Time.—It occurs most frequently between August and November and in those of from fifteen to twenty years of age. The Peyer's patches and solitary glands of the bowel enlarge, become reddish and are somewhat raised. These go on and ulcerate until the blood vessels may be eaten into and bleeding sometimes results, it eats through the bowel, then there is perforation and peritonitis. The spleen is enlarged, the liver shows changes, the kidney functions are also deranged.
Symptoms.—The symptoms are variable. The following gives the symptoms in a typical case:
Incubation.—The period of incubation lasts from eight to fourteen and sometimes to twenty-three days. During the period the patient feels weak, is almost unable to work, has chilly feelings, headache and tiring dreams, does not know what is the matter with him, constipation or diarrhea, has no appetite, may have some pain in the abdomen which is occasionally localized in the right lower side. Soreness on deep pressure is often found there. In some cases there is nosebleed.
First Week.—After the patient is obliged to take to his bed: During the first week there is in some cases a steady rise in the fever each evening showing a degree or degree and one-half higher than the preceding evening, reaching 103 to 104, and each morning showing higher fever than the preceding morning. The pulse is characteristically low in proportion to the temperature, being about 100 to 110, full of low tension, often having double beat. The tongue is coated; there is constipation or diarrhea; the abdomen is somewhat distended and a little tender to the touch in the lower right portion. There may be some mental confusion at night. Bronchitis is often present. The spleen becomes enlarged between the seventh and tenth day and the eruption usually appears during this period on the stomach and abdomen.
Second week.—All the symptoms are intensified in the second week, the fever is always high and the weakening type; the pulse is more frequent; the headache is replaced by dullness; the bowel symptoms increase and we have the "pea soup" discharge if there is diarrhea; there is a listless, dull expression on the face; the tongue is coated in the center, red along the edges and the tip, becomes dry and sometimes cracked and almost useless. It is hard to put it out of the mouth, it sticks to the teeth or lips and curls there, and sometimes the patient allows it to remain partly out of the mouth. There may be bleeding from the bowels and perforation of the bowel, producing peritonitis.
[INFECTIOUS DISEASES 197]
Third week.—The temperature is lower in the morning with a gradual fall; the emaciation and weakness are marked. Perforation of the bowel or bleeding may occur. Unfavorable symptoms now include low muttering, delirium, shakings of the muscles, twitching of the tendons, grasping at imaginary things, lung complications and heart weakness.
Fourth week.—In a favorable case: The fever gradually falls to normal, the other symptoms disappear. Death may occur at any time after the second week from the disease or complications. The convalescence is very gradual and the appetite is very great.
Special symptoms and variations.—It may come on with a chill sometimes it is observed by nervous symptoms only.
Walking type.—In this type the patient is able to be around and can walk. The temperature is as high, but some of the other symptoms are not so violent. This is a dangerous kind because the patient is able to walk and thinks it foolish to remain quiet in bed. Walking and being around are likely to injure the bowels, and there is then more danger of bleeding from the bowels. A typhoid fever patient should always go to bed and remain there until he has fully recovered.