Paratyphoid fever

“ The granular degenerations of the heart, liver, and kidneys, as a whole, usually occur simultaneously, and afford a most important means for the post-mortem recognition of the infective diseases. The condition is therefore to be looked for in the exanthemata, especially in small-pox and scarlet fever, also in erysipelas, septicæmia in its manifold forms, diphtheria, typhoid and typhus fevers, cerebro-spinal meningitis, etc. A common feature in all these cases is the occurrence of fever, and it has been claimed that this element is the cause of the degeneration. ”

“ Cause.—The parasite, which lives in the blood and tissues, is known, but its exact method of transmission to man is still in the realm of uncertainty.
Symptoms.—The disease begins in an indefinite manner and then assumes the form of a continued fever, associated with enlargement of the spleen and liver and progressive emaciation. Bleeding from the nose is not uncommon, and in Europeans the peculiar earthy-grey colour of the skin is very striking. The disease lasts for months and even years and is very frequently fatal. ”

“ From a review of the commotions excited in the system by bleeding, a reason may be given why the physicians, who do not bleed in the depressed state of the pulse, have so few patients in what they call malignant fevers, compared with those who use a contrary practice. The disease, in such cases, being locked up, is not permitted to unfold its true character; and hence patients are said to die of apoplexy, lethargy, cholera, dysentery, or nervous fever, who, under a different treatment, would have exhibited all the marks of an ordinary malignant fever. ”

“ When persons have lived for a long time in malarial regions, the intermittency of the chill and fever is less noticeable and the continuous character of the fever often leads the disease to be mistaken for typhoid. The intermittent regularity of the fever, however, although between attacks the temperature never falls to normal, distinguishes this type of malarial fever from true typhoid. The positive determination of the disease is possible by an examination of the patient's blood, in which the malarial parasite can readily be found. ”

“ Sternberg accompanied these gentlemen to the Santo Spirito Hospital, where a most satisfactory demonstration was made to him of the presence and amœboid movements of the parasite, in blood drawn from the finger of a patient in the first stage of a malarial paroxysm. Marchiafara and Celli have induced types of intermittent fever, in previously healthy persons, by injecting into the circulation a small quantity of blood drawn from a malarial patient during his fever. ”

“ While certain cases, or even epidemics, of malarial fevers are attended by remarkable adynamia, often manifesting itself from the very incipiency of attacks, it differs widely from that utter nervous ataxia which characterizes typhoid fever. Again, the adynamia of malarial attacks is generally ascribable to some cause not essential to those affections. Imperfect reaction from a chill, long persistent hyperpyrexia, diarrhoea or vomiting, or chronic paludal cachexia, or, it may be, some epidemic influence, may produce it. The ataxia of typhoid fever is part of its morbid process. ”

“ Jefferson Randolph Kean declared that "Typhoid fever is today, on account of its wide dissemination, the persistent vitality of its infecting organism, the duration and severity of its attack and its large death rate, the most formidable infectious disease with which we have to contend in military life." ”

“ The contagion, -like that of typhus, appears to be most active in the immediate vicinity of the patient and to be greatly lessened by the access of fresh air. It is capable of being conveyed by clothing. The incubation of the disease is about one week. The symptoms of the fever then show themselves with great abruptness and violence by a rigor, accompanied with pains in the limbs and severe headache. ”

“ Typhus fever may, however, prove fatal during any stage of its progress and in the early convalescence, either from sudden failure of the heart's action—a condition which is specially apt to arise—from the supervention of some nervous symptoms, such as meningitis or of deepening coma, or from some other complication, such as bronchitis. ”

“ When the fit is prolonged and periodicity is marked by only a slight fall of temperature, a slight sweating, a slight feeling of chilliness, the fever is said to remit to be a remittent. Sometimes there is no remission; such a fever is said to be continued. It occasionally happens that two distinct pyrexial attacks come off the same day; such a fever is said to be double. All sorts of blendings of malignant infections, benign tertians, and quartans occur; in such the infection is said to be a mixed infection. ”

“ When a daily paroxysm occurs, this is believed to be due to the alternate development of two groups of parasites of the tertian variety, as it has not been possible to distinguish the parasite found in the blood of persons suffering from a quotidian form of intermittent fever from that of the tertian form. Very often, also, the daily paroxysm occurs on succeeding days at a different hour, while the paroxysm every alternate day at the same hour is a fact which sustains the view that we have to deal, in such cases, with two broods of the tertian parasite which mature on alternate days. ”

“ There is no real immunity to malaria, it is a continuance of the infection, but the parasites are not in sufficient numbers to give rise to fever. If, however, the patient becomes chilled or fatigued or otherwise depressed, fever results. ”

“ In those animals in which death occurs within a few days of infection the parasites become very numerous, and, after one or two oscillations of temperature, death occurs suddenly. In those animals in which death is delayed a very striking cachexia is established. There is a chronic recurring fever, the numbers of parasites visible in the blood being greatest during the febrile accessions; there is also a peculiar firm oedema from infiltration of coagulable lymph into the connective tissue of the neck, abdomen, sheath of penis, genitals, and limbs ”

“ Thus the introduction of another sensorial power, that of sensation, converts an intermittent fever into a continued one. If it be attended with strong pulse, it is termed febris sensitiva irritata, or pyrexia, or inflammation; if with a weak pulse, it is termed febris sensitiva inirritata, or typhus gravior, or malignant fever. The seat of the inflammation is in the glandular or capillary system, as it consists in the secretion of new fluids, or new fibres, which form new vessels, as they harden, like the silk of the silk-worm. ”

“ It not unfrequently happened that persons, who had passed through the different stages of the disease, and were advancing rapidly to convalescence, were suddenly seized with an affection of the chest, pleurisy, bronchitis or pneumonia, and speedily carried off by the violence of the inflammation. The skin, exquisitely sensible in its denuded state to atmospherical vicissitudes, transmits with great promptness the morbid impression to the lungs, already prone to take on disease, in consequence of the active part they are compelled to play during the eruptive fever. ”

“ Suppuration of the tissues involved is common in the severer forms. Should the tongue become dark and diarrhea set in, attended with great prostration, the case is very serious, and energetic means must be employed to save life. A retrocession of the inflammation from the surface to a vital organ is an extremely dangerous symptom. The disease is not regarded as contagious, but has been known to become epidemic.
Treatment. The treatment during the initial stage of this disease should correspond with the general principles laid down for the treatment of fever. ”

“ The parasite associated with each of these types of fever may be recognized by an expert, and there is no longer any doubt that the difference in type is due to the fact that different varieties or 'species' of the malarial parasite exist, each having a different period of development. Blood drawn during a febrile paroxysm shows the parasite in its different stages of intra-corpuscular development. The final result of this development is a segmenting body, having pigment granules at its center, which occupies the greater part of the interior of the red corpuscle. ”

“ As a rule the disease begins with headache, stiffness of the neck and chilly sensations. There may be vomiting, and the temperature is raised. The mind is often confused, and the patient may be delirious. The skin eruption, which occurs especially on the back and about the joints, and which is responsible for the name “spotted fever,” is not very frequently seen, and can hardly ever be detected on a dark skin. In very bad cases there is violent delirium, laboured breathing, and a purulent discharge from the nostrils. ”

“ Further, it is only at this stage that the disease can be artificially transferred from one man to another. All efforts to transmit the gametocytes have ended in failure.
Hæmamœba vivax, which causes the tertian fever, passes through the various stages of its life-history in man in forty-eight hours; hence the febrile paroxysm occurs every second day. Malaria is usually of the tertian type, and this is certainly the most common form in temperate climates. ”

“ Probably the most enduring immunity is in smallpox, although cases are known of two and even three attacks; the immunity is high in scarlet fever, measles, mumps and typhoid fever. The immunity from diphtheria is short, and in pneumonia, although there must be a temporary immunity, future susceptibility to the disease is probably increased. In certain cases the immunity is only local; the focus of disease heals because the tissue there has evolved means of protection from the parasite, but if any other part of the body be infected, the disease pursues the usual course. ”

“ They are at all times too serious to be left, with safety, in the hands of the domestic practitioner. Medical aid, therefore, should be instantly sought for, as much depends on proper management during the first stage of the fever. The approach of this disease may be known, by attending to the symptoms which precede the eruption, in the following order: First, the patient complains of shivering, with a sense of coldness, a thin watery discharge from the nose, hoarseness, cough, and a continued flow of tears from the eyes, which appear red and inflamed. ”

“ In some instances the first paroxysm is so violent as to destroy life in a few hours, while in others it comes on insidiously, the first one or two paroxysms being comparatively mild. It is frequently characterized by stupor, delirium, a marble-like coldness of the surface, vomiting and purging, jaundice, or hemorrhage from the nose and bowels. In America this fever is only met with in the Mississippi valley, and in other localities where the air contains a large quantity of malarial poison. ”

“ Those that died showed all the symptoms of what is called spontaneous splenic fever. The period of incubation lasted as long as eight or ten days, although, in its latter stages, the disease exhibited those startling features which have caused a belief that the incubating period is a very short one—short, that is to say, for those conditions of contagion where the parasite is not deposited in its pure state under the animal's skin. ”

“ That such a cause exists, he proves from observing that “of any number of men, one half of whom go near a person ill of a fever, and the other half do not, a greater number of the former will be infected, in a short period afterwards, than in those who do not.” He says he has known, in such circumstances, seven out of nine infected with the disease. This infection is not discoverable by smell or any other organ of sense; neither can the greatest attention to cleanliness disarm it of its malignity. ”

“ When it is not prevalent the diagnosis is never easy, and in pneumonia and septicaemic cases it is impossible without bacteriological assistance. The earliest cases have hardly ever been even suspected at the time in any outbreak in a fresh locality. It may be taken at first for almost any fever, particularly typhoid, or for venereal disease or lymphangitis. In plague countries the diseases with which it is most liable to be confounded are malaria, relapsing fever and typhus, or broncho-pneumonia in pneumonia cases. ”

“ We have already seen how, in the course of various diseases, the pulse is quickened, and the temperature raised, constituting that state which we commonly call fever, but as the local ailment subsides the fever disappears. There is, apart from smallpox, measles, and the other so-called eruptive fevers, only one real essential fever commonly met with in childhood, and that is what the doctors call typhoid fever. ”

“ One attack usually confers immunity.
Symptoms.—Incubation is about three to four days. There may be a fore-warning period, but the attack is usually sudden, with chills, headache, backache, rise in fever, and general feverish symptoms, vomiting, and constipation. Early in this disease the face is flushed, while the conjunctiva and the mucous membrane lining the eyelids is congested and slightly jaundiced. Fever is 102 or 103 degrees, and falls gradually after one to three days. Pulse is slow, and while the temperature rises, it again falls. ”