Typhoid fever

“ Some people resist powerfully the encroachment of all infectious diseases, while others seem fated to have an opportunity of testing in their own person every prevailing malady. Experience teaches, however, that typhoid fever, unlike many other diseases of the group, is favored in its development by unhygienic surroundings. Bad air, bad food, uncleanliness, and over-population of a house or quarter of a city, create a condition in the system favorable to a rapid and virulent development of the fever after an infection by the germs. ”

“ But the germs of typhoid fever and of bubonic plague are more resistant and, without doubt, under certain circumstances, these diseases are extensively propagated by means of dust containing desiccated excreta. There is a good reason to believe that in several of our camps, during the Spanish-American War, this was an important factor in the etiology of typhoid fever epidemics. The average mortality from typhoid fever in our regular army since the Civil War has been, for the first decade (1868-1877) 95 per 100,000 of mean strength ”

“ Typhoid Fever.—One of the most common germ diseases in this country and Europe is typhoid fever. This is a disease which is conveyed by means of water and food, especially milk, oysters, and uncooked vegetables. Typhoid fever germs live in the intestine and from there get into the blood and are carried to all parts of the body. A poison which they give off causes the fever so characteristic of the disease. The germs multiply very rapidly in the intestine and are passed off from the body with the excreta from the food tube. ”

“ In typhoid fever, especially, the onset is insidious and slow. Days and even weeks may be passed in a depressed, languid state of the health, before the disease is recognized as typhoid fever. Among business men these initial symptoms are often explained by taking cold, or by overwork. During the epidemic at Basle a few persons were attacked after a residence in the city of from seven to fourteen days ”

“ Finally, it is possible to acquire the disease by direct contact—not that the germs of typhoid are in the air in the room where a typhoid fever patient is lying, but rather that the nurse in some way soils her hands and then infects herself by putting her fingers in her mouth, or handles dishes or food afterwards used by other people, and so infects those others. It is not uncommon, for example, to see food partly consumed by a sick person given to children, or it may be that a child in the sick room is fed dainties prepared for the use of the patient. ”

“ Nor will it live in the soil or in water indefinitely, and a great deal of study has been expended in trying to determine just how long typhoid fever germs will live under different conditions. It has been found, for example, that drying kills the typhoid bacillus in a few hours, although a few may survive for days. Experiments have also shown that it cannot leave a moist surface. It cannot, for instance, jump out of cesspools and drains and take to flight through the air, conveying the disease. ”

“ When typhoid fever assumes a severe type, the success of the physician in the management of the disease will depend largely upon the readiness with which he detects indications for treatment and the promptness with which he meets them. Usually, one of the first symptoms to demand attention is the high temperature. This is not only an early symptom in many bad cases, but may continue throughout the attack; or it may suddenly supervene in cases in which the fever has previously been moderate in degree, and when excessive may be the direct or indirect cause of death. ”

“ The leading physicians and pathologists, in regions where these fevers prevail, are now convinced that they are not malarial fevers, but are simply more or less typical varieties of typhoid fever—a disease due to a specific bacillus and which is commonly contracted as a result of the ingestion of contaminated water or food. The error in diagnosis, upon which the inference has been based that malarial fevers may be contracted through drinking water, has been widespread, in this country, in Europe and in the British possessions in India. ”

“ Probably the most effective method of preventing typhoid food infection is to investigate every case of typhoid fever and trace it, so far as practicable, to its origin. In this way typhoid-carriers may be discovered and other foci of infection brought to light. Carriers, once found, may be given proper advice and warned that they constitute a danger to others; the complete control of typhoid-carriers who are not disposed to act as advised is a difficult problem and one not yet solved by public health authorities. ”

“ That typhoid fever in this country is still a very prevalent disease depends mainly upon two facts: First, not only is the195 typhoid bacillus very resistant, but it may remain for a long time in the body of a person after recovery from typhoid fever, and such persons, in apparent good health, may be a source of contamination. With many of the conditions favoring the persistence and growth of the bacillus outside the body we are not yet familiar. The experience in the Spanish-American War illustrates how dangerous is the concentration together of large numbers of individuals. ”

“ The statistics of the London Fever Hospital show that laundresses are more liable to contract typhoid fever than the immediate attendants upon the sick. This liability is greatest in those cases in which the bed-linen and clothes of patients are not immediately disinfected after use. According to Budd, the sputa in cases of typhoid fever where bronchitis is excessive may sometimes contain the germs of the disease, and mentioned a case in which he believed they were the means by which the disease was propagated. ”

“ The one who is attacked by typhoid fever may not be the one who has left dirt for the disease to breed in.
Typhoid fever germs are bred chiefly in manure piles, sewers, or cess-pools, and would not be transmitted to man directly, but there are several indirect ways in which they may be carried. Flies also breed in the same places. Their legs become covered with typhoid germs, and then they fly into houses directly on the food and cooking utensils. ”

“ Diseases of the intestinal tract may also be communicated by dust. Food and water, if contaminated with sewage, are the commonest vehicles of infection in typhoid fever and dysentery, but it is quite conceivable that some cases of obscure origin may be the result of dust inhalation or ingestion of raw food on which dust has fallen. Studies of typhoid fever epidemics have led sanitarians to recognize that food and water do not account for all cases and sometimes disease may be due to contact infection or inhalation of infected dust from the air. ”

“ In the mortality of French civil life, which remains at eleven per thousand, the destructiveness of typhoid fever is still greater, at least in a large number of towns and cities.
Doctors have long known the cause of the prevalence of this disease; but it is not easy to persuade the ordinary citizen of the necessity of precaution in the use of so common a thing as water. Jules Simon tells a story, good by way of illustration, of the alarming typhoid epidemic in Paris a few years ago. ”

“ The typhoid processes require very much the same measures which are applicable in uncomplicated cases of that disease. The stools of the early stages of attacks should not be checked unless excessive, and mercurials and laxatives should be more freely used than in simple typhoid fever. The effects of the malarial fever and of the hyperpyrexia of typhoid fever, when combined, must almost necessarily entail more accumulation of excrementitious material in the blood than would occur either disease existing separately. ”

“ The facts substantiate the assumption that for every person dying with typhoid fever there are ten cases of it, so it is a fair statement that in the rural part of New York State, in 1908, there were not far from 5000 persons afflicted with this disease. ”

“ Since the disease is not contagious, the minute directions for isolation, disinfection, destruction of clothing, etc., so eminently proper in really contagious diseases, are useless in typhoid fever. In our present knowledge of the causes of the disease, but little can be done, and that only in a general way, to prevent it. ”

“ During the wars of the last twenty-five years, typhus and hospital gangrene have been unknown, but some extensive outbreaks of typhoid fever have occurred, showing that our knowledge of the causes and mode of transmission of this disease has not been practically applied to the extent to which it should have been; this remark applies also to some of the most fatal diseases in civil life. In the United States diphtheria and typhoid fever each causes from twenty to thirty thousand deaths a year, while more than one hundred thousand deaths are annually due to consumption. ”

“ On the other hand, Liebermeister, who believes that the breeding-places of typhoid fever lie deep in the earth, holds that the time is consumed in the penetration of the changes of temperature to the place where the typhoid poison is elaborated, in the development of the poison without the human body, and in the period of incubation. In some places the maximum of the disease is observed earlier in the year than in others. ”

“ I have known, for instance, the general disease to be entirely overlooked in a case of typhoid fever complicated by pneumonia, and, on the other hand, it has sometimes been supposed to be present in a case of pure typhoid pneumonia. Gastro-enteritis is another disease which is also occasionally confounded with typhoid fever. The diagnosis in these cases will rest principally upon the presence or absence of epistaxis, enlargement of the spleen, tympanites, the rose-colored eruption, and of a temperature range presenting some similarity to that usual in typhoid fever. ”

“ In the words of one of the State reports, "The death-rate from typhoid fever has generally fallen as the per cent. of the population supplied with public water has risen, for the reason that the majority of the deaths from this disease have occurred among communities and portions of communities not supplied with public water." ”

“ Thus, persons long resident in a badly-drained house, although frequently ailing in various ways, may never be laid up with typhoid fever; a certain immunity has been obtained by the slow adaptation of the system to bad air, but at the sacrifice of vigorous health. But if a new and healthy family move into the same house a deadly outbreak of typhoid or diphtheria may at once result. ”

“ Causes of its outbreak.That all insanitary conditions in respect of drainage of houses and localities furnish the most ready means for the introduction of the contagion of typhoid there is a general agreement, as there is equally that the most certain means of preventing its appearance or spread are those which provide a thoroughly trustworthy and secure drainage, a safe method of disposal of sewage, and a pure and abundant water supply. Typhoid fever is much less directly communicable from the sick to the healthy than typhus. ”

“ The rose-colored eruption is more often wanting in them than in adults, and the fever more apt to assume a distinctly remittent type; and hence, no doubt, the difficulty which is often experienced in diagnosticating this fever from other forms of fever in children. There is no doubt that many cases which have been described by authors under the head of infantile remittent fever are really examples of typhoid fever modified simply by the age of the patient. ”

“ 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. ”

“ Concerning the eradication of typhoid fever, to mention a single concrete example, competent authorities declare that we now possess all of the information necessary to make typhoid fever as obsolete in civilized communities as is cholera or smallpox. "The average third-year medical student knows enough about typhoid fever to be able to stamp it out if he were endowed with absolute power." ”

“ TYPHOID FEVER. The chief seat of this terribly prevalent disease is in the stomach and intestines, particularly the colon. It is a foul, bacterial disease, and originates in filth. The germs may be taken into the system in impure water or milk, inhaling the gases from defective drains or by eating food which has absorbed such gases. Once in the system, the bacteria must have decayed matter to feed upon, therefore it is impossible for a person who is clean both inside and out to take typhoid fever, there being no facilities for the germs to breed and multiply. ”

“ While no micro organism has yet been found which can be asserted to be the peculiar origin of typhoid fever, the view that that disease arises from a specific contagion, and is not propagated de novo, is gaining ground; and we have learned so much regarding the mode of origin and spread of the disease, that the discovery of its active cause would probably not greatly affect the measures now taken for its prevention. ”

“ But, to regard typhoid fever as contagious in the sense that small-pox and typhus fever are so, is to divert attention from the true source of danger, to lead to the adoption of measures which are uncalled for, to the neglect of those which are urgently required; is to cause unnecessary concern to the sufferer and his friends, and to deprive him and them of the mutual comfort and solace which a little daily intercourse affords. The peculiarities of the illness may be such as to make it right to exclude the friends ”