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637

TYPHOID FEVER: CLINICAL FEATURES

frican Medical Journal Suid frikaanse Tydskrif vir GeneeskundeKaapstad 1 Augustus 1959eel 33

made to deal with the disposal of excreta, and to ensurethat all crockery and cooking utensils are sterilized afteruse. The attendant should not handle food eaten by otherpeople. Flies must be shut ou t from the sickroom.Curative TreatmentWhere the clinical picture is one of typhoid fever (pyrexiafor over a week, headache with apathy, distended abdomen,splenomegaly and leucopenia), specimens should always besent for laboratory confirmation, but t reatment must startimmediately without waiting for the results. The institution

of t reatment dur ing the early bacteraemic stage, before thePeyer s patches have s loughed to form ulcers, makes all thedifference between straightforward recovery, on the one hand,and non-recovery or recovery with complicat ions andsequelae, on the other.Curative t reatment augments but does not replacepreventive measures. Full treatment must be applied inevery single case irrespective of race or station failure willundermine the safety of every member of the public. Drug TreatmentChloromycetin (chloramphenicol) has revolutionized theout look in typhoid fever, an d it is essential to give it asearly as possible. It is taken orally at 8-hourly intervals;but i vomiting interferes with taking it, or excessive diarrhoeawith its absorption, it must be given by the intramuscular

route (or, if the new soluble preparation proves satisfactory,the intravenous).The starting dose in an adult depends on the weight-for an average female 075 g., for an average male 1 g.8-hourly. In children, 40-50 mg. per lb. body-weight perday is divided into three 8-hourly doses. This dosage is tobe continued until the tempera ture remains normal. Thisusually takes 4-7 days. Then the 8-hourly chloromycetinis continued, but in exactly half the previous dosage. Thetotal duration of the course is 14 days, after which the drugis stopped. Lengthening the per iod of treatment beyond 14days does not materially reduce the relapse rate, but shortening does increase it.Salicylate (aspirin) must most specifically be avoided. t

causes a sudden drop in temperature accompanied by serioussigns of collapse, with sweating, vomiting etc.Chloromycetin has reduced the mortali ty rate of typhoidfever from about 10 to well under 1, and the amount

of suffering correspondingly. Nevertheless the treatment timein bed remains much the same as before, and a very realdanger arises from the fact that a pa tient with a bowel fullof ulcers may feel relatively well.

No. 31olume 33

H. R ACKERMANN, M.B.. CH.B. APE TOWN), T.D.D. WALEs); R. RABKlN, M.B., CH.B., D.P.H. CAPE TOWN);and A. CAVVADAS, M.B. CH.B. CAPE TOWN); ity Hospital for Infectious Diseases ape Town

DIAGNOSISoid fever has two components, a bacteraemia with itssurate toxaemia, an d an enterit is. While either may

the commonest early symptoms are oforigin persistent headache, apathy. anorexia,generalized body pains. A harsh, dr y cough is commonepistaxis occUrs in about }(l of cases. Even at thisy stage some abdominal complaint is present usuallyt ipation, occasionally diarrhoea and abdominal dis

examination pyrexia with a relatively slow pulse is at an t finding, p lus a dr y furred tongue and a slightlynded abdomen. Both ose spots and splenomegalyimportant diagnostically, the former invisible on coloured

an d neither constantly present. n South Africa, anywith an illness of insidious onset running a conpyrexia o fu p to 104F for over a week is most likelyring from typhoid fever.ratory confirmation should always be obta ined, nohow certain the diagnosis. This is perfectly possible

in a remote village. n hospital practice the followingare demanded:Blood culture for typhoid organisms in bile broth.Stool and urine culture.The Widal test, which l::ecc.mes positive in the secondek. Later, when a higher titre would be invaluable,omycetin treatment may interfere with development. A white blood count, which shows a charac teristic

of 3,000 - 5,000 white blood cells per c. mm.TREATMENT

object of treatment is twofold, viz. a to prevent theof infection, and b curative.

of the pread of Infectionfever is a disease of filth faecal and urinaryof food or drink. Isolation of a case offersexcellent means of preventing spread, and admission toinfectious diseases hospital is the best isolation. Whereospital is not available, to set aside a house or even a

under supervision, is fa r preferable to having numerousant family members exposed to the r isk, or certainty,acquiring the disease too. t is possible to obtain theof an immune nurse who is tr ained to observe bedation with the use of gowns and disinfection technique,is able, moreover, to dispose safely of the highly inious excreta. This last service is so impor tant that itbe left to chance. Precise arrangements should be

T ow n. 1 August 1959

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6 8 S M E D I C A L JO U R N L 1 August 1959 Rest

In order to get the perfect rest which materially influencesno t only th e patient s comfort, bu t hi s r ecov er y too, g oo dnursing remains of prime importance. This means absoluter es t, d ur in g w hi ch t he patient must be fed an d washed an dhave his every need a tt end ed to. Special a tt en ti on is p ai dto oral hygiene an d the prevention of bedsores. Any movement of the patient must be mi nima l an d gentle never sithim upright or allow him ou t of bed), particularly after thes ec on d week, whe n the ul cer s of t he s mal l bowel ar e deep,necrotic an d ripe to bleed or perforate. It ca n be understoodho w movement of a p at ie nt by ambulance for an y distanceunder these conditions is attended with th e greatest danger,an d should be avoided at all costs.

Th e temperatures an d pulse should be taken 4-hourly;this chart often supplies the first indication of a perforationor haemorrhage of the bowel. A fluid intake/output chartis also valuable in indicating the myocardial integrity,kidney filtration, etc.A typhoid patient needs constant watching by a competentnurse. Any compl aint of abd ominal p ain or vomiting, asudden drop in temperature or rise in pulse-rate, an d the. presence of b lo od i n the s to ol , nee d i mm ed ia te r epo rt ing. Ar is e i n t em pe ra tu re a bov e 104F calls for t ep id s po ng ing inorder to avoid hyperpyrexia.3 Diet

Th e old starvation diet, with its attendant wastage, debilityan d deficiencies, has given way to the rati onal modemtreatment in which adequate, non-residue feeding is given.Fo r the first few days the diet consists mainly of m lk fortifiedwith glucose. This is given at 2-hourly intervals during thed ay n ot at night), an d should no t exceed 8 oz. pe r feed foran adult, 4 oz. fo r a child. Th e milk may be flavoured an dfortified with cocoa, ovaltine or other preparations. A glassof fresh orange juice should be given daily, or maintenancevitamin Strained porridge or s ou p c an be added, an d jelly, custard,an d cream are allowed, together with plain chocolate,glucose sweets an d butterscotch to give the necessary dietaryrequirements. After a few days, plain biscuits Marie),bread an d butter no crusts), soft-boiled or poached eggsmay be added. Additional foods such as minced chicken orfish, mashed potatoes or pumpkin, farinaceous puddingsan d pureed f rui t are added quite soon, until the patienthas virtually a full diet an d only foods leaving bulky residuesar e avoided, e.g. tomatoes, cabbage etc.A sufficient calorie an d fluid i nt ak e is i mp or tan t. Dehyd ra ti on m ay necessitate th e giving of fluid by -intravenousdrip. Debilitated patients need protein in concentratedform.

TH E COURSE OF THE DISEASEIn the uncomplicated case, the temperature becomes normalan d th e patient feels much b etter in 4-7 days. Th is nei thermeans that the drug treatment ca n be stopped, no r that theabsolute rest ca n be relaxed. Th e bowel remains full ofulcers. B ed r es t fo r 3 weeks must be enforced, often againsta patient s wishes, an d on ly t he n ar e m or e pi llows allowed,t og et he r w it h t he m ov em en t in bed. By the middle of the5t h week f rom th e commencement of treatment the patientis allowed to be ou t of bed, an d he goes h ome at t he e ndof the week provided he is free from typhoid organisms.

ComplicationsToxaemia may be severe fairly early in the bacteraemicstate, an d is th e commonest cause of death, through myocardial failure, which is evidenced by prostration, a galloprhythm, bradycardia an d EC G changes. Although cortisoneis rationally dangerous .to a patient with an ulcerated bowel,

an d should never be used lightly, there are exceptional casesin which death from toxaemia would appear imminent, an din these cortisoneh as at times been life-saving. We repeat,cortisone has no place in the routine treatment of typhoidfever. Th e later development of th e ty p ho id state of thetext-books has largely been abolished by cWoromycetin.

Perforation the bowel as already stated, is oftenprecipitated by movement. Th e symptoms are ab do min alpain, sometimes vomiting an d collapse. Th e signs a re a riseof p ul se r at e \vith a drop in temperature, abdominal tenderness an d increasing rigidity, absence of bowel sounds an ddisappearance of liver dullness. It is confirmed by th e findingof a ir u nd er the diaphragm on an X-ray plate taken in theerect position. Conservative treatment has totally supersededoperation, an d a d eat h is now very exceptional. Treat byplacing the patient in the Fowler s position,start continuousgastric suction , an d give all fluids iJ).travenously an d alltreatment parenterally. In addition to intramuscular chloromycetin, al so give s tr ep to my ci n an d penicillin similarly.T hi s regimen is c on ti nu ed u nt il bo wel s ou nd s r et ur n, whe nordinary treatment ca n be resumed. n a few cases a pelvicabscess forms, an d this ma y have to be surgically drainedwell on in the convalescent stage-when the pat ient is fitto stand it.

Bowel haemorrhage is a c at as tr op he o ft en r es ul ti ng f ro minjudicious transporting of a pa ti ent . Th e diagnosis ca noften be made before th e passage of tarry melaenic stools orbright red blood- n th e stool. There is no abdominal tenderness or rigidity, the bowel so und s ar e present-sometimeseven increased-and the liver dullness is normal. An immediate blood transfusion may be necessitated by th e severeloss of blood. Wh ere the bleeding is no t so severe, it m ay bewise to wait till it has stopped, an d then to transfuse i necessary. All solid f oods per mouth are entirely withheld, an donly fluids given.

Relapse is fa r less common since cWoromycetin treatmentha s become standard, bu t does still occur. Th e usual timeis in th e 4th or even 5th week, w he n t he p at ie nt is almostready to leave hospital. Th e temperature rises an d allsymptoms an d signs of t he di seas e r et ur n, often n lesspr ono un ce d for m. CWoromycetin t rea tm en t is luckily aseffective as in th e original attack, an d a full c ou rs e must berepeated.

Meteorism or extreme abdominal distension, is no t onlydistressing, bu t embarrasses both pulmonary an d heartfunctions. t is useful treatment to citrate th e m lk f ~ sDiarrhoea when excessive say m or e t ha n 10 stools pe rday), m ay prevent the absorption of cWoromycetin, whichshould then be given by intramuscular injection. Intravenousfeeding may be required.Pneumonia Lobar pneumonia occasionally occurs andresponds well to cWoromycetin.Cholecystitis Pain an d tenderness in th e right. hypo. c ho nd ri um is common in typhoid fever. It ha s to be The head of the bed raised or 20 inches.

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VACCINATION AGAINST TYP OI FEVERR. TUR.1 \ ER, M.B., CH.B., D.P.H. CAPE TOWN)

Senior Government Pathologist Cape Town and Advisor in Pathology Union Healrh Department

639of the 3rd week b lood is taken for the agglutination test,and specimens of faeces and urine are sent to the laboratoryat intervals of 5 days. the Vi test s negative, and notyphoid bacilli are found in 3 specimens of faeces and urine,the patient can be released from hospi tal or isolation at theend of the 5th week.Carriers. the Vi test proves to be posit ive, or the stoolor urine is found to contain typhoid organisms, the patientneeds more extensive investigation to determine whether heis a carrier . t is good pract ice to submit 10 stools at intervalsof 5 days; all must prove negative if the patient is to bereleased from hospital. any are posit ive, then the pat ientis a carrier, and further efforts should be made to rid himof organisms. Chloromycet in has often proved ineffectivein eradica ting the organisms in the urinary or faecal carrierstate, but it should be given a good trial-say 3 courses withan interval between. Achromycin should also be given atr ial before surgical measures are invoked, as they are insome cases. All these may prove ineffective and the resultingpermanent carrier is a health hazard needing continuouscontrol.

and evidence was obtained f rom some of them, where therisk of typhoid fever was high, which indicated that thevaccine was only of value in reducing mortality and not inreducing morbidity. There is, however, sound evidencefrom other recent sources to show that typhoid vaccinemay be of definite though l imited value in reducing theincidence of the disease. Thus, in 1943, a study of a g roupof men exposed to infection from a common contaminatedwater supply showed that the incidence of typhoid feverin the inocula ted per sons was only 11 as compared with7 0 amongst the uninoculated.On the whole it would thus appear that typhoid vaccine of definite but limited value in that it may reduce boththe incidence of typhoid fever and its mortality, but that t heimmunity it confers is only relative and will no t withstandheavy assaults. The immunity would also appear to fadegradually, and hence the desirabil ity of repeated boosterdoses at intervals of one to several years.W Yugoslavia ReportRecently the preliminary report of the World HealthOrganization on the s trictly control led field trials held inYugoslavia on the value of typhoid vaccine has thrownsome very valuable light on this difficult problem. About48,000 subjects took part in these trials , which were carried

out over the period 1954-56 in a district in which typhoidfever was endemic at the t ime. The subjects were dividedat random into 3 comparable groups subjected to the samerisks. One group was immunized with phenolized vaccine,another with alcoholized vaccine, and the third was given acontrol Flexner vaccine. The results of the t rials were somewhat surpris ing. They indicated tha t, under the conditionsof the trials and with the particular vaccines employed,the phenolized vaccine gave a 70 protection rate, whereasthe alcoholized vaccine appeared to be no better than the

S.A. TY SKRIF VIR G N SKUNfrom a perforation. The tenderness is localizedthe gall-bladder, an d liver dullness persists.oral thrombosis is very rare i gentle leg movementscarried ou t daily.ipheral neuritis used to be common, probably as aof dietary deficiency. With increased feeding it sseen today.parotitis is preventable and is an indication of poorhygiene.oid psychosis is of toxic origin. t is rare and

to shock therapy.complications such as meningitis, osteitis and typhoidare very rare.

1959

RELEASE FROM lSOLAnONr the init ial diagnostically important s tool culture ford bacilli, it is poin tless to have further bacteriological

made until after treatment is completed. Thencomes imperative once more to know whether organismsto be excreted in the faeces and urine; that is towhether the pat ient has become a carrier. At the end

cination against typhoid fever was first introduced atend of last century and this prophylactic method hase been extensively employed in armed forces throughoutworld. From experience in these forces it was soon

that this vaccine was very effective in reducing theof typhoid fever an d very convincing figures werein support of this contention.

the period between the world wars, however,began to arise about the true efficacy of this vaccine,it was found tha t a ttacks of typhoid fever were by noof means as uncommon in persons who apparentlye adequately inoculated as was generally supposed,

when they were exposed to heavy risks of infec t was then suggested that much of the apparentof the vaccine in reducing typhoid fever in armiesbe attributed to other improvements in hygiene, e.g.

chlorination of water supplies , which was introducedout the same time as routine vaccination against typhoid.e discovery of the Vi antigen, and the supposedlyrole it played n protection as evidenced by animalmental studies, led to efforts to improve the vaccine;the alcoholized form of the vaccine, which is preparedcarefu lly selected, smooth, fully virulent s trains of

in which the Vi antigens are effectively preservedalcohol, was int roduced. This latter vaccine, in certainbegan slowly to replace the older (phenolized)

of vaccine, which was thought to be deficient in theVi antigen.fter the second world war still further doubts, as a

of experience in prisoner-of-war camps in Northca, began to be thrown on the efficacy of typhoid vaccine.hoid fever was prevalent in some of these camps wheree was gross overcrowding and poor hygienic conditions,