Sewer gas and emanations from sewage and filth will not communicate typhoid fever directly, but the latter afford nutriment for the growth of the germ, and after becoming infected, may eventually come in contact with drinking water or food, and so prove dangerous. Improper care of discharges of excrement and urine—with the assistance of flies—are responsible for the enormous typhoid epidemics in military camps, so that in the late Spanish-American War one-fifth of all our soldiers in camp contracted the disease. In the upper layers of the soil typhoid germs may live for six months through frosts and thaws. The disease is preventable, and will probably be stamped out in time. In some of the most thickly populated cities in the world, as in Vienna, its occurrence is most infrequent, owing to intelligent sanitary control and pure water supply, while in the most salubrious country districts its inroads are the most serious and fatal through ignorance and carelessness.
Development.—From eight to twenty-three days elapse from the time of entrance of typhoid germs into the body before the patient is taken sick. One attack usually protects one against another, but two or three attacks are not unheard of in the same person.
Symptoms.—Typhoid fever is subject to infinite variations, and it will here be possible only to outline what may be called a typical case. In a work of this kind the preliminary symptoms are of most importance in warning one of the probability of an attack, so that the prospective patient can govern himself accordingly, as in no other disease is rest in bed of more value. Patients who persist in walking about with typhoid fever for the first week or so are most likely to die of the disease.
The average duration of the disease is about one month. During the first week the onset is gradual, the temperature mounting a little higher each day—as 99.5° F. the first evening, 101° the second, 102° the fourth, 104° the fifth, 105° the sixth, and 105.5° the seventh. In the morning of each day the temperature is usually about a degree or more lower than that of the previous night. From the end of the first week to the beginning of the third the temperature remains at its highest point, being about the same each evening and falling one or two degrees in the morning. During the third week the temperature gradually falls, the highest point each evening being a degree or so lower than the previous day, while in the fourth week the temperature may be below normal in the morning and a degree or so above normal at night. So much for this symptom. After the entrance of typhoid germs into the bowels and before the recognized onset of the disease, there may be lassitude and disinclination for exertion. The disease begins with headache, backache, loss of appetite, sometimes a chill in adults or a convulsion in children, soreness in the muscles, pains in the belly, nosebleed, occasional vomiting, diarrhea, coated tongue, often some cough, flushed face, pulse 100, gradually increasing as described.
These symptoms are, to a considerable extent, characteristic of the beginning of many acute diseases, but the gradual onset with constant fever, nosebleed, and looseness of the bowels are the most suggestive features. Then, if at the end of the first week or ten days pink-red spots, about as large as a pin head, appear on the chest and belly to the number of two or three to a dozen, of very numerously, and disappear on pressure (only to return immediately), the existence of typhoid fever is pretty certain. Headache is now intense. These rose spots—as they are called—often appear in crops during the second and third weeks, lasting for a few days, then departing.
During the second week there is often delirium and wandering at night; the headache goes, but the patient is stupid and has a dusky, flushed face. The tongue becomes brownish in color, and its coat is cracked, and the teeth are covered with a brownish matter. The skin is generally red and the belly distended and tender. Diarrhea is often present with three to ten discharges daily of a light-yellow, pea-soup nature, with a very offensive odor. Constipation throughout the disease is, however, not uncommon in the more serious cases. The pulse ranges from 80 to 120 a minute.
During the third week, in cases of moderate severity, the general condition begins to improve with lowering of the temperature, clearing of the tongue, and less frequent bowel movements. But in severe cases the patient becomes weaker, with rapid, feeble pulse, ranging from 120 to 140; stupor and muttering delirium; twitching of the wrists and picking at the bedclothes, with general trembling of the muscles in moving; slow, hesitating speech, and emaciation; while the urine and fæces may be passed unconsciously in bed. Occasionally the patient with delirium may require watching to prevent him from getting out of bed and injuring himself. He may appear insane.
During the fourth week, in favorable cases, the temperature falls to normal in the morning, the pulse is reduced to 80 or 100, the diarrhea ceases, and natural sleep returns.
Among the many and frequent variations from the type described, there may be a fever prolonged for five or six weeks, with a good recovery. Chills are not uncommon during the disease, sometimes owing to complications. Relapse, or a return of the fever and other symptoms all over again, occurs in about ten per cent of the cases. This may happen more than once, and as many as five relapses have been recorded in one patient. A slight return of the fever for a day or two is often seen, owing to error in diet, excitement, or other imprudence after apparent recovery. Death may occur at any time from the first week, owing to complications or the action of the poison of the disease. Pneumonia, perforation of and bleeding from the bowels are the most frequent dangerous complications. Unfavorable symptoms are continued high fever (105° to 106° F.), marked delirium, and trembling of the muscles in early stages, and bleeding from the bowels; also intense and sudden pain with vomiting, indicating perforation of the intestines. The result is more apt to prove unfavorable in very fat patients, and especially so in persons who have walked about until the fever has become pronounced. Bleeding from the bowels occurs in four to six per cent of all cases and is responsible for fifteen per cent of the deaths; perforation of the bowels happens in one to two per cent of all cases and occasions ten per cent of the deaths.
Detection.—It is impossible for the layman to determine the existence of typhoid fever in any given patient absolutely, but when the symptoms follow the general course indicated above, a probability becomes established. Unusual types are among the most difficult and puzzling cases which a physician has to diagnose, and he can rarely be absolutely sure of the nature of any case before the end of the first week or ten days, when examination of the blood offers an exact method of determining the presence of typhoid fever. Typhoid fever—especially where there are chills—is often thought to be malaria, when occurring in malarial regions, and may be improperly called "typhoid malaria." There is no such disease. Rarely typhoid fever and malaria coexist in the same person, and while this was not uncommon in the soldiers returning from Cuba and Porto Rico, it is an extremely unusual occurrence in the United States. Examination of the blood will determine the presence or absence of both of these diseases.