the United S'late.t (ih.,
