TYPHOID

From Big Medical Encyclopedia

TYPHOID (typhus abdominalis) — an acute infectious disease of the person from group intestinal, caused by typroid bacteria, characterized by a cyclic current, bacteremia, intoxication, rash on skin and a canker limf, the device of a small bowel.

Statistics and geographical distribution

B. of t. and paratyphus is everywhere widespread diseases. Incidence of tifo-paratyphoid infections in a recent period is characterized by the expressed tendency to decrease in economically developed countries, emergence of territories where sporadic incidence takes place, against the background of a cut also local flashes are registered. In developing countries high incidence with wavy change of the periods se increases and decrease still constantly is registered.

According to official figures to WHO and data of the certain countries, in 1950 — 1962 in 113 countries of the world 2 056 168 sick B. are registered by t., in 1963 around the world — to 100 000. According to WHO materials for 1959 — 1963, the least intensive incidence (less than 1 on 100 000 population) was noted in Norway, Denmark, England and Wales, the highest (more than 30 on 100 000 population) — in Spain and Italy. In the USA where, as well as in the majority of other countries, data of hospital statistics are published in the basic, in 1951 a little more than 2000 cases of B. of t are registered., in 1964 — 486, in 1967 — 397. From 1942 to 1968 an indicator of incidence of B. of t. decreased with 4,0 to 0,2 on 100 000 population. In developing countries of the African and Asian continents and first of all in the countries which are recently freed from colonial dependence where the accounting of incidence is carried out insufficiently fully, B.'s incidence of t. much higher. So, on the African continent in 1950 — 1962 343 594 cases of B. of t are registered., the greatest number of the diseased were the share of the Arab Republic of Egypt where from 7000 to 18 000 patients annually came to light. In 27 countries of Asia from 30 000 to 45 000 sick B. of t annually are registered. The highest incidence in Iran, Indonesia, Turkey, the Southern Vietnam, etc.

According to WHO data for 1971 — 1972, tifo-paratyphoid diseases remain everywhere widespread. On incidence of these infections of the country of the world can be divided into several groups: the 1st group (incidence less than 1 on 100 000 population) — Iceland, Ireland, the Netherlands, Norway, Sweden, England and Wales, New Zealand, Canada, Belgium, Bulgaria; the 2nd group (incidence from 1,1 to 10 on 100 000 population) — Hungary, Yugoslavia, Poland, Czechoslovakia, Romania, Finland, France, Spain, Turkey, Philippines, Mali, Nigeria, Upper Volta, Argentina, Cyprus, Israel, Jordan, Pakistan, Sudan, Laos, Paraguay, Martinique; the 3rd group (from 10 to 20 on 100 000 population) — the Malagasy Republic, Bolivia, Iraq, Tunisia, Guatemala, Malaysia; the 4th group (30 on 100 000 population) — Chile (44,7), Colombia (32,0), Peru (48).

In our country B.'s incidence of t. steadily decreases. So, if in 1913, according to not full identification of patients, 423 791 cases of a typhoid and paratyphus were registered (266 on 100000 population), then in 1940 on 100 000 population of such patients there were 62; in 1950 — 26,8; in 1960 — 22,1; in 1965 — 11,1; in 1966 — 11,8; in 1967 — 10.0; in 1970 — 9,0; in 1972 — 8,0. And though comparison of indicators of incidence of B. of t. in 1913 and 1972 it is illegal owing to incomparably higher completeness of identification of the patients with this infection in comparison with pre-revolutionary Russia, nevertheless it is visible that incidence during the considered span decreased almost by 35 times. It is result of huge shifts in improvement of welfare of our people, basic changes in municipal services of settlements, broad carrying out a dignity. - a gigabyte. and protivoepid. actions.

It should be noted that if owing to rationally organized state system of identification and the statistical accounting of all patients with tifo-paratyphoid infections the published indicators reflect the true nature of their distribution, then data on incidence in the USSR, in particular B. of t. and paratyphus, a row (including and industrially developed) the countries of the world, published by WHO, do not reflect its valid level since during the development of materials are used preferential this hospital statistics.

A lethality at B. of t. during wide use of antibiotics sharply decreased: in 1956 — 1958 in comparison with 1936 — 1940 in England and Wales — by 4 times, in Japan — by 5,3 times, in Italy — by 7,5 times. During the period from 1961 to 1965 an indicator of a lethality at B. of t. in the USA — 2,3%, in England — 2,2%.

In a number of the countries, and first of all in recently exempted from colonial dependence where the health care is in a stage of formation, B.'s incidence of t. is followed by a high lethality (e.g., in Nigeria in 1966 the lethality made 24%).

Etiology

Activator B. of t. Salmonella typhi (synonym: You. typhi abdominalis, Bact, typhosum, Eberthella typhi, Eber-thella typhosa, Sal. typhosa) was opened by G. E berth in 1880 at microscopic examination of cuts of a spleen, mezenterialny limf, nodes and peyerovy plaques of the people who died of B. of t. G. Gaffky, R. Koch's pupil, in 1884 allocated this microbe in pure growth. The typroid stick belongs to an extensive sort Salmonella (see) families of intestinal (Enterobacteriaceae) Le L. Le Minor and soavt also enters the 1st subgenus [F. Kauffmann, 1966] or a type of S. kauffmanii [., 1970].

B.'s bacteria of t. are eurysynusic around the world and are pathogenic only for the person. The natural place of their dwelling is the human body, but they can be found also in places where allocations of patients, bacillicarriers get: in water of reservoirs, in drain waters, in the soil etc. where they can remain rather long. On morfol, to properties they do not differ from representatives not only the sort Salmonella, but also other enterobakteriya and have the form of sticks with the rounded-off ends. Length varies them from 1 to 3 microns, and width — from 0,5 to 0,8 microns.

In old bouillon cultures sometimes it is possible to see longer individuals — to 10 microns and in some cases the whole threads. In smears they are located randomly. Bacteria are mobile thanks to existence on their surface peretrikhialno of the located 8 — 14 and more flagellums; the dispute and capsules is not formed; are well painted with all aniline paints; gramotritsatelna. They are facultative aerobes and well grow on usual mediums. Optimum temperature of growth 37 ° and pH of the environment 7,2 — 7,4. At lower (20 °) or higher (39 °) temperature and pH values from 5,0 to 8,0 their reproduction can happen, but much more slowly.

Under the influence of antibiotics, immune antibodys, chemical, physical. and other factors activators B. of t. can change therefore there are strains differing from typical (existence of a yellow pigment, a reduced agglyutinabelnost in the presence of specific immune serums to separate antigens, an agglyutinabelnost under the influence of heterologous serums, napr, serums of causative agents of dysentery, etc.; medicinal stability, etc.). With a growth on dense mediums (on an agar) they can form smooth and rough colonys or their transitional forms. Smooth forms — round, dome-shaped, wet, with a smooth surface, translucent colonies in a transmitted light. The expressed rough forms — colonies of irregular shape, dim, dry, muddy with a rough surface and uneven edges.

Smooth colonys correspond to a serological S-form more often, and rough and transitional forms of colonies — the culture of bacteria which is in T - or R-forms. However there is no full coincidence between outward of colonies and a serological form of culture of bacteria. At crops in broth smooth forms give uniform opacification of broth, rough — form bottom sediment of a test tube with a transparent nadosadochny part of broth.

Color table. The scheme of a bacteriological research on a typhoid. 1 — the environment Rapoport, 1a — the same environment sowed by bacteria of a typhoid; 2 — Endo's circle, 2a — growth of bacteria of a typhoid on the same environment; 3 — Ploskirev's circle, 5 and — growth of bacteria of a typhoid on the same environment; 4 — Wednesday bismuth-sulfite an agar, 4a — growth of bacteria of a typhoid on the same environment; 5 — selenitovy broth, 5a — the same environment sowed by bacteria of a typhoid; 6 — Russell's circle, 6a — the same environment sowed by bacteria of a typhoid; 7 — a pure slide plate, 7a — the smear with culture of bacteria of a typhoid painted across Gram; 8 and 9 — a slide plate with a drop of mix of salmonellezny O-serums, 8a and 9a — agglutination of bacteria of a typhoid with the same serum; 10 — Wednesday with lactose, 10a — the same environment sowed by bacteria of a typhoid; 11 — Wednesday with glucose, 11a — the same environment sowed by bacteria of a typhoid; 12 — Wednesday with a mannitol, 12a — the same environment sowed by bacteria of a typhoid; 13 — Wednesday with a maltose, 13a — the same environment sowed by bacteria of a typhoid; 14 — Wednesday with sucrose, 14a — the same environment sowed by bacteria of a typhoid; 15 — a beef-extract broth with indicator pieces of paper for definition of an indole and hydrogen sulfide, 15a — the same environment, blackening of edge of one of indicator pieces of paper indicates formation of hydrogen sulfide; 16 — semi-fluid (0,2%) a beef-extract agar columns for definition of mobility of bacteria, 16a — the same environment sowed by bacteria of a typhoid (uniform opacification); 17 — a slanted beef-extract agar, 17a — growth of bacteria of a typhoid on the same environment; 18 — a slide plate with drops salmonellezny monoreceptor About (9 and Vi) and Η (alpha) - serums, 18a — agglutination of bacteria of a typhoid in the presence of the specified serums; 19 — a beef-extract broth, 19a — the same environment sowed by bacteria of a typhoid; 20 — a Petri dish with an alkalescent agar, 20a — the test of a lysotypy of bacteria of a typhoid.

On usually used differential and diagnostic environments: Endo, Ploskirev's baktoagara, Levin's circle and some other (tsvetn. tab.) — activator B. of t. grows in a look colourless, slightly bluish, is more rare than pinkish transparent colonies; on the Wednesday bismuth-sulfite the agar (Wilson's circle — Blair) forms the colonies, black with metallic luster, surrounded with a black rim of the painted-over environment.

Enzymatic activity of bacteria of B. of t. is slightly weaker, than other representatives have sorts Salmonella and differs in the expressed constancy. It comes to light on the relation of microbes to a number of the carbohydrates and some connections added to mediums. They never ferment an adonit, lactose, sucrose, rhamnose and an inositol; ferment with formation of acid without gas glucose, a mannitol, a maltose, sorbite and trehalose; do not split urea and glycerin; do not utilize sodium malonate; do not liquefy gelatin; do not grow in presence of potassium cyanide; reduce nitrates in nitrites; give positive reaction of Foges — Proskauyera and negative with methyl red; decarboxylize a lysine, arginine and ornithine; do not possess a glutaminedecarboxylase and fenilalanindezaminazy; have unequal ability to split some organic acids (d-tartrate is split, an i-and Z-tartrate, mukat and citrate split in a slowed-up way and changeably); do not form an indole, form hydrogen sulfide. The relation to xylose, pectine sugar and dulcite at separate strains of these bacteria unequal that allowed to subdivide them into several stable biochemical, types which existence can be used at establishment (exception) epidemiol. bonds between separate cases of diseases. The typroid stick possesses two main antigenic complexes: somatic (thermostable) O-antigen and flagellar (thermolabile) N-antigen. O-antigen represents a difficult lipopolisakharidny complex, Vi-aptigen, being polymer N-acetyl-aminohexuronic to - you can be a part to-rogo (see. Vi-antigen ). N-antigen — connection of the proteinaceous nature. To each of the receptors making About - and N-antigens, the agglutinating (monoreceptor) serums which are used at identification of a microbe can be received. Depending on sensitivity to specific standard Vi-bacteriophages these bacteria can be subdivided into a large number of stable fagotip from which fagotipa of A, F1 and E1 are the most widespread. Results lysotypies (see) with success are used in epidemiological practice.

The typroid stick has rather expressed resistance to influence various physical. and chemical factors can also remain rather long in objects of external environment. During the heating in an aqueous medium to t ° 50 ° she perishes within an hour, and at t ° 100 ° — instantly. Solutions of corrosive sublimate (1: 1000), phenol (5%), lysol (3%), chloroamine (3%) kill her within 2 — 3 min. In artificially infected water she worries from 30 to 90 days; in a drain water and the soil on fields of irrigation — to 2 weeks, on vegetables and fruit — 5 — 10 days, in ice — more than 60 days.

Identification of typroid bacteria is based on definition of their morphology, biochemical properties and an antigenic structure. The last is decisive and is reached at statement of an agglutination test with salmonellezny monoreceptor serums.

Epidemiology

B. of t. treats antroponoza with the fecal and oral mechanism of transfer. A source of contagiums at B. of t. the patient or the bacillicarrier is.

In modern conditions sick B. of t., as they come to light easier and more stoutly and are timely isolated, less often externally healthy bacillicarriers are a source of activators, than. Depending on the period and a form of a current of B. of t. epidemiol. value of the sick person as source of activators unequally: the patient in the period of a heat of a disease (if he is not hospitalized) is the most dangerous as the distributor of activators (plentiful allocation of the activator with a stake, urine).

In epid, the relation patients with easily are especially dangerous and atypically proceeding forms of a disease which identification is complicated, patients at the same time keep mobility and activity, intensively disseminating activators B. of t. in the environment. In a stage of reconvalescence, in process of release of an organism from the activator, epid, danger of the patient decreases. However clinical recovery is not always followed by release of an organism from activators. Carrier state can be short-term (an acute carriage up to 3 months) or very long, even throughout all life (hron, a carriage). Distinguish also tranzitorny carriage when the activator gets into intestines of the person, unreceptive to B. of t.; such carriage proceeds only several days. The bacteriocarrier forms at 1,5 — 11,6% of the t which had B.

Numerous kliniko-immunological and laboratory observations demonstrate that a bacteriocarrier — the general, but not local process, formation to-rogo begins not in the period of reconvalescence as considered before, and from the very beginning of B.'s development by t. Believe that possibilities of formation of this difficult and still inaccessible to active influence from the outside of process are predetermined by genetic features of the activator B. of t. A certain role in this process belongs to marrow, morfol, the picture to-rogo at bacillicarriers-hronikov is characterized by existence of a large number of the macrophagic cellular elements infected in some cases with various forms of the activator. Typroid bacteria can not only remain in phagocytes, but also breed in these cells. Therefore localization of activators B. of t is clear. in marrow where the cellular elements capable to phagocytosis arise and are differentiated.

Existence of S. typhi in bile, excrements and urine is caused by sekretornoekskretorny functions of an organism since allocation of its activators is carried out by means of the mechanisms which developed as a result of long evolution. Every year t collect this, testimonial of huge value hron, carriers in B.'s distribution. and, therefore, in maintenance of incidence.

B.'s infection with t. from bacillicarriers, but to data of various authors, makes 6,6 — 94,2% of epidemiologically deciphered cases of a disease. At the same time apprx. 63% of cases of infection occurs before identification of carriers, therefore, they are the main and most dangerous source of an infection. Epid, danger of bacillicarriers depends on intensity of their communication with people around, on a condition of zhilishchnobytovy conditions in which they live, on observance of rules of personal hygiene by them. Hron, the carriers living in rural areas in the conditions of less secure a dignity. improvements, are the reason of infection of B. of t more often., despite smaller population density in rural areas. The carriers working at the enterprises for processing and implementation of foodstuff and at water constructions are especially dangerous.

Transfer of activators to the healthy person comes from a source in the contact, water, food way and flies.

If in the past infection of water quite often brought in the large cities to B.'s epidemics of t., in a crust, time the role of a water factor significantly decreased since the modern level of utility improvement provides needs of the population for high-quality drinking water, and only disturbances of water supply and the sewerage (accident) can cause infection of water with typroid microbes.

At the water epidemics connected with use for drink of the water infected with the activator B. of t., the population living in the territory of action of a water supply system usually is surprised. One of characteristic features of water epidemics of B. of t. existence unusually big for this area and a season of year of number of diseases of a gastroenteritis of various etiology which quite often precede development of epidemic is. The flashes connected with use for drink of water of technical water supply systems are characterized by the expressed selective prevalence of certain groups of the population: industrial working certain workshops of factory or plant, the persons living in the hostel of a certain enterprise, etc. Cases of pollution of mains water through viewing wells as a result of their wrong device or disturbance of an integrity are known. At the same time diseases are noted among the population living in the territory of this quarter or the street and using water from this water analysis. At emergence of negative pressure in a water supply system the ground waters infected with activators B. of t., can be sucked in in a water supply system. It is possible also at non-compliance with admissible distance between highways of water supply and sewer system. Epid, B.'s flashes t. in such cases are characterized by a prevalence of the population living in the limited territory and using water from a certain site of network whereas B.'s diseases of t. among other population consuming water from other sites of a water supply system it is not observed.

Water epidemics of B. of t., resulting from fecal pollution of sources of water supply, can be long or acute (short-term) character. The acute flashes connected with accidental pollution of a water source have no the expressed seasonal nature. The winter rise connected with higher keeping of pathogenic microorganisms in a cold water owing to decrease at this time in intensity biol, processes of self-cleaning is typical for the long rises in incidence which are continuously continuing throughout all seasons of year. At the decentralized water supply though incidence can also be rather high, epidemics, as a rule, do not arise. At pollution of the river surface sewage, especially in the spring, B.'s flashes t. are possible in the settlements located on a watercourse places of its pollution are lower. At well flashes of B. of t. incidence has focal character: inhabitants of the houses using this well get sick. Water flashes of B. of t. are characterized by the following: diseases cover the limited territories connected by the general source of water use; diseases generally proceed easily, with a long incubation interval, a low lethality as a result of infection with rather small dose of the activator. The curve of incidence as a result of single-step mass infection has the steep slope and the subsequent bystry recession after acceptance corresponding a dignity. died on a water supply system and existence of a so-called contact tail.

In a summer span open reservoirs (especially in hot climatic zones) are used for mass bathings. At accidental swallowing the infected water there can be B.'s infection with t. This way of distribution of the activator B. of t. plays an essential role in incidence of children of school age. The increased incidence in the areas adjoining open water sources is noted.

Main condition for emergence of food flashes of B. of t. (hl. obr. through milk and dairy products) non-compliance a dignity is. norms and rules of technological process of processing of raw materials, storage, transportation and implementation of foodstuff. Depending on the infected product, the mode and terms of its storage, the number of the people consuming it both flashes of a food origin, and separate cases of B. of t can be observed. Vegetables, fruit, bread can be the cause of sporadic or limited group cases of B. of t. The infected dairy products, in which the activator B. of t. not only remains. but also breeds, especially in hot season at their storage out of the refrigerator, are the reason of larger flashes more often. The flashes of a milk origin connected with consumption on a centralized basis of implementable milk in character remind water: bystry increase and subsequent falling of incidence, existence of a contact tail. Infection during milk epidemics is connected with receiving a high dose of the activator since its concentration in milk can increase therefore B. of t. «a milk origin» proceeds with the shortened period of an incubation, a heavy clinical picture and is followed by the raised lethality. At consumption not on a centralized basis of the infected milk distributed (market) sporadic are observed, group cases of B. of t are more rare. among the people using such milk without boiling.

At rather low incidence of B. of t. major importance has a contact and household way of transmission of infection (the hands contaminated by excrements of a bakteriovydelitel, ware, linen, bed-pans, chamber-pots, toilet seats in toilets, etc.).

In the conditions of density of the population, pollution of the territory, unsatisfactory system of cleaning and removal of sewage and garbage important value in transfer of activators belongs to flies.

B.'s incidence of t. it is characterized by the expressed aestivo-autumnal seasonality: for 3 — 4 months from 42 to 60% which had in a year are necessary. Seasonal rise in incidence of B. of t. is defined preferential by disturbance of reactivity of an organism under the influence of excess insolation and bathing in open reservoirs, and also the increased consumption of drinking water, change of conditions of food (a large number of uglevodsoderzhashchy products, disturbance of water exchange and the related disturbance of barrier function of a stomach), increase in population density of flies at insufficiency of disinsection actions.

Age structure of incidence of B. of t. it was in the late sixties characterized by increase in number of sick children of 7 — 14 years (to 60 — 75% of total number of patients) whereas incidence among adults did not undergo essential changes, the greatest number of the diseased constantly is registered among persons 15 — 29 years. Distinctions in incidence of men and women are noted.

Pathological anatomy

For B. of t. the focal inflammatory processes which are most brightly shown in lympho-reticular formations of an ileal gut and its mesentery are typical. Inflammatory reaction has generally productive character, being expressed by formation of the granulomas consisting from enough large roundish or angular «typhus» cells with massive light cytoplasm. These cells often contain the absorbed erythrocytes or particles of a detritis and the macrophages formed of reticular macrophages and histiocytes represent. On the 2nd week of a disease of a granuloma are exposed to a necrosis and there is a leukocytic reaction like a demarcation inflammation.

Initial stages of focal defeats at B. of t. are not known since its deadly outcomes before the end of the first — the beginning of the second week of a disease was not observed. Also the reasons of formation of the granulomas which are obviously connected with the settlement in such places of the contagiums which are constantly allocated from here at bacterial are insufficiently clear. researches (crops). In such granulomas also intracellularly located bacteria which are coming to light only at special coloring are found very small. However the microcolonies of well painted sticks meeting at a bacterioscopy between cells of granulomas are result of reproduction of S. typhi in bodies of a corpse.

Damages of intestines at B. of t. have characteristic localization and the known recurrence. Along with non-constant signs of diffusion Qatar (nek-paradise a nabukhlost and pink coloring of a mucous membrane), the main specific changes are found in the distal site of an ileal gut. The lymphoid educations which are here, solitary follicles and peyerova of a plaque on the first week of a disease considerably bulk up. Their fabric, giperplazirovanny at the expense of accumulation of «typhus» cells, is soft and juicy, has grayish and reddish coloring (mozgovidny swelling). Typroid granulomas, going beyond follicles, usually occupy all thickness of a submucosal layer, and group of the macrophages who extended on limf, to ways, can be located also in a muscular coat, even under a serous cover.

Fig. 7. Lymph nodes of an ileocecal corner of a mesentery at a typhoid. Fig. 8. Necrosis of giperplazirovanny peyerovy plaques.

On the 2nd and at the beginning of the 3rd week of a disease fabric of the increased group and single follicles almost completely (except for edges) necrotizes. It is noticeable also with the naked eye owing to dryness and dim gray or zheltovatozelenovaty (treatment by bile) colourings of sites of a necrosis (tsvetn. fig. 8). After their rejection happening on the 3rd and 4th weeks of a disease the ulcers reaching a muscular layer, and sometimes more deeply are formed. In this period heavy complications of a typhoid develop: plentiful bleedings from the vessels damaged and not closed by blood clots yet and the perforation of ulcers leading to peritonitis. Perforation (usually one of ulcers, but occasionally and multiple) most often occur in the lower site of an ileal gut. However perforations can arise also in other departments of a gut if there were specific defeats limf, the follicles disseminated through all digestive tract. As casuistic cases are described typhus perforations of a worm-shaped shoot and a large intestine.

At safe disease at the end of the 4th and the beginning of the 5th week there occurs the healing of ulcers never leading to formation of hems or a stenosis; in several months from them there is no noticeable trace left at all.

The specified duration and the sequence of separate stages of a disease are observed not always (only in 1/2 — 2/3 cases of B. of t.). Children usually have no continuous necrosis group limf, follicles and granulyatsionny fabric can undergo gradual involution. Apparently, and at adults necrosis of granulomas is not obligatory. Besides, separate plaques and follicles are surprised not at the same time: in limf. the educations located near the ileocecal valve more far the come changes are usually visible, than in it is located ykh follicles above. It is almost important that parallelism between clinical and morfol, displays of a disease is not always observed. Cases when at «out-patient» B. of t are known. there was a perforation of a gut and on opening extensive specific defeats of a small bowel opened.

B. t. proceeds as a generalized infection. The same changes as in single and group follicles, occur in limf, nodes of a mesentery of a small bowel, especially in those which are located in an ileocecal corner. On the 1st week of a disease they increase (tsvetn. fig. 7), become soft and juicy. The expanded «typhus» cells in them, as well as in an intestinal wall, then perish. If there are sites of a necrosis (that, apparently, is not obligatory), they are encapsulated, sometimes being exposed to calcification. Sequestration or suppuration of the centers of a necrosis in limf, nodes, leading to development of limited or diffuse peritonitis were in rare instances observed.

Constantly the spleen increases (by 2 — 3 times). In its homogeneous dark red pulp giving considerable scraping at a gist. a research find a plethora and a diffusion hyperplasia of a reticuloendothelium. Besides, separate small knots — the granulomas which are exposed to necrobiotic changes are formed here. The small heart attacks which sometimes are exposed to suppuration are much more rare.

Along with more or less expressed phenomena of parenchymatous dystrophy also find the separate small knots representing or specific granulomas, either accumulations of lymphoid cells, or an ochazhka of a necrosis in a liver. The same ochazhka of a necrosis meet also in marrow where there is also the general hyperplasia of a reticuloendothelium. Changes of marrow in itself do not affect disease, but typroid sticks can remain also after its termination here, being a basis of a long bacteriocarrier. In such cases of a salmonella parasitize in cells like macrophages.

Formation of roseolas on integuments belongs to specific displays of a typroid infection. Except inflammatory infiltration, it is possible to find microcolonies of salmonellas in them if pieces of fabric previously to subject incubations in the thermostat.

B. t. quite often is complicated by the consecutive infection which is shown suppurative processes or development of pneumonia which can be connected with a basic disease etiologically. The pneumonia, purulent meningitis, nephrite, pancreatitis, osteomyelitis caused by typroid bacteria are described. At the same time A. I. Abrikosov specified. that existence of a meningotif, pneumotyphus etc. as independent (primary) diseases is not proved.

To t, nonspecific, but quite characteristic of B. a complication is the wax-like (tsenkerovsky) necrosis of direct muscles of a stomach which is usually accompanied with hemorrhage.

To reproduce typical B. of t. at animals it is not possible. However to them the pathological processes caused in mice and rabbits by other salmonellas have considerable looking alike. At such experimental infection of a salmonella find ability to parasitize in macrophages. Intracellular finding of salmonellas was confirmed also at a submicroscopy limf, a node of the person who was ill B. in t.

A pathogeny

Having got through a mouth into a human body, the activator B. of t. through a stomach and a duodenum passes into a small bowel and in the lower piece meets her optimum conditions for existence and reproduction. The activator is implemented in single and group limf, follicles. Limf, the device of a small bowel of a disease-producing factor in it answers implementation with reaction of proliferation, formation of large «typhus» cells. Then on limf, to ways typroid bacteria get in mezenterialny and retroperitoneal limf. nodes.

At the end of an incubation interval the activator from retroperitoneal limf, nodes gets to the chest canal, and then to circulatory system what is result of bacteremia (see), remaining throughout the feverish period of a disease. Owing to bacteremia there is a hematogenous drift of the activator in various bodies and fabrics: in a liver, a spleen, marrow where a number of the fabric centers of an infection is formed, there are typroid granulomas. From these centers activators repeatedly come to a blood flow that supports and strengthens bacteremia. From a blood flow of a bacterium get to bilious capillaries of a liver, a gall bladder where there are optimum conditions for their existence and reproduction.

Together with bile typroid bacteria are allocated in a gleam of a small bowel where there is their repeated implementation in group and single limf, follicles, earlier sensibilized bacterial antigens. At the same time giperergichesky inflammatory reaction as Artyus's phenomenon develops (see. Artyusa phenomenon ). Consecutive phases of development reflect it a stage of mozgovidny swelling of fabric limf, formations of a small bowel, necrosis of these fabrics, rejection of nekrotizirovanny fabric with formation of ulcers and their gradual healing. In cases of the natural course of a disease without antibioticotherapia each of the listed four stages of changes group and single limf, follicles proceeds about a week. An important role in a pathogeny of a disease is played by intoxication of an organism caused by impact of endotoxin of typroid bacteria on bodies and fabrics, especially on cardiovascular and nervous systems. As a result of toxic influences on arterioles and capillaries arterial and venous blood pressure falls, the speed of a blood-groove is slowed down. Toxic defeat of c. the N of page, and also an abdominal brain and celiac nerves promotes redistribution of considerable mass of blood in vessels of internals (especially in a liver and a spleen) that promotes development of a circulator collapse, a degrowth of the circulating blood and its venous inflow to heart with simultaneous decrease in systolic and minute volume of heart. These hemodynamic disturbances are combined with development of the dystrophic and inflammatory changes in a muscle of heart accepting the nature of myocarditis in cases of heavy disease.

Toxic influences on ts.n.s. cause such characteristic symptoms of B. of t., as depression and adynamia. Owing to paresis of a motive innervation of intestines and oppression of products of digestive enzymes locks and a meteorism develop. Decrease in coagulability of blood, the increasing permeability of walls of small blood vessels and developing of ulcers in the field of group and single limf, follicles create conditions for development intestinal a shelter of currents as one of t, possible about B.'s knife-neny. Owing to bacteremia the hepatolienal syndrome develops, and with 8 — the 10th day from an onset of the illness on skin characteristic rozeolezny rash develops.

Long receipt of the activator in a blood flow from primary and secondary centers of an infection causes wavy character of a temperature curve inherent to sick B. to t. Mass death of typroid bacteria in an organism of the patient leads to intoxication and the characteristic «typhus status». A part in a pathogeny of a disease is played by disbolism (especially proteins and vitamins), and also acid-base equilibrium. Owing to toxic influences on marrow at sick B. of t. the leukopoiesis is oppressed that explains character of a gemogramma with a leukopenia inherent to this patient, a neutropenia, an aneosinophilia and nuclear shift of leukocytes to the left. Difficult pathogeny of B. of t. causes variety of clinical symptoms and existence of a number of forms of this disease.

Immunity

B.'s Disease of t. it is peculiar only to the person. Under natural conditions at animals it is not observed and it is not possible to cause it experimentally even in the closest to the person of representatives of fauna — subhuman primates.

At the same time on experimental animals by introduction of the killed and live cultures of typroid bacteria, their antigens by it (e.g., Vi-and O-antigen) was possible to study processes of formation of humoral antibodys and cellular mechanisms of protection of an organism. Research of dynamics of immunity at people, sick B. of t., confirmed participation of small lymphocytes in antibody formation various physical. - the chemical nature (immunoglobulins of various classes). A congenital immunity to the activator B. of t. does not exist. The postponed disease leaves strong, is more often lifelong immunity and therefore cases of recurrent diseases of B. of t. — big rarity. However at a part of patients development of a recurrence and a bacteriocarrier which pathogeny at had is connected considerably with individual imperfection of immunity (see is possible. Carriage of contagiums ).

Clinical picture

B.'s Classification t. considers a big variety of various forms of this disease, edges it can be characterized by considerable polymorphism of symptoms, a possibility of a recurrence, aggravations and complications. According to these features it is accepted to allocate first of all the uncomplicated and complicated B. to t. On degree of manifestation of clinical symptoms, first of all on intoxication, allocate easy, moderately severe and a severe form of B. of t. Typical B. of t. differs in a moderately severe cyclic current. Easy disease is characterized by weak expressiveness of symptoms and the short feverish period. Carry abortal B. to easy forms of a disease of t.

In seldom found cases the disease proceeds with dominance of symptoms of defeat of separate bodies and systems: lungs, meninx, caecum (so-called pneumotyphus, meningotif, kolitif). At such atypical forms of a disease, as well as in cases of an abortal current of B. of t., a number of its characteristic signs can be absent completely. Also most hard proceeding giperpirektichesky and hemorrhagic forms of a disease are provided in classifications. It is accepted to allocate B.'s current of t also. at vaccinated.

Duration of an incubation interval of a disease makes from 3 to 21 days, 10 — 14 days are the most frequent.

B. t. is among diseases with gradual and slow increase of all symptoms reaching the full development only to 6 — to the 9th day from the beginning of a disease. However chances with subacute and even acute beginning (25 — 30% of all sick B. of t.).

As a rule, the disease begins with slow increase of body temperature of the patient and continuously amplifying intoxication.

Fig. 1. Temperature curve (Botkin type), pulse rate (dashed line) and terms of emergence of some clinical symptoms in the patient with a typhoid.

At many patients it is possible to track the prodromal stage preceding the first clinical symptoms of a disease. During the period a prodrome the diseased can have a febricula, feeling of weakness in all body, headaches, deterioration in a dream and appetite, decrease in working capacity, subfebrile condition. These anamnestic signs can be absent at physically strong young people. Duration of an incubation interval the prodrome exerts a nek-swarm impact and on character of symptoms: at a long incubation they are expressed more definitely. At the same time clinical form B. of t. moderately severe it is characterized by slow stupeneobrazny increase of the temperature curve reaching 38,8 — 39,8 ° only to 4 — to the 6th day from an onset of the illness. In the next 6 — 7 few days temperature remains at this level (a curve like continua); then wavy character of a temperature curve (Botkin type, fig. 1) is noted.

At the patient sharp general weakness, indifference to all surrounding, sharp apathy, an adynamia owing to a considerable depression of c develops. N of page. Such peculiar change of psychological activity is result of intoxication of an organism. The typical «typhus status» develops.

At some patients already at the very beginning of a disease the loss of consciousness, visual, auditory, tactile hallucinations, nonsense is possible.

Subjective complaints of sick B. of t. are not numerous: headaches, sleeplessness, deterioration in appetite, locks. Appearance of the patient is characteristic: indifferent look, sharp pallor of outside covers, especially persons, visible mucous membranes. Skin is dry, hot to the touch. During the first 7 — 8 days of a disease skin of the patient remains pure, then on it there are elements of rash — the roseolas having an appearance of separate round specks of saturated-pink color to dia. 3 — 3,5 mm which are accurately delimited from surrounding pale skin. Roseolas appear preferential on skin of a stomach. The quantity them can be limited only to 4 — 6 elements or reach 20 — 25; occasionally rash can be more plentiful. The monomorfnost of elements is characteristic. If on site roseolas to stretch skin or to pressure her a finger, then the element of rash stops being noticeable until such pressing or stretching of skin continues. At some patients owing to exudation the elation of a roseola over the surface of skin (a roseola papule, roseola elevata) is noted. Elements of a rash remain within 4 — 6 days, then turn pale, leaving behind slightly pigmented speck. Additional rashes are possible. In certain cases rash on skin is not formed. Sometimes in early terms from the beginning of a disease it is possible to see the icteric coloring of skin of palms (a so-called symptom of Filipovich) depending on a xanthosis as a consequence of adjournment in epidermis of karotin.

In a clinical picture B. of t. symptoms of damage of lungs are observed often, hl. obr. diffusion bronchitis, is more rare focal pneumonia. At height of development of feverish reaction pulse rate lags behind the level of body temperature of the patient (relative bradycardia). Quite often two-wave character (Dicrotism) which is observed more often at adults, than at children, and besides svoystven by hl has pulse. obr. to men. Since 5 — the 6th day from an onset of the illness tension and filling of pulse decrease, arterial and venous blood pressure falls. In the same terms with the subsequent progressing the shift of a knaruzha of borders of heart, muting of tones on all points is noted. At more expressed damage of heart on its top, and also on an aorta and a pulmonary artery systolic noise is listened. On the electrocardiogram reveal decrease in a voltage of a tooth of T (especially in chest assignments), regarding cases — decrease in a segment S — T, lengthening of time of atrioventricular conductivity (increase of an interval P — Q), reduction of sokratitelny ability of a myocardium, disturbance of phases of a systole of heart.

It should be noted sick B.' tendency of t. to vascular collapses which possibility of development is the greatest in late terms (18 — the 25th day from an onset of the illness at its natural course) in the patients who were not receiving antibiotics.

Fig. 9. Language of the patient with a typhoid.

Survey of a pharynx at patients reveals, as a rule, an easy diffuse hyperemia. The type of language of sick B. of t is characteristic. in the first 6 — 8 days from the beginning of a disease: edematous, increased in sizes, with prints of teeth on side surfaces (tsvetn. fig. 9). The back of the tongue is covered with quite massive plaque of gray color, but so that a tip and its edges remain pure, saturated-pink color. In further disease language becomes dry, the plaque on it gets a brown shade, on a mucous membrane there can be bleeding cracks.

The chair at patients is, as a rule, detained. The stomach is blown up owing to a meteorism, considerably increased in sizes. At a palpation of a stomach in the right ileal area rumbling as a result of replacement of gases from a caecum is defined at se palpations. At certain patients at percussion in the right ileal area, directly over an edematous, infiltrirovanny caecum and giperplazirovanny limf, shortening of a percussion sound (Padalki's symptom) is defined by nodes of a mesentery. Increase in the sizes of a spleen is noted with 4 — the 5th day of a disease at first perkutorno that allows to reveal even moderate increase in this body, and then and by a palpation. With 5 — the 7th day from the beginning of a disease also the liver (fig. 1) increases in the sizes. Thus, a hepatolienal syndrome at B. of t. is obligatory.

Gemogramma after 4 — from an onset of the illness becomes the 5th day characteristic: the quantity of leukocytes in 1 mkl blood decreases to 4500 — 2500, in a leukocytic formula the neutropenia with shift of a leukocytic row to the left, an aneosinophilia, a relative lymphocytosis is noted; ROE is accelerated. After 6 — the 8th day from an onset of the illness the clinical picture gets a full ocherchennost; in the next days of the feverish period of a disease the degree of intoxication of an organism, disturbance from separate bodies and systems described above continue to accrue. On this background there can be B.'s aggravations of t.

In cases of favorable disease after the long term of elevated temperature at the natural course of B. of t. the temperature curve gains amphibolic character (with fluctuations in 2 — 2,5 ° between morning and evening temperature), intoxication weakens, become less expressed many important symptoms of a disease: the period of recovery begins.

To features of a current of uncomplicated B. of t. (a moderately severe cyclic form) it is necessary to carry those cases of a disease which are followed by development of a recurrence and bacteriocarriers. At advanced and senile age the disease proceeds in the absence of a number of the symptoms inherent to diseases at young people: the temperature curve has uncertain character, rozeolezny rash often is absent, the hepatolienal syndrome is expressed slightly, instead of a leukopenia the normal or slightly increased quantity of leukocytes in 1 mkl can be observed. These features of clinical disease considerably complicate diagnosis; at development of complications in elderly sick B. of t. (especially in cases of perforation of an ulcer in a wall of a small bowel with development of peritonitis) there are also big diagnostic difficulties.

From options of a clinical current of B. of t. it is necessary to call first of all an abortal form, at a cut after the short rather expressed period of development of clinical symptoms there is a sharp change and the patient begins to recover. At atypically proceeding easy and easiest forms of a disease (the old name «out-patient typhoid») intoxication is expressed poorly, health and physical. forces remain in such measure that the diseased can continue to work, goes, visits policlinic, etc. At such patients intoxication of an organism is expressed slightly, temperature happens not higher than 38 °, the feverish period short, increase in a liver and spleen is absent or is expressed poorly, rash on skin develops seldom.

Severe forms of B. of t. — giperpirektichesky and hemorrhagic — meet not more often than in 0,5% of cases. The last from the called forms is characterized by development of multiple hemorrhagic elements (petechias, ecchymomas) on skin and mucous membranes in combination with usual rozeolezny elements; such patients can have nasal, intestinal, uterine bleedings, a gross hematuria. In the separate, seldom found cases it is observed so-called kolitif which is characterized by high feverish reaction, spontaneous pains in the right ileal area and local pains at a palpation of a stomach according to the provision of a caecum, a meteorism, a liquid or semi-fluid chair with impurity of slime.

At B.'s diseases of t. immunizirovanny persons clinical disease differs in a number of features. In particular, the shortened feverish period, the beginning of a disease acute or subacute is observed, temperature increase is limited 38 — 38,5 °, the hepatolienal syndrome is expressed poorly, rozeolezny rash on skin is noted only at certain patients. Early the begun treatment by antibiotics (levomycetinum) leads to quite bystry easing and disappearance of a number of the main symptoms of a disease. So, in particular, within 2 — 5 days from an initiation of treatment levomycetinum the temperature curve comes to norm, intoxication disappears, the functional condition of a cardiovascular and nervous system improves, the dream and appetite improves; later the hepatolienal syndrome ceases to be defined, the gemogramma is normalized.

It is necessary to carry the following to the main features of a course of a typhoid: a possibility of an acute and subacute onset of the illness (in 25 — 30% of all cases), moderately expressed intoxication, considerable reduction of percent of severe forms, falloff of a lethality, moderately expressed disturbances of a cardiovascular and nervous system, lack of purulent complications. In many respects it is connected with broad use of the antibiotics which significantly changed clinical disease. Considerable frequency of atypical, easy and easiest clinical forms of a disease is observed.

To features of a current of B. of t. at certain patients a recurrence belongs (see. Recurrence ). In the past the frequency of a recurrence in separate years reached 12 — 14%. With introduction to therapeutic practice of antibiotics and their rational use the frequency of a recurrence averages apprx. 7 — 9%. Duration of the feverish period at a recurrence can fluctuate from 1 — 3 (a rudimentary recurrence) up to 20 and more days. After the postponed B. of t. regarding cases the bacteriocarrier connected with stay of the activator in bilious and uric ways, and also in marrow, with development of a special form of unresponsiveness develops hron.

It must be kept in mind a possibility of a combination of B. of t also. with other intestinal infectious diseases (e.g., acute dysentery).

A typhoid at children

Differences from B. of t. at adults are most expressed at children of the first years of life. At school age clinical symptomatology and B.'s current of t. do not differ from clinical manifestations of B. of t. at adults. B. t. at children, as well as at adults, can be various weight.

Fig. 2. Types of temperature curves at a typhoid at children of various age: And — 1 year; B — 3 years; In, and D — 4 years; Ε — 5 years; — 9 years; 3 — 10 years; And — 12 years; To — 13 years.

According to a number of authors, easy forms made 10 — 30%, medium-weight — 45 — 60% and heavy — 18 — 30%. In recent years in 60 — 80% of cases the acute onset of the illness with bystry rise in temperature to the maximum figures at the senior children during 3 — 4, at younger — is observed 1 — 2 days. Various types of temperature reactions (fig. 2), a bowl of wavy Botkin and wrong type are noted: the first — it is preferential at heavy, the second — it is equally frequent at severe and easy forms. At the height of a disease temperature from 38,5 to 40 ° prevails, morning remissions are characteristic. Duration of the feverish period is shorter, than at adults — on average 16 days. Temperature drop happens as the lysis which is quite often shortened. After decrease in temperature at considerable number of children subfebrile condition to 10 — 12 days is noted. At the vast majority of children symptoms of typroid intoxication are expressed in a varying degree: apathy, adynamia, frustration of a dream, headaches, mental block. The stupor develops seldom. The nonsense is observed more often at children 5 years are more senior. In hard cases encephalitic symptoms, the Meningeal phenomena, usually without changes in liquor are more expressed.

Cardiovascular frustration are shown by muting of cordial tones, small expansion of borders of heart. Pulse at most of patients corresponds to temperature, bradycardia is observed infrequently and only at children of advanced age, the Dicrotism — in isolated cases. Lowering of blood pressure is more expressed at severe forms. Myocardites are observed seldom. More often than adults, and in earlier terms have a bronchitis. Pneumonia, preferential secondary etiology, complicates B. of t. in 10 — 16% of cases and is more often at children of preschool age. Defeat went. - kish. a path it is characterized by a loss of appetite up to anorexia, dryness laid over in the middle and pure at the edges of language, tendency to locks less often to a diarrhea. The stomach is blown up, quite often painful; in the right ileal area obtusion of percussion tone and rumbling can be defined. Increase in a liver — an early and constant symptom. Its sizes and functional disturbances increase by the heat of a disease and depend on B.'s weight of t. Increase in a spleen is observed in 1/3 — 1/2 diseases and it is found with 3 — the 5th day of a disease. Roseolas find in 45 — 60% of cases; they more plentiful at severe forms and a thicket are found in the senior children. At chest age of a roseola scanty and pale. It is peculiar to a picture of blood at children smaller, than at adults, constancy is leukopenias: in 40% of cases the normal or increased quantity of leukocytes is noted. Neutrocytosis with nuclear shift, hypo - both the aneosinophilia and acceleration of ROE are found in 80 — 90% of children of all age groups. A recurrence is observed in 10 — 15% of cases. They arise through various periods after decrease in temperature, is more often 2 — 3 weeks later. An easy recurrence lasting 4 — 10 days prevails.

Babies of B. have a t. proceeds most peculiar and hard. The disease breaks violently, with bystry rise in temperature and development of symptoms of intoxication. More often than at other age, motive frustration are noted: spasms, tremor, atetoidny and horeopodobny movements, Meningeal phenomena. Into the forefront quite often act went. - kish. frustration: vomiting and a diarrhea or alternation of a diarrhea with a lock. At diarrhea a chair plentiful, green color. The meteorism is sharply expressed. The long diarrhea can lead to dehydration of an organism and further to dystrophy. Sometimes in a picture of a disease pneumonia prevails. In similar cases the diagnosis of toxic dyspepsia, a colienteritis, pneumonia is mistakenly made. Difficulties of diagnosis are aggravated with weak expressiveness of roseolas and frequent lack of a leukopenia. The feverish period lasts 1 — 3 weeks, but maybe longer. Complications at children the same, as at adults, but meningoentsefalita and collapses are rare. The toksiko-allergic reactions increasing danger of a recurrence and complications figure prominently.

Complications

the Complications observed at B. by t., it is possible to subdivide into two main categories: a) caused by pathogenic influence of the activator and its endotoxin and b) caused by influence of the accompanying, consecutive infection.

At the natural course of B. of t. the collapse preferential develops in late terms from an onset of the illness (18 — the 25th day) and is observed more often at young people. With approach of a collapse of the patient becomes uneasy, alarmed, quite often deafened. On a forehead there are drops of sweat, skin becomes very pale, and sometimes and sticky from sweat, mucous membranes of lips, a tip of a nose, fingers on top and bottom extremities get a cyanochroic shade, are cold to the touch, body temperature decreases to subnormal figures (up to 35 ° below). Features are pointed, eyeballs sink down, eyelids of a tsianotichna. Superficial veins on the back of a brush and feet, in temples are fallen down, zapustevat, elbow veins often are also fallen down.

Pulse is threadlike, very frequent, it is hardly probed; blood pressure sharply falls (maximum — to 30 — 40 mm of mercury., minimum to zero). On a top of heart tones are sharply muffled, the blowing systolic noise is listened. Venous pressure is reduced, the electrocardiogram reveals decrease in a voltage of a tooth of, reduction of sokratitelny ability of a myocardium. Approach of repeated collapses is possible (see the Collapse).

Fig. 3. A temperature curve at the patient with the typhoid complicated by intestinal bleeding and a recurrence.

Intestinal bleeding is observed in the same terms from an onset of the illness, as a collapse. The clinical picture of this complication in many respects depends on massiveness of bleeding. The size of blood loss varies ranging from 50 to 300 ml and more. There are direct and indirect symptoms of the come bleeding. It is necessary to refer detection in the fecal mass of impurity of blood to number of straight lines as in the form of changed, black color (a melena — a tar-like chair) that is observed at the slowed-down evacuation of contents of intestines, and in the form of scarlet blood if the patient had a chair soon behind the occurred intestinal bleeding. Temperature drop (fig. 3), increase of pulse, decrease in level of arterial pressure can be the indirect symptoms of intestinal bleeding (which are the most expressed at massive blood losses) (see. Gastrointestinal bleeding ).

Perforation of a wall of a small bowel in the area izjyazvivshikhsya single or groups limf, follicles is observed by hl. obr. on 9 — the 15th day from an onset of the illness. In the past this complication was noted usually on 3 — the 4th week.

Perforations of typroid ulcers at the beginning of the century occurred in our country at 5 — 8% of sick B. of t., and in 60 — the 70th years only at 0,5 — 1,5%; however in some countries of Asia and Africa the percent of similar complications is still high and reaches 15.

More often perforation of typroid ulcers arises in terminal department of a small bowel at distance of 10 — 40 cm from the ileocecal valve, is more rare in a large intestine (blind, sigmoid). Extremely seldom meet perforation of typroid ulcers of a gall bladder though defeats of bilious ways at B. of t. make about 2,5%.

Perforations at B. of t. meet at men of advanced age at medium-weight or severe forms of a disease more often. Direct dependence between depth of defeat group limf, follicles and the frequency of intestinal complications is noted. As a rule, are noted single perforation, but perforations on 3, 5 and more times at the same patient during a disease are described.

Perforation involves development of diffuse peritonitis (see). Regarding cases the perforation opening in a wall of a gut can be covered with an epiploon, and then at the patient establish the phenomena of limited (local) peritonitis.

Development of peritonitis is possible also in cases of a deep penetration of a typroid ulcer. A necrosis mesenteric limf, nodes, the suppurated heart attack of a spleen, a typhus salpingitis can also serve as the reason of bryushnotnfozny peritonitis.

Perforation of a wall of a gall bladder is followed by development of bilious peritonitis; at the same time both in bile, and find typroid sticks in a purulent exudate.

Symptoms, pathognomonic for perforations of typroid ulcers, do not exist. The clinic of such complications consists of B.'s symptoms of t. and peritonitis. Such symptoms as «knife-like» abdominal pains, jump of the general condition of the patient, a point of features, frequent pulse of small filling, meet seldom, generally at the erased, so-called out-patient forms B. of t. Symptoms of peritonitis mask the serious general condition of the patient caused by oppression of c. N of page. Considering weight of a state, nonsense, the confused consciousness, complaints of such patients it is necessary to perceive very critically. Lack of hepatic dullness at percussion or the availability of free gas in an abdominal cavity defined radiological, signs of free liquid in an abdominal cavity, a muscle tension of a front abdominal wall form the sufficient basis for the diagnosis of perforation of a typroid ulcer.

A perforation of a typroid ulcer in cases of an easy form B. of t. it is diagnosed easier, than at a severe form. In the conditions of sporadic distribution of B. of t. perforation often timely are not distinguished, and before emergence of such complications and audit of an abdominal cavity do not diagnose B. for some patients of t.

The moment of perforation at a number of patients is followed by acute abdominal pains, symptoms of a collapse. Features are pointed, on a forehead there are droplets of sweat, pulse becomes frequent, its tension and filling weaken, arterial pressure falls. Body temperature of the patient decreases, can become normal or subnormal. Desires on vomiting are sometimes observed. Language in 2 — 3 hours which passed from the moment of development of this accident becomes dry, the leukopenia which was available before is replaced normo-or a leukocytosis. The peristaltics of guts is weakened, hepatic dullness disappears. Symptoms of irritation of a peritoneum can gradually develop: the muscle tension of a front abdominal wall, a positive symptom of Shchetkin — Blyumberg quite often come to light only 2 — 4 hours later from the moment of perforation. At the same time after 6 — 8 hours from the moment of perforation there can occur paralytic relaxation of muscles of a front wall of a stomach.

In certain cases B.'s current of t. can be complicated in different terms from an onset of the illness by the focal pneumonia caused by typroid bacteria or coccal flora. A rare complication of a disease is defeat of a peripheral nervous system, hl. obr. elbow nerve and humeral neuroplex.

After 1949 — 1953 when antibiotics entered therapeutic practice, thrombophlebitises, and also myocardites began to be observed much less often. The last arise preferential in the late period of a disease, are characterized by tachycardia, shift of a knaruzha of borders of heart, considerable muting of cardiac sounds, emergence of systolic noise on a top. The electrocardiogram reveals considerable flattening of a tooth of becoming sometimes negative in chest assignments, decrease in a segment S — T is possible. Inspection reveals easing of sokratitelny ability of a myocardium.

With introduction to therapeutic practice of antibiotics practically disappeared at B. of t. purulent defeats of various bodies and fabrics (parotitises, otitises, mastoidites, pansinusites, osteomyelites).

The diagnosis

For justification of the diagnosis of B. of t. the careful analysis of a clinical picture and disease with carrying out differential diagnosis, epidemiol, and datas of laboratory is required. Need of timely and correct treatment of patients, and also implementation of a complex protivoepid. demands actions from doctors of early diagnosis of a disease. To the clinical data having the greatest value for the diagnosis in the first 5 — 6 days from the beginning of a disease of B. of t., the following belongs: gradual (at 70% of patients) an onset of the illness with increase of temperature, headaches, deterioration in a dream and appetite, apathy, an adynamia, pallor of integuments, relative bradycardia, sometimes the Dicrotism of pulse, edematous, reinforced, with prints of teeth on side surfaces, the dry, laid-over by rather dirty-white plaque language, a considerable meteorism, rumbling at a palpation of a stomach in the right ileal area, a positive symptom of Padalki, locks. With 4 — the 5th day there are changes of a gemogramma described above.

Laboratory diagnosis

Laboratory diagnosis of B. of t. it is based on allocation from an organism of the activator (tsvetn. tab.). and detection of specific antibodies. Excite it can be allocated from blood, excrements, urine, duodenal contents, marrow (punctate of a breast), roseolas, cerebrospinal fluid, pus or exudate (at complications). For retrospective diagnosis at a lethal outcome investigate section material.

The blood analysis is the earliest and most reliable method bacterial. B.'s diagnoses t. Blood is taken the syringe from an elbow vein in number of 5 — 10 ml and directly at a bed of the patient sow in a bottle from 50 — 100 ml 10 — 20% of bilious broth or the environment Rapoport. In the absence of bile blood can be sowed in a usual beef-extract broth. If blood is received from the patient in later terms (on 2 — the 3rd week of a disease), its bigger quantity (20 — 25 ml) is exposed to a research. Bottles with crops of blood bring to laboratory for a research. If blood cannot be sowed in a medium at a bed of the patient, it is brought in a test tube to laboratory where separate serum from a clot, the last is carefully crushed (a glass rod or a tube) and sowed in a medium in the same ratio, as well as a whole blood (1: 10). Crops of blood place in the thermostat at t ° 37 °. In the next days (3 — 5 — the 7th days) resowings are made of fluid medium on dense differential and diagnostic environments (Endo or Levin).

Excrements subject bacterial, to a research for the purpose of diagnosis of a disease, before an extract of a convalescent, and also at inspection on a bacteriocarrier. The research of excrements is conducted repeatedly, since 1st week of a disease and up to an extract of the patient from a hospital. The most full-fledged material for a research are the excrements collected directly after defecation. Collecting tests is made by the sterile wooden pallet or a glass rod from the vessel, a pot, a special tray, a paper plate or a diaper. In the vessel or a pot there should not be traces of disinfecting solution, the Crimea they were processed for what they need to be washed out carefully after disinfection hot water. Excrements can be received and directly from a rectum, by means of a rectal tube (Tsimann's tube). The excrements placed in test tubes (jars) bring to laboratory. In the absence of a possibility of immediate crops collected material (or rectal tubes) is placed in test tubes with the preserving solution (glyceric mix or buffered solution of phosphate salts, pH 8,0), at the same time the amount of the studied material shall make apprx. 1/3 volumes of preservative. The laboratory of an excrement sows in Petri dishes with dense differential and diagnostic environments (bismuth sulfite agar, Ploskirev and Endo's environment) and at the same time on Wednesday enrichments (selenitovy broth, Müller or Kauffmann's environments, etc.). At crops of excrements on Wednesdays the ratio of an inoculum and Wednesday shall make enrichments not less than 1:5. If excrements are delivered in preservative, carefully mix them and apply a drop of a suspension (the stick which is built in in a stopper, a pasterovsky pipette or a loop) on a surface of the dense environment and pound the glass or aluminum pallet on all surface of the environment. If excrements are received by means of a rectal tube, apply its contents after hashing with preservative with the same tube on the dense environment and pound on its surface. Crops of excrements on fluid and dense mediums place in the thermostat at t ° 37 ° for 18 — 20 hour.

The research of urine is made repeatedly up to an extract of the patient from a hospital, however the greatest percent of positive takes is observed on 2 — the 3rd week of a disease. Urine in number of 20 — 30 ml is collected in sterile ware (banks, bottles) with observance of the conditions excluding introduction of foreign flora. Before crops it is centrifuged and the deposit is sowed on Wednesday by enrichments and on dense differentsialnodiagnostichesky environments. At crops of urine in selenitovy broth the last is prepared for double concentration and parted in half with the sowed urine.

The research of bile (duodenal contents) can be made at the patient in the period of reconvalescence (for an exception of a bacteriocarrier) and at healthy faces — for identification hron, bacteriocarriers. The bile received by means of the duodenal probe is brought to laboratory in test tubes (all three portions — And, In and With — separately or together) where it is sowed in a beef-extract broth and placed in the thermostat at t ° 37 ° for 18 — 20 — 48 hour.

The research of contents of roseolas quite often appears the only way of allocation of culture at the patient. For this purpose skin over a roseola is wiped with the tampon moistened with alcohol, then a sterile dry tampon then slightly scarify. This place is wiped with the small sterile cotton plug moistened with broth or fiziol, solution, and lower a tampon in a test tube with bilious or selenitovy broth. Crops place in the thermostat at t ° 37 ° for 18 — 20 — 48 hour.

Resort to a research of cerebrospinal fluid in the hard cases of a disease which are followed by the meningeal phenomena. The liquid received at a puncture is collected in a sterile test tube and brought to laboratory where it is sowed in bilious broth and placed in the thermostat at t ° 37 ° for 18 — 20 — 48 hour.

The research of punctate of the inflammatory centers (pus) is made when the disease is followed by the corresponding complications, and pursues the aim of identification of their etiology. Punctate is collected in sterile test tubes, brought to laboratory where it is sowed in bilious broth and placed in the thermostat at t ° 37 ° for 18 — 20 — 48 hour.

The research of section material is conducted for specification or retrospective diagnosis. For bacterial, researches send to laboratory in sterile ware (banks, Petri dishes, etc.) pieces of parenchymatous bodies (a liver, a spleen, a kidney), blood from heart, mezenterialny limf, nodes, marrow, pieces of a small bowel with contents. In laboratory pieces of the sent material crush in porcelain mortars to which add 1 — 2 ml fiziol, solution; from an upper part of a suspension suck away a pipette 0,1 ml and sow on dense differentsialno - diagnostic environments, and entirely transfer the remained suspension to the environment of enrichment. Contents of intestines are sowed the same as excrements. Blood is sowed in bilious broth. All crops place in the thermostat at t ° 37 ° for 18 — 20 hour.

After thermostating of crops of the specified materials (blood, excrements, urine, etc.) study their growth on dense differential environments. For the 2nd day suspicious colonies (3 — 5 or more) are removed and oversown on Russell's circle or on the so-called short motley row including a slant, Giss's circles with lactose and glucose.

From environments of enrichment (including and from bilious broth) do resowings on dense differential environments. All crops place in the thermostat till next day. Crops in bilious broth of blood, cerebrospinal fluid, contents of roseolas and some other materials maintain in the thermostat after the first seeding some more days, and repeat seedings on dense environments. For the 3rd day look through all resowings from environments of enrichment on dense environments and carry out allocation of suspicious colonies for the subsequent studying. Identification of the marked-out cultures is begun with the accounting of their enzymatic activity; the cultures which are fermenting glucose with formation of acid without gas, not fermenting lactose and not splitting urea subject to further studying. They are in addition oversown on a slant, Giss's circles with a mannitol and sucrose, in Hottinger's broth (for definition of formation of an indole) and in semi-fluid (0,2 — 0,5%) an agar (for definition of mobility). Hydrogen sulfide is determined on Wednesdays, saliferous Mora, or on iron-chloride gelatin by F.Kauffmann. On kulturalno-enzymatic properties it is necessary to be convinced of belonging of the marked-out culture of bacteria to the sort Salmonella. In the same day studying of an antigenic structure of the marked-out cultures can be begun, edges is established in an agglutination test with monoreceptor salmonellezny serums. First of all they are tested concerning mix of O-serums, and then concerning separate O-serums. After establishment of belonging of the marked-out culture to group D (an agglyutinabelnost serum 0-9) it is tested with H-(d) and Vi-serums in the presence of which agglyutinabelnost testifies to belonging of culture to B.'s bacteria of t. For the 4th day the final accounting of results of studying of the marked-out cultures is made and the answer about results of a research is issued. In view of that in definition of belonging of culture to a certain serotype (in this case to S. typhi) their antigenic structure is decisive, with accurate results of agglutination with monoreceptor serums, the answer about a positive take of a research can be given also for the 3rd day from the beginning of a research. In the conclusion of a research the marked-out cultures subject to a lysotypy (see), a cut carry out on site or in special regional laboratory where cultures are sent in process of their allocation.

Serological blood analyses belong to number of auxiliary diagnostic methods of B. of t. From them the agglutination test with complex or monoreceptor diagnosticums has the greatest use (see. Vidalya reaction ), and also reaction indirect hemagglutinations (see), at a cut as antigens use erythrocyte diagnosticums (O, H and Vi). Apply also other immunological methods of a research of blood serum: a) definition of antibodies various physical. - the chemical nature, the immunoglobulins belonging to various classes — IgM (19S) and IgG (7S) which come to light by means of processing of serums the reducing substances (2 mercaptoethanol, cysteine, etc.). The research is conducted by a technique. offered Deychem and Morton (H. F. Deutsch, J. J. Morton, 1957) and E. V. Chernokhvostova (1965); b) definition of the general bacterial action of blood serum is carried out by Uordlo's method — Pillemera (Ampere-second. Wardlaw, L. Pillemer, 1956) in J. Karolcek's modification et al. (1959), and also definition of a caption of bactericidal antibodies of serum [F. Kauffmann; Landi (M. Landy) et al., 1962, etc.].

By all mentioned immunological (serological) tests it is possible not only to confirm the clinical diagnosis of a disease in that case when the activator is not allocated, but also to confirm an etiological role of the allocated microbe, to reveal the hidden state hron, bacteriocarriers, and also to define character of the revealed bacteriocarrier (acute, tranzitorny, chronic). Reliability of results of a serological blood analysis increases at its repeated research in dynamics of a disease or a bacteriocarrier.

The differential diagnosis

the Differential diagnosis shall be carried out with those infectious diseases which are similar to B. of t. in the symptoms and a current. At the same time the period of a disease as symptoms have certain dynamics shall be considered. Strong likeness with B. of t. have paratyphus And yes V. Odnako from B. of t. these diseases differ in the fact that at paratyphus And yes In a thicket observe repeated oznoba, sweats, a hyperemia of the person, conjunctivitis, cold, sometimes rashes of herpetic bubbles on a mucous membrane of lips; the spleen increases with 3 — the 4th day from an onset of the illness, rozeolezny rash on skin can be plentiful (see. Paratify ). In the first 2 — 3 days from an onset of the illness of B. of t. it is necessary to differentiate with flu and adenoviral infections. For flu (see) acute temperature increase, short duration (2 — 3 days) of the feverish period of a disease, hyperemia of the person, conjunctivitis, pains in the field of superciliary arches and eyeglobes, feeling of «congestion» behind a breast is characteristic (tracheitis), quite often cold and cough. In the first 3 — 5 days from an onset of the illness B. follows t. to differentiate with a typhus and Brill's disease. In the specified terms this or that extent of psychological excitement, a hyperemia and puffiness of the person, quite early increase in a spleen, tachycardia, morbidity during the pressing on roots of cervical nerves, dot hemorrhages at the basis of a uvula is inherent to typhous patients, dry, evenly coated tongue; the gemogramma is characterized normotsitozy or moderately expressed leukocytosis. Patients with a sapropyra have no such important symptoms of B. of t., as considerable pallor of integuments (including persons), characteristic type of language, meteorism. At a sapropyra earlier, already on 4 — the 6th day from an onset of the illness, a characteristic enanthesis — plentiful rozeolezny or rozeolezno-petekhialny rash with its favourite localization on side surfaces of a thorax, on spin and on the flexion surface of hands appears. Kiari's symptoms — Avtsyna are found (see. Kiari-Avtsyna symptom ), Govorova — Godelye (see. Sapropyra epidemic ).

Fig. 4. Temperature sheets of patients belly and sypny typhus and brucellosis. The major differential diagnostic characters are reflected.

In the first 6 — 10 days from the beginning of a disease of B. of t. in some cases, in the presence of corresponding epidemiol, data, there is a need to carry out the differential diagnosis with brucellosis (see). At the same time for a brucellosis will testify: chilling, frequent sweats, pains in muscles of a neck and lumbosacral area, in large joints, existence of fibrosites, bursitis, a polyadenitis. Dnagnoz of a brucellosis is confirmed by positive takes of serological researches and a skin allergy test. The major differentsialno - diagnostic characters of B. of t., a typhus and a brucellosis are presented in the figure 4.

In some cases carrying out the differential diagnosis with a tifoidny form of food toxicoinfection is necessary — salmonellosis (see) and malaria (see).

For the first 4 — 6 days a clinical picture B. of t. can remind a disease of an infectious mononucleosis, especially when the polyadenitis is poorly expressed and there are no symptoms of quinsy. Specification of the diagnosis is promoted by a research of dynamics of a gemogramma: at an infectious mononucleosis the leukocytosis accruing to 15 — 18 thousand in 1 mkl with increase in percent of cells of a lymphocytic row is found; later it is possible to find shirokoplazmenny one-nuclear cells, characteristic of this disease, in smears of peripheral blood. Data of serological researches are used (see. Mononucleosis infectious ).

For the first 6 — 8 days from the beginning of a disease it is necessary to carry out the differential diagnosis with miliary tuberculosis. In this early period of development it is lovely pair tuberculosis the temperature curve of the wrong type (with considerable fluctuations between morning and evening temperature), the perspiration clearly expressed, cyanosis of lips, an asthma is noted; on the roentgenogram of lungs executed with the dosed rigidity «grid» and multiple prosovidny ochazhka of consolidation of pulmonary fabric is visible.

The forecast

Due to the successful use of antibiotics, hl. obr. levomycetinum (chloramphenicol), in combination with pathogenetic therapy, observance of a diet, bed rest and on condition of a careful nosotrophy the forecast is favorable. However it can become doubtful at development of such terrible complications as a perforation of the ulcer of intestines with the subsequent phenomena of peritonitis, intestinal bleeding, collapse.

The forecast at typroid peritonitises depends on timeliness of the diagnosis and operation, weight of a basic disease, age of the patient, existence of associated diseases, etc. At rational and timely treatment the forecast concerning life and working capacity favorable. Temporary disability after an extract from a hospital lasts in such cases of 1 — 3 month. The delay with operation does the forecast very doubtful. Complications, napr, the post-typhus myocarditis tending sometimes to progressing are occasionally possible late (though seldom meeting). In the period of recovery physical. strengths of the patient, as well as a functional condition of its bodies and systems, are recovered slowly. After an extract from a hospital of the person, had a typhoid, shall remain on the house mode with release from physical. and brainwork within 10 — 15 days. If and after this term there did not occur sufficient recovery of working capacity, convalescents after B. of t. transfer to the facilitated mode of work within the next month. All t which had B. are subject within the same span to careful observation in offices of infectious diseases.

Treatment

all sick B.' Hospitalization t. is obligatory. All patients shall be on a high bed rest of 8 — 12 more days from the moment of normalization of temperature at them. Only after this term they are allowed to sit down in beds, and after 4 — 5 more days — to go in chamber. Observance of these requirements, early detection of all changes in a condition of the patient menacing to it with quite often very serious complications make important conditions of successful treatment of sick B. of t., especially at severe forms of this disease. It is necessary to watch hygiene of an oral cavity, a regularity of a chair (at locks enemas are applied), at the weakened patients in the presence of the general exhaustion to take the measures directed to the prevention of decubituses.

As B.'s disease of t. leads to sharp exhaustion of an organism of the patient, special attention shall be paid to a balanced diet. The diet shall consider the period of a disease and to be the most sparing ambassador 10 — the 12th day from an onset of the illness, considering a possibility of development of a number of serious complications in these and in later terms. At the choice of dishes for sick B.'s food of t. it is important to provide the various and digestible food subjected to the correct culinary processing (preferential semi-fluid dishes), providing protein sick with enough at the daily caloric content of 2500 — 3000 kcal.

Approximate daily diet of sick B. of t. shall include curdled milk, kefir or acidophilus milk (to 500 g of one of these dairy products), fresh butter (20 — 30 g), cottage cheese (to 200 g) and sour cream (75 g), white crackers (75 g), semi-stale white loaf (150 — 200 g), yolks of egg (2 pieces a day). Porridge, rice or semolina soups with meat frikadelyam, low-fat beef or chicken broth, steam cutlets with mashed potatoes are recommended, 10 g of fresh butter, well boiled thoroughly vegetables puree, free of a large amount of cellulose, well boiled thoroughly semi-fluid rice porridge, fresh boiled fish with vermicelli are added to Krom. Appoint also fruit and berry kissels, jelly, mousses, creams, natural fruit and berry juice (from blackcurrant, oranges or lemons), infusion of a dogrose, tea, in a small amount natural coffee; at the begun recovery it is necessary to add the baked apples, meat roll to the specified products (from low-fat beef). Patients shall eat food not less than 4 times a day; if the weakened seriously ill patient is not able to eat food independently, nurses persistently shall feed him.

After 10 — the 12th day from the moment of normalization of temperature at the patient his diet can be gradually expanded, and by the time of an extract from a hospital (i.e. by 23rd day from establishment of standard temperature) recovering can be transferred to a table d'hote, however with an exception of a diet acute, mechanically and chemically irritating dishes.

The effective drugs used for sick B.' treatment by t., antibiotics are. The greatest use was received by levomycetinum possessing the expressed bacteriostatic action on typroid bacteria. Levomycetinum is appointed for intake in the form of tablets or in gelatin capsules (the last puncture with a needle just before reception to facilitate transition of drug to contents of a small bowel).

Soluble drug of levomycetinum — sodium succinate of levomycetinum is used in 30% aqueous solution for intramuscular injections: its use is shown to hl. obr. when the patient cannot accept levomycetinum inside because of persistent vomiting; doses are calculated by amount of pure substance of levomycetinum.

Levomycetinum in tablets appoint up to the day 2nd (inclusive) from the moment of normalization of temperature on 0,5 g of 6 times a day (with a night break), then on 0,5 g 4 times a day to 10 — the 12th day from the moment of normalization of temperature. At such long continuous course of treatment levomycetinum in average therapeutic doses achieves the best results.

Fig. 5. Temperature curve of the patient with a typhoid (treatment by levomycetinum).

Along with intake of levomycetinum according to indications appoint antifungal (nystatin in tablets for the prevention of candidiasis) and antihistaminic drugs (Diazolinum, Suprastinum, Pipolphenum, Dimedrol). Under the influence of levomycetinum within 2 — 5 days intoxication sharply decreases, temperature (fig. 5) is normalized, development of a number of symptoms of a disease is late. However treatment by levomycetinum does not eliminate danger of a recurrence and formation of a bacteriocarrier. Thereof for the prevention of a recurrence and a bacteriocarrier (for stimulation of specific immunity) it is recommended to combine carrying out a full course of treatment by levomycetinum with single (perhaps earlier!) introduction under skin of 400 mkg of chemically purified drug of Vi-antigen of typroid bacteria.

Treatment of children, sick B. of t., as well as adults, it is carried out taking into account age dosages of medicines.

At development of intestinal bleeding the high bed rest, restriction of drink of N the termination of meal on 10 — 12 hours (with the subsequent very sparing diet), transfusion of 125 — 150 ml of an odnogruppny or I (0) blood group (a haemo static dose) and 10% of solution of a gluconate of calcium are necessary (it can be entered and intramusculary); besides, inside appoint Vikasolum.

At sharply expressed intoxication, and also in cases of development of a collapse apply at first jet (of 400 — 500 ml), and then drop intravenous injection of infusional liquids (0,9% of solution of sodium chloride and 5% of solution of glucose in the relations of their volumes 1:1; the polyionic solutions containing sodium chlorides and potassium, sodium bicarbonate). The patient who is in a condition of a collapse enter a phenylephine hydrochloride, noradrenaline, ephedrine a hydrochloride.

In cases of perforation of an ulcer of a gut urgent surgical intervention is necessary.

The extract from a hospital of the persons who had a typhoid is made after absolute clinical recovery, but not earlier than the 23rd day from the moment of establishment of standard temperature and after carrying out a bacteriological research (double) a calla and urine.

Treatment of perforations

Treatment only surgical. Operation shall be performed in perhaps early terms and can be carried out as under local anesthesia, and under anesthetic. The most convenient access is lower median laparotomy (see).

Audit is begun with survey of terminal department of a small bowel. Anyway it is necessary to make full audit of a gut since can be multiple perforation. At single perforation of a small bowel the opening is taken in two rows of silk seams in transverse direction. In cases of several perforative openings located close to one from another it is reasonable to make a resection of an affected area of a gut. Bowel resection is shown also at the big size of a perforated opening when danger of sharp narrowing of a gut after its sewing up is created.

At destructive or perforative typroid cholecystitis it is shown cholecystectomia (see). The suppurated heart attack of a spleen demands splenectomy (see). Typroid appendicitis demands appendectomies (see).

After operation such patients shall be in infectious department under obligatory joint observation of the infectiologist and surgeon: it is necessary to combine the actions directed to elimination of the phenomena of peritonitis with the continuing antityphoid treatment. Appoint inhalations of oxygen, vitamins, heart, vascular drugs, intravenous administration of liquids, hemotransfusion, blood substitutes, continue antibacterial treatment.

At paresis of intestines, in cases when healing of ulcers can be late, fight against this complication demands a certain care — it is impossible to stimulate sharply a peristaltics since it can promote a repeated perforation. It is reasonable to use introduction of a stylet through a nose in a stomach or a duodenum that not only promotes fight against paresis, but also allows to enter drugs, food and so forth.

Sometimes in the postoperative period there are repeated perforations that is much more difficultly distinguished and burdens disease.

Prevention

In conditions epid, the center the leading measures are neutralization of sources of contagiums, suppression of ways of their transfer. It is implemented in the form of a wide complex a dignity. - a gigabyte. actions in the field of water supply, construction of the sewerage in settlements, cleanings of territories, observance of the mode of collecting, transportation, processing and implementation of foodstuff, a dignity. - a gleam, works.

It is well-known that improvement of water supply in settlements with rather high and steadily registered indicators of incidence of B. of t. leads to considerable decrease in incidence soon. Improvement of water sources of the centralized water supply is carried out by establishment of security zones, a right choice of the place of an intake of water, observance of the mode of operation of water constructions, planned laboratory control behind cleaning and disinfecting of water and so forth.

At the decentralized water supply the main attention shall be paid a dignity. - those. to a condition of wells and other sources of water use. Wells shall have a tight felling, densely closed cover and a public bucket. During the use for the drinking purposes of a river water of the place of a fence shall be located on a watercourse above the settlement, water shall not be consumed without preliminary disinfecting or boiling. Water consumption is completely excluded from technical water supply systems.

Construction of the sewerage, ensuring the correct and timely removal of garbage and garbage from settlements, improvement of dwellings, chlorination of bathrooms, garbage cans, dustbins, especially in summertime, extermination of flies — the major actions in prevention of tifo-paratyphoid diseases.

In the food industry and at catering establishments it is necessary to observe a dignity. - a gigabyte. the mode of operation of the enterprises, constantly to watch for a dignity. condition of objects for collecting, storage, transportation and implementation of foodstuff, semi-finished products and finished food products; to carry out a dignity. - bacterial, researches on the course of technological process «raw materials — a semi-finished product — products — retail chain stores»; to respect the rules and rules according to the prevention of pollution of milk and dairy products at all stages of collecting, transportation, processing and implementation. Great value in B.'s prevention t. has observance of rules of personal hygiene both employees of the food enterprises, and all population in general.

Along with a wide complex a dignity. - the prof. died very important early detection and isolation (hospitalization) of sick B. of t is. and bacillicarriers.

T, sick and suspicious on B. surely hospitalize in diagnostic departments (chambers) at infectious diseases hospitals (in the cities no later than 3 hours, in rural areas — not later hour; from the moment of their identification) also inspect on a hemoculture. The earlier blood from an elbow vein is taken on crops, the more probably and rather B.'s diagnosis of t can be established. Behind the center from where sick B. is hospitalized by t. or with suspicion of this disease, observation within 21 days with a daily termometrirovaniye of all persons contacting to the diseased is established. From the moment of sick B.'s identification t. or suspicious on this disease and up to its hospitalization in the center carry out the current disinfection, and after hospitalization of the patient — final disinfection. At the same time allocations of the patient, objects of a surrounding situation, premises, bathrooms, garbage recipients are exposed to disinfecting; in the presence of flies — they are exterminated prior to disinfection.

Add water, then dry lime chloride to the issued excrements of the patient in the ratio 1: 5 to the volume of contents or 1:10 DTSGK (dvetretiosnovny salt of calcium hypochlorite), stir and maintain not less than 60 min. Add 10 g of lime chloride or 5 g of DTSGK on 1 l to urine, mix and maintain 15 min. Linen is boiled in 1 — 2% soda solution or any soap powder within 15 min. from the moment of boiling. At impossibility of boiling linen without traces of fecal pollution is presoaked in 0,2% solution of chloroamine for 60 min. (on 1 kg of dry linen of 4 l of disinfecting solution). Ware of the patient (the bacillicarrier, a convalescent) is disinfected after each use of it of boiling in 1 — 2% soda solution or washed within 15 min. from the moment of boiling.

One of the major preventive measures is the prevention of formation of a bacteriocarrier. It is established that use of a tifo-paratyphoid divaccine or Vi-antigen reduces the frequency of formation of a bacteriocarrier respectively more than in 3 and 2 times. At persons who to a disease were imparted against B. by t., the acute carriage arose in 1,5, and hron. — by 9 times less than at the diseased from among not vaccinated.

Actions concerning bacillicarriers come down to their identification and elimination from objects where they can threaten health of the population, carrying out a dignity. - a gleam, and scheduled maintenance on the place of their residence and work. The volume and character of the held events depend from epidemiol, the importance of carriers, edge the dignity is defined by their profession, conditions of life. condition of the settlement, character of a carriage (acute, hron., tranzitorny).

Identification of bacillicarriers is made with the preventive purpose and on epid, to indications.

Preventive bacterial, the t which had B. are exposed to inspection all discharged from hospitals. Not later than the 10th day after an extract from hospital conduct a fivefold research a calla and urine at an interval of 1 — 2 day (in case of negative takes workers of the food and equated to them objects are allowed to work). In the next 3 months a research the calla and urine is carried out once a month; by the end of the 3rd month bile is once investigated; then for two years 1 conduct a triple research a calla and urine quarterly; in 2 years after recovery once bacteriological investigate bile and define availability of Vi-hemagglutinins in blood serum; in case of the negative takes which had (except employees of the food enterprises and the objects equated to them) strike off the register in a dignity. - epid, stations.

Feature of inspection the objects which had, allowed to work in the food enterprises and equated to them, is the monthly single research a calla and urine for the first year after recovery, and in the subsequent — throughout all work once in a quarter; in case of positive takes bacterial, researches discharge them of work and place in a hospital for a period of 1 month.

The persons for the first time going to work in food and the enterprises equated to them, are inspected twice (kcal and urine) at an interval of 1 — 2 day; blood serum is once investigated in reaction of the V i-gem-agglutination. At positive takes of a serological research (credits 1: 100 and above) the fivefold research a calla and urine and single — bile is conducted.

On epid, to indications the persons communicating with sick B. of t are inspected. in the center, employees of the food and equated to them enterprises (employees of waterworks, enterprises for public service of the population, to lay down. - professional, institutions, etc.) at suspicion that they are a source of an infection.

The bacteriocarrier is established at allocation of culture of the activator; the serological research of blood serum by means of reaction of passive Vi-hemagglutination serves as an auxiliary (alarm) method of identification of carriers.

All revealed bacillicarriers are taken on the constant account in SES. The bacillicarriers found among the persons going to work on the food and equated to them enterprises are not employed. The carriers revealed among already working at such enterprises, to work are not allowed and go to a hospital. If in a hospital tranzitorny character of a carriage (lack of growth of microbes is established at repeated crops), employees of the food and equated to them enterprises are allowed to work, but are quarterly inspected throughout all work; hron, carriers are not allowed to work and shall change a profession. Acute carriers if they after treatment in a hospital within 1 month continue to allocate the activator, are transferred to the work which is not connected with their direct participation in process of collecting, processing, transportation and implementation of foodstuff.

In case of identification of a carriage at children they are allowed in organized children's collectives, but behind them observation is established.

With the bacillicarriers staying on the registry in SES the dignity is conducted. - a gleam. work; at the place of residence the current disinfection is carried out, and do to family members inoculations.

Is subject to definition fagotip the microbes allocated at hron, the bacillicarrier who is entered in his registration form. It in the subsequent facilitates carrying out epidemiol, the analysis in B.'s centers of t. Order of identification, account and overseeing by carriers of activators B. of t. it is defined by the existing instruction of M3 of the USSR.

The problem of sanitation of bacillicarriers, despite of wide experience of use of various antibiotics, bacteriophages, specific serums, vaccines, remains unresolved.

Specific prevention (vaccination) is an auxiliary measure in system protivoepid. actions at B. of t. In our country mass immunization is not justified since B.'s incidence of t. at us has sporadic character, and the existing vaccines are ineffective at their considerable reactogenicity.

Immunization against B. of t. carry out both in a planned order, and on epid, to indications. Planned inoculations at various enterprises and in institutions, in educational institutions, state farms, collective farms and to separate groups of the «unorganized» population are carried out at high rates of incidence of B. of t. in the last several years and also if water handling does not exclude danger of infection of the population of B. of t.

In the territory with the raised B.'s incidence of t. among children of school age special attention is paid on carrying out inoculations within this age group.

Inoculations on epid, to indications carry out at high probability of infection of B. of t.

The question of immunization in conditions epid, flashes is solved every time depending on a specific situation.

In 1955 — 1964 under the WHO recommendation a number of strictly controlled field experiments according to preventive efficiency of a number of the corpuscular and chemical typroid vaccines made in various countries is carried out. The acetonic agar corpuscular vaccine (foreign production) and a grety bouillon corpuscular vaccine (USSR) which were characterized approximately equal (respectively 79% and 81%) by coefficient of preventive efficiency were the most effective of the tested drugs.

In our country also chemical typroid vaccines are generally applied to vaccination of the population spirit. Also chemical sorbed typhus and paratyphoid and tetanic vaccine which production technology is improved recently is issued and applied, and the quantity of components in comparison with a polyvalent vaccine of NIISI is reduced; vaccinate it once subcutaneously, in 9 — 12 months carry out a revaccination. Impart adults and children from 15-year age. To children from.7 to 14 years enter a typroid monovalent vaccine.

From 1967 to 1973 in the certain regions of the USSR applied Vi-antigen of typroid bacteria which is used as a component of complex drug — the dry spirit typroid vaccine enriched with Vi-antigen of typroid bacteria to vaccination of children of 3 — 7 years.

As means of express prevention in B.'s centers of t. the bacteriophage is applied. There are instructions that B.'s incidence of t. among contacting to patients in the centers and undergone a fagoprofilaktika below, than among not accepting a phage (see. Vi-typroid phage ).

Features of epidemiology and prevention of a typhoid in troops

B. of t. in the past represented big epid, danger to troops not only in military, but also in peace time. Not without reason it was carried to so-called military, or soldier's, to infections. On B.'s incidence of t. in troops of various armies (tab.) always the general level a dignity exerted impact. conditions of troops which sharply worsened during the periods of wars.

INCIDENCE of the TYPHOID IN TROOPS during WARS


the Community of food and water supply is a major factor which can at a drift of an infection in collective promote a bystry and wide spread occurance of B. of t.

In the Russian army the most high level of incidence is noted in 1915, and since 1916, after introduction of a new method of disinfecting of water by chlorine and inoculations against B. in t., it considerably decreased almost everywhere. During all Great Patriotic War of 1941 — 1945 B.'s incidence of t. in the Soviet Army had sporadic character. Only in 1945, during fighting of our troops in the territory of Poland and Germany, B.'s incidence of t. increased in szyaz with considerable epidemics of this infection among local population a little. The total indicator of incidence in the Soviet Army for years of the Great Patriotic War was the lowest of all which were noted ever in the Russian army in last wars.

In the USSR a basis epid, wellbeing according to B. of t. troops and the country in general great success of communistic construction in all spheres of the national economy, health care, the increased level of the general and a dignity is. the cultures of the population which led practically to the termination of incidence of this infection in troops. The last became possible thanks to implementation of a wide complex a dignity. - a gigabyte, and protivoepid. the events held by military-medical service on the basis of powerful it protivoepid. organizations.

In a crust, time absence of mass diseases of B. of t. in the country reduces danger of a drift them in troops, however features of epidemiology of this infection do not belittle value of preventive actions.

B.'s prevention t. in troops it is carried out taking into account features of epidemiology and B.'s clinic of t.

For the prevention of developing of diseases of B. of t. in troops the strict dignity is carried out. supervision of the maintenance of the territory of arrangements of parts, its systematic cleaning and disinfection, of the organization and condition of food of staff, transportation and storage of foodstuff, preparation and distribution of food. All these actions are regulated by the Charter of internal service and other leading documents MO USSR.

In all bodies and by the ships systematic medical control of the state of health of employees of the kitchens, table, food warehouses, bakeries, faces which are daily allocated in a dress for kitchen and to the dining room and also workers of water supply of a part (ship) and grocery stores of system of Voentorg is exercised. To medical survey of all specified persons subject weekly, a dress on kitchen and to the dining room daily, and bacterial, to inspection during the letneosenny period — monthly, in the rest of the time of year — not less once a quarter.

The employees of the Soviet Army who are again going to work in a power supply system and water supply, not having in the anamnesis of diseases of B. of t., are allowed to performance of official duties after medical inspection and three negative bacterial, researches of excrements. At epidemiol, indications subject to a research as well duodenal contents.

In each body strict account of all persons who had in last B. t is kept., and their periodic check on a bacteriocarrier. The revealed carriers isolate and direct to hospital treatment.

The extract of the had and debrided carriers is made after triple bacterial, inspections with a negative take. The admission of convalescents to work on objects of food and water supply is allowed after 3 months after an extract and triple bacterial, inspections with a negative take (apart from made in hospital before an extract).

In the prevention of a drift of B. of t. in troops the important role belongs to an observation (quarantine) of the arriving replenishment, in time the cut is made medical examination all arrived and bacterial, inspection according to indications. Great value for early detection of t, sick and suspicious on B.'s disease. persons active identification has them in the course of the daily polls on constructions of staff. Existence in each body of insulators allows to isolate timely persons, suspicious on B.'s disease of t., and patients.

Planned inoculations against B. of t. in troops are carried out by the complex vaccine supporting typroid, paratyphoid And both B antigens and tetanic anatoksinony For inoculations on epid, to indications apply a typroid monovalent vaccine (grety). Immunization of troops against tifo-paratyphoid infections is an important auxiliary way of the prevention of these diseases, especially in wartime.

In case of emergence regarding B.'s diseases of t. the patient is immediately hospitalized, report on the commander of a part and the senior medical chief, then out epidemiol, inspection for the purpose of establishment of a source of infection in or out of a part. In a part reveal a possible factor of transfer of activators (food or water), strengthen control of food and water supply. The persons endangered infection are observirut and daily termometrirut for the purpose of early identification of the diseased. The carriers which are on the account undergo extraordinary inspection. After hospitalization of sick (carrier) carry out final disinfection to parts and take measures for strengthening a dignity. - a gigabyte. the mode, especially in the field of food and water supply.

For the prevention of a drift of B. of t. the dignity is carried out to troops at field placement them in training centers, on polygons, and also at commission of a march. - epidemiol, investigation of these areas; special attention is paid on existence of diseases among the population, by a condition of water sources and quality of water (see. Medical investigation ). Depending on results a dignity. - epidemiol, investigations in troops the relevant preventive activities are held. In all cases the dignity amplifies. control of catering services, water supply and systematic cleaning of the territory.

See also Disinfection , Immunization , Isolation of infectious patients .



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K. V. Bunin; V. I. Agafonov (soldier.), M. V. Voyio-Yasenetsky (stalemate. An.), G. B. Katkovsky (Abd. hir.), V. A. Ki-lesso (bakt.), H. M. Nikitin, A. A. Sumarokov; (epid.), M. E. Sukhareva (ped.).

Яндекс.Метрика