THE NATURAL HISTORY OF TYPHOID FEVER
Why should not a disease have a natural history, as well as an
individual? At first sight, this might appear like a reversion to the
old, crude theory of disease as a demonic obsession, or invasion by an
evil spirit, of which traces still remain in such expressions as, "She
was _seized_ with a convulsion," "He was strong enough to _throw off_
the illness," "He was _attacked_ by a fever," etc. But apart entirely
from such conceptions, which were perfectly natural in the infancy of
the race, while clearly recognizing that disease is simply a perverted
state of nutrition or well-being in the body of the patient, a
disturbance of balance, so to say, yet it is equally true that it has a
birth, an ancestry, a life-course, and a natural termination, or death.
This recognition of the natural causation and development of disease has
been one of the greatest triumphs, not merely of pathology, but of
intelligence and rationalism. It has done more to diminish that dread of
the unknown which hangs like a black pall of terror over the mind of the
savage and the semi-civilized mind than any other one advance. It
contributes enormously to our courage, our hopefulness, and our power of
protection in more ways than one: first of all, by revealing to us the
external cause of disease, usually some careless, dirty, or bad habit
on the part of an individual or of the community, and thus enabling us
to limit its spread and even exterminate it; secondly, by assuring us
that nearly all diseases, excepting a few of the most obstinate and
serious, have not only a definite beginning, but a definite end, are, in
fact, if left to themselves, self-limited, either by the exhaustion and
loss of virulence of their cause, or by the resisting power of the body.
All infectious diseases, and many others, tend to run a definite course
of so many days, or so many weeks, within certain limits, and at least
ninety per cent of them tend to terminate in recovery. It is a most
serious and fatal disease which has a death-rate of more than twenty per
cent. Typhoid, pneumonia, diphtheria, and yellow fever all fall below
this, smallpox barely reaches it, and only the bubonic plague, cholera,
and lockjaw rise habitually above it. The recognition of this fact has
enormously increased the efficiency of the medical profession in dealing
with disease, by putting us on the track of imitating the methods which
the body itself uses for destroying, or checking the spread of, invading
germs and leading us to trust nature and try to work with her instead of
against her. Our antitoxins and anti-serums, which are our brightest
hope in therapeutics at present, are simply antidotes which are formed
in the blood of some healthy, vigorous animal against the bacillus whose
virulence we wish to neutralize, such as that of diphtheria or
septicemia.
Diphtheria antitoxin, for instance, the first and best known triumph of
the new medicine, is the antidotal substance formed in the blood of a
horse in response to a succession of increasing doses of the bacilli of
diphtheria. Similar antidotal substances are formed in the blood in all
other non-fatal cases of infectious diseases, such as typhoid,
pneumonia, blood-poisoning, etc.; and the point at which they have
accumulated in sufficient amounts to neutralize the poison of the
invading germs, forms the crisis, or "turn" of the disease. So that when
we speak of a disease "running its course," we mean continuing for such
length of time as the body needs to produce anti-bodies in sufficient
amounts to check it.
The principal obstacle to the securing of antitoxins like that of
diphtheria for all our infectious diseases is, that their germs form
their poison so slowly that it is difficult to collect it in sufficient
amounts to produce a strong concentrated antitoxin in the animal into
which it is injected. But the overcoming of this difficulty is probably
only a question of time.
Obviously, if infectious disease be, as we say, "self-limited," that is
to say, if the body will defeat the invaders with its own weapons, on an
average in nine cases out of ten, our wisest course, as physicians, is
to back up the body in its fight. This we now do in every possible way,
by careful feeding, by rest, by bathing, by an abundance of pure water
and fresh air, with the gratifying result that we have already reduced
the death-rate in most fevers, even such as we have no antitoxin
against, or may not even have discovered the causal germ of, to one-half
and even three-fourths of their former fatality. The recognition of the
fact that disease has a natural history, a birth, a term of natural
life and a death, has already turned a hopeless fight in the dark into a
victorious campaign in broad daylight. Huxley's pessimistic saying that
typhoid was like a fight in the dark between the disease and the
patient, and the doctor like a man with a club striking into the mélée,
sometimes hitting the disease and sometimes the patient, is no longer
true since the birth of bacteriology.
Nowhere can the natural history of disease be more clearly seen or more
advantageously studied than in the case of typhoid fever.
The cause of typhoid is simplicity itself, merely drinking the excreta
of some one else, "eating dirt," in the popular phrase; simple, but of a
deadly effectiveness, and disgracefully common. The demon may be
exorcised by an incantation of one sentence: _Keep human excreta out of
the drinking water._ This sounds simple, but it is n't. Eternal
vigilance is the price of health as well as of liberty.
We can, however, make our pedigree of typhoid a little more precise. It
is not merely dirt of human origin which is injurious, but dirt of a
particular type, namely, discharges from a previous case of the disease.
Just as in the fight against malaria we have not the enormous problem of
the extermination of all varieties of mosquito, but only of one
particular genus, and only the infected specimens of that, so in
typhoid, the contamination of water or food which we have to guard
against is that from previous cases. From one point of view, this leaves
the problem as wide as ever, for, obviously, the only way to insure
against poisoning of water by typhoid discharges is to shut out
absolutely all sewage contamination. On the other hand, it is of immense
advantage in this regard,--it enables us to fight the enemy at both ends
of the line, to turn his flank as well as crush his centre.
While we are protecting our water-supplies against sewage, we can, in
the meantime, render that sewage comparatively harmless by thoroughly
disinfecting and sterilizing all discharges from every known case of the
disease. A similar method is used in the fight against yellow fever and
malaria. Not only are the breeding places of the two mosquito criminals
broken up, but each known case of the disease is carefully screened, _so
as to prevent the insects from becoming infected_, and thus able to
transmit the disease to other human victims.
It cannot be too emphatically insisted upon that every case of typhoid,
like every case of yellow fever and of malaria, _comes from a previous
case_. It is neither healthy nor exhilarating to drink a clear solution
of sewage, no matter how dilute; but, as a matter of fact, it is
astonishing how long communities may drink sewage-laden water with
comparative impunity, so long as the sewage contains no typhoid
discharges. One case of typhoid fever imported into a watershed will set
a city in a blaze.
The malevolent _Deus_ in the sewage _machina_ is, of course, a germ--the
_Bacillus typhosus_ of Eberth. The astonishing recentness of much of our
most important knowledge is nowhere better illustrated than in the case
of typhoid. Although there had been vague descriptions of a fatal fever,
slow and lingering in its character and accompanied by prolonged stupor
and delirium, which was associated with camps and dirty cities and
famines, from as far back as the age of Cæsar, the first description
clear enough to be recognizable was that of Willis, of an epidemic
during the English civil war in 1643, both Royalist and Roundhead armies
being seriously crippled by it. Since that time a smouldering, slowly
spreading fever has been pretty constantly associated with armies in
camps, besieged cities, filthy jails, and famines, to which accordingly
have been given the names, familiar in historical literature, of "famine
fever," "jail fever," and "military fever."
So slowly, however, did accurate knowledge come, that it was actually
not until 1837 that it was clearly and definitely recognized that this
famine fever was, like Mrs. Malaprop's Cerberus, "two gentlemen at
once," one form of it being typhus or "spotted fever," which has now
become almost extinct in civilized communities; the other, the milder,
but more persistent form, which, like the poor, we have always with us,
called, from its resemblance to the former, "typhoid" (typhus-like).
Typhus was a far more virulent, rapid, and fatal fever than its twin
survivor, though as to the relations between the two diseases, if any,
we are quite in the dark, as the former practically disappeared before
the days of bacteriology. The fact of its disappearance is both
significant and interesting, in that it was unquestionably due to the
ranker and viler forms of both municipal and individual filthiness and
unsanitariness, which even our moderate progress in civilization has
now abolished. There can be no question that, with a step higher in the
scale of cleanliness, and further quickening of the biologic conscience,
typhoid will also disappear.
Typhus, the bubonic plague, the sweating sickness, were alike plagues
and products of times when table-scraps were thrown on the dining-room
floor and covered daily with fresh rushes for a week at a stretch, and
fertilizer accumulated in a living-room as now in a modern stable.
Clothing was put on for the season, shirts were unknown, and strong
perfumes took the place of a bath. Michelet's famous characterization of
the Middle Ages in one phrase as _Un mille ans sans bain_ (a thousand
years without a bath) was painfully accurate.
Doubtless certain habits of our own to-day will be regarded with equal
disgust by our descendants. Typhus, by the way, may possibly be
remembered by the dramatic "Black Assize" of Oxford, in 1577, in which
not merely the wretched prisoners in the jail, but the jurors, the
lawyers, the judges, and every official of the court were attacked, and
many of them died.
It was only in 1856 that the method of transmission of the disease was
clearly recognized, and in 1880 that the bacillus was discovered and
identified by the bacteriologist Eberth, whose name it bears, so that it
is only within the last thirty years that real weapons have been put
into our hands with which to begin a fight of extermination against the
disease.
What is the habitat of our organism, and is it increasing its spread?
Its habitat is the entire civilized world, and it goes wherever
civilization goes. In this sense its spread is increasing, but, in every
other, we have good ground for believing that it is on the wane.
Positive assurance, either one way or the other, is, of course,
impossible, simply for the reason that the disease was not recognized
until such a short time ago that no statistics of any real value for
comparison are available; and, secondly, because even to-day, on account
of its insidious character and the astonishing variety of its forms, and
degrees of mildness and virulence, a considerable percentage of cases
are yet unrecognized and unreported.
It might be mentioned in passing that this statement applies to the
alleged increase of nearly all diseases which are popularly believed to
be modern inventions, like appendicitis, insanity, and cancer. We have
no statistics more than thirty years old which are of real value for
purposes of comparison.
However, when it comes to the number of deaths from the disease, there
is a striking and gratifying diminution for twenty years past, which is
increasing in ratio instead of diminishing. That we are really getting
control of typhoid is shown by the, at first sight, singular and
decidedly unexpected fact that it is no longer a disease of cities, but
of the country. The death-rate per thousand living in the cities of the
United States is lower than in the rural districts. For instance, the
mortality in the State of Maryland, outside of Baltimore, is two and
one-half times as great as that in the city itself. Our period of
greatest outbreak in the large cities is now the month of September,
when city dwellers have just returned from their vacations in the pure
and healthful country, bringing the bacilli in their systems.
The moral is obvious. Great cities are developing some sort of a
sanitary conscience. Farmers and country districts have as yet little or
none. Bad as our city water often is, and defective as our systems of
sewage, they cannot for a moment compare in deadliness with that most
unheavenly pair of twins, the shallow well and the vault privy. A more
ingenious combination for the dissemination of typhoid than this
precious couple could hardly have been devised. The innocent householder
sallies forth, and at an appropriate distance from his cot he digs two
holes, one about thirty feet deep, the other about four. Into the
shallower one he throws his excreta, while upon the surface of the
ground he flings abroad his household waste from the back stoop. The
gentle rain from heaven washes these various products down into the soil
and percolates gradually into the deeper hole. When the interesting
solution has accumulated to a sufficient depth, it is drawn up by the
old oaken bucket or modern pump, and drunk. Is it any wonder that in
this progressive and highly civilized country three hundred and fifty
thousand cases of typhoid occur every year, with a death penalty of ten
per cent? Counting half of these as workers, and the period of illness
as two months, which would be very moderate estimates, gives a loss of
productive working time equivalent to thirty thousand years. Talk of
"cheap as dirt"! It is the most expensive thing there is.
Typhoid still abundantly earns its old name of "military fever," and its
sinister victories in war are even more renowned than its daily triumphs
in peace. Strange as it may seem, the deadliest enemies of the soldier
are not bullets but bacilli, and sewage is mightier than the sword. For
instance, in the Franco-Prussian War, typhoid alone caused sixty per
cent of all the deaths. In the Boer War it caused nearly six thousand
deaths as compared with seven thousand five hundred from wounds in
battle, while other diseases caused five thousand more. In the majority
of modern campaigns, from two-thirds to five-sixths of all deaths are
due to disease and not to battle. It may be that we sanitarians will
achieve the ends of the peace congresses by an unexpected route, and
make war a healthful and comparatively harmless form of national
gymnastics. Its battle-mortality rate, for the number engaged, is not so
very far above football now!
Given the bacillus, how does it get into the human system? Here the
evidence is so abundant and overwhelming that we may content ourselves
with bald statements of fact. The three great routes of this pestilence
are water, milk, and flies. Of the three, the first is far the most
common and important. While only a rough statement is possible, probably
eighty-five per cent of all cases from water, five per cent from milk,
five per cent through flies, and five per cent through other channels,
would fairly represent the percentage.
That it is conveyed through water is as certain as that the sun rises
and sets. The only embarrassment in proving it lies in selecting from
the swarm of instances. There is the classic case of the Swiss villages
on opposite sides of the same mountain chain, the second of which drew
its water-supply from a spring that came through the mountain from a
brooklet running by the first village. Typhoid fever broke out in the
first village, and twenty days later it appeared in the second village,
twenty miles away on the other side of the mountain. Colored particles
thrown into the brook on one side promptly appeared in the spring upon
the other. Then there was the gruesome modern instance of Plymouth,
Pennsylvania, in 1885. A single case of imported typhoid occurring on
the watershed of a reservoir was followed, thirty days later, by an
epidemic of eleven hundred cases in a population of eight thousand.
An equally vivid instance came under my own observation. A school and a
penitentiary drew their water-supply from the same power-flume, carrying
a superb volume of purest water from a mountain stream. Early in the
autumn a single case of typhoid appeared in a small town near the head
of the flume. The discharges were thrown into the swiftly running water.
Two weeks later an epidemic of typhoid broke out in the school, and
three weeks later in the penitentiary. An unexpected freak, however, was
the appearance of fifteen or twenty cases in another state institution
farther down on the same stream, which did not draw its water-supply
from the flume, but from deep wells of tested purity. This was a puzzle,
until it was found that, owing to a fall in the wells, the water from
the flume had been used for sprinkling and washing purposes in the
institution, being allowed to run through the water-pipes only at night,
while the well-water was used in the daytime. This was enough to
contaminate the pipes, and a small epidemic began, which promptly
stopped as soon as the cause was suspected and the flume-water no longer
used.
This last instance is peculiarly interesting, as illustrating how
typhoid infection gets into milk, the second--though at a long
interval--most frequent means of its spread. It does not come from the
cow, for, fortunately, none of the domestic animals, with the possible
exception of the cat, is subject to typhoid. Nor is it possible that
cattle, drinking foul and even infected water, can transmit the bacillus
in their milk. That superstition was exploded long ago. Every epidemic
of typhoid spread by milk--and there are scores of them now on
record--can be traced to the handling of the milk by persons suffering
from mild forms of typhoid, or engaged in waiting upon members of the
family who are ill of the disease, or the dilution of milk with infected
water, or even, almost incredible as it may seem, to such slight
contamination as washing the cans with infected water.
Health officers now watch like hawks for the appearance of any case of
typhoid among or in the families of dairymen. The New York City Board of
Health, for instance, requires the weekly filing of a certificate from
the family physician of all dairymen that no such cases exist. And the
more intelligent dairymen keep a vigilant eye upon any appearance of
illness accompanied by fever among their employees, some that I have
known even keeping a fever thermometer in the barn for the purpose of
testing every suspicious case. How effective such precautions can be
made may be illustrated by the fact that, in the past five years, there
has not been a single epidemic of typhoid traceable to milk in Greater
New York, even with its inadequate corps of ten inspectors, and the six
states they have to cover. The moment a single case of typhoid appears,
the dairy or milkman supplying that customer is given a most rigid
special inspection, and, if any source of infection can be discovered,
the milk is shut out of New York City until the department is satisfied
that all danger has been removed. One or two lessons of this sort are
enough for a whole county of dairymen. The danger of transmission of
typhoid through milk has been enormously exaggerated, and, as in the
case of all other milk-borne diseases, is entirely due to filthy
handling, and may be prevented by intelligent sanitary policing. Even
with our present exceedingly imperfect systems, probably not more than
between five and ten per cent of typhoid is transmitted in this way;
and, if the water-supply were kept clean, this would practically
disappear.
Typhoid may not only be transmitted from the earth beneath and the water
under the earth, but also from the heavens above, through the medium of
flies and dust. The first method is bulking larger every day, especially
in country districts and in camps. The _modus operandi_ is simplicity
itself. The fly lives and moves and has its being in dirt. It breeds in
dirt and it feeds on food, and, as it never wipes its feet, the
interesting results can be imagined. Just to dispel any possible doubt,
plates of gelatine have been exposed where flies could walk on them,
then placed in an incubator, and within forty-eight hours there was a
clearly recorded track of the footprints of the flies written in clumps
of bacilli sown by their filthy feet. More definitely, flies have been
caught in the houses of typhoid patients, put under the microscope, and
their feet, stomachs, and specks found swarming with typhoid bacilli. A
single flyspeck may contain three thousand.
Fortunately, we have a simple and effective remedy. We cannot disinfect
the fly nor make him wipe his feet, but we _can_ exterminate him
utterly! This sounds difficult, but it isn't. Like the mosquito, the fly
can only breed in one particular kind of place, and that place is a heap
of dirt, preferably horse manure, but, at a pinch, dust-bins,
garbage-cans, sweepings under porches or behind furniture,
vaults,--anywhere that dirt is allowed to remain undisturbed for more
than a week at a stretch. Abolish, screen, or poison these dirt
accumulations, and flies will disappear, and with them not merely risks
from typhoid, but half a dozen other diseases, as well as all sorts of
filth and much discomfort and inconvenience. It was largely through
flies that the disgraceful epidemic of typhoid, which ravaged our camps
on our own soil during the Spanish-American War and killed many times
more than fell by Spanish bullets, was spread.
It is also believed that typhoid bacilli may be carried in the infected
dust of streets and camps. Here again we are dealing with a dangerous
public enemy to both health and comfort, which can and ought to be
abated by cleanliness, oilings, and sprinklings. Typhoid bacilli are
also occasionally carried by shellfish, especially oysters, on account
of the interesting modern custom of planting them in bays and harbors
near the mouths of sewers to fatten them. The cheerful motto of the
oysterman is, "The muddier the water the fatter the oyster." And nowhere
do the bivalves plump up more quickly than near the mouth of a sewer.
The last method of transmission is by direct contact with the sick. This
is a relatively rare means of spread, so much so that it is generally
stated that typhoid is not contagious; but it is a real source of danger
and one against which precautions should by all means be taken. The only
method is, of course, by the soiling of the hands of the nurse or other
attendant, and then eating or touching food, or putting the fingers into
the mouth before thoroughly cleansing. If the hands be washed with a
strong antiseptic solution after waiting upon the patient, and the
cheerful habit sometimes indulged in of putting fruit or other
delicacies into the sick-room for a day or so, in the hope that they may
tempt the appetite of the patient, and then taking them out and letting
the children eat them as a treat, be abolished, and the nurse be not
allowed to officiate in the kitchen, risk from this source will be done
away with.
When the bacillus has been introduced into the stomach through food or
drink, it rapidly proceeds to diffuse itself throughout the tissues of
the body. Because the most striking symptoms of the disease are
diarrh[oe]a, abdominal distention, and pain, and the most striking
lesions after death ulcers in the small intestine, it was supposed that
the process was confined to the abdominal organs. This is now known to
be an error, as cultures and examinations made from the blood and
various parts of the body have shown the presence of the typhoid
bacillus in almost every organ and tissue. This process of scattering,
or invasion of the body, takes from three to ten days to accomplish; and
the first sign of trouble is usually a feeling of depression, with
headache, and perhaps slight nausea, before any characteristic bowel
symptoms begin to show themselves.
The general invasion of the system throws an interesting sidelight upon
the subject of premonitions. There are several well authenticated cases
on record where individuals just before coming down with typhoid have
been strangely impressed with a sense of impending death, and have even
gone so far as to make their wills and set their affairs in order.
Because these strong impressions appeared before any clearly marked
intestinal symptoms of the disease, they have been put down in popular
literature as instances of the "second sight," or "sixth sense," which
popular superstition believes many of us to possess under certain
circumstances. Now, however, we know that the tissues of that individual
were already swarming with bacilli, and his fear of impending death was
simply the effect of his toxin-laden blood upon his brain centres. In
other words, it was prophecy after the fact, like nearly all prophecies
that happen to come true; and the "premonition" was an early symptom of
the disease itself.
As it is, of course, difficult to fix the precise drink of water or
mouthful of food in which the infection was conveyed, we were for a long
time in doubt as to the length of time which it took to spread through
the system,--the "period of incubation," as it is termed,--although we
knew in a general way that it averaged somewhere about ten days. But,
about a year ago, fortune was kind to us. A nurse in one of the Parisian
hospitals, in a fit of despondency, decided to commit suicide. Like a
true Parisienne, she would be nothing if not up to date, and chose, as
the most _recherché_ and original method of departing this life, to
swallow a pure culture of typhoid germs, which she abstracted from the
laboratory. Three days later she began to complain of headache, and
within a week had developed a beautiful crop of symptoms, and a typical
case of typhoid, from which, under modern treatment, she promptly
recovered,--a wiser and, we trust, a happier woman.
By just what avenue the infecting bacilli go from the stomach into the
general system we do not know. Metschnikoff suggests that they can only
penetrate the intestinal wall through wounds or abrasions of the mucous
membrane, made by intestinal worms or other parasites. Certain it is
that the average stomach has a considerable degree of resisting power
against them, for in no known civil epidemic has the number of those who
caught the disease exceeded ten per cent of the total number drinking
the infected water or milk. In one or two camps in time of war the
percentage has risen as high as eighteen or twenty per cent of those
exposed, but this is exceptional. However, now that we know that
intestinal symptoms do not constitute the entire disease, and may even
be entirely absent, we strongly suspect that many cases of slight
depression, with feverishness, loss of appetite, and disturbances of the
digestion, which occur during an epidemic, may really have been very
mild cases of the disease.
One of the singular features of the disease is that, unlike many other
infections, we are entirely unable to say what conditions or influences
seem either to protect against it or to predispose toward it. In the
days when we believed it to be an exclusively intestinal disease it was
naturally supposed that chronic digestive disturbances, and especially
acute attacks of bowel trouble or dysentery, would predispose to it, but
this has been entirely disproved. Soldiers in barracks with chronic
digestive disturbances, and even with dysentery, have shown no higher
percentage of typhoid during an epidemic than others. Nor does it seem
much more likely to occur in those who are constitutionally weak, or run
down, or overworked, as some of the most violent and unmanageable cases
occur in vigorous men and women, who were previously in perfect health.
So that, although we have unquestionably a high degree of resistance
against it, since not more than one in ten exposed contracts it, and
only one in ten of those who contract it dies, we have not the least
idea in what direction, so to speak, to build up our resisting powers in
order to increase them.
The best remedy is to destroy the disease altogether, and this could be
done in five years by intelligent concerted effort. It was at one time
supposed that typhoid fever was a disease exclusively confined to adult
life; but it is now known to occur frequently in children, though often
in such a mild and irregular form as to escape recognition. Something
like seventy per cent of all cases occur between the fifteenth and the
fortieth year, and it is, for some reason, though rarer, peculiarly
serious and more often fatal after the fiftieth year.
When once the outer wall has been pierced, the sack of the city rapidly
proceeds. The bacilli multiply everywhere, but seem for some reason to
focalize chiefly in the alimentary canal, and especially the middle part
of it, the small intestines. After headache, backache, and loss of
appetite comes usually a mild diarrh[oe]a. This diarrh[oe]a is due to an
attack of the bacillus or its toxins upon certain clumps of lymphoid
tissue in the wall of the small intestine, known as the "patches of
Peyer." This produces inflammation, followed by ulceration, which in
severe cases may eat through the wall of a blood-vessel, causing profuse
hemorrhages, or even perforate the bowel wall and set up a fatal
peritonitis. The temperature begins to swing from two to five degrees
above the normal level, following the usual daily vibration, and ranging
from 100 degrees to 101 degrees in the morning up to 102 degrees to 105
degrees in the afternoon. The face becomes flushed.
There is usually comparatively little pain, and the patient lies in a
sort of mild stupor, paying little attention to his surroundings. He is
much enfeebled and seldom cares to lift his head from the pillow. A
slight rash appears upon the surface of the body, but this is so faint
that it would escape attention unless carefully looked for. Little
groups of vesicles, containing clear fluid, appear upon the chest and
abdomen. If one of these faint rose-colored spots be pricked with a
needle and a drop of blood be drawn, typhoid bacilli will often be found
in it, and they will also be present in the clear fluid of the tiny
sweat blisters.
This condition will last for from ten days to four weeks, the patient
gradually becoming weaker and more apathetic, and the temperature
maintaining an afternoon level of 102 to 104 degrees. Then, in the vast
majority of cases, a little decline of the temperature will be noticed.
The patient begins to take a slight interest in his surroundings. He
will perhaps ask for something to drink, or something to eat, instead of
apathetically swallowing what is offered to him. Next day the
temperature is a little lower still, and within a week, perhaps, will
have returned to the normal level. The patient has lost from twenty to
forty pounds, is weak as a kitten, and it may be ten days after the
fever has disappeared before he asks to sit up in bed.
Then follows the period of return to health. The patient becomes a
walking appetite, and, after weeks of liquid diet, will beg like a
spoiled child for cookies or hard apples or pie, or something that he
can set his teeth into. But his tissues are still swarming with the
bacilli, and any indiscretion, either of diet, exposure, or exertion, at
this time, may result in forming a secondary colony, or abscess,
somewhere in the lungs, the liver, or the muscles. He must be kept quiet
and warm, and abundantly, but judiciously, fed, for at least three
weeks after the disappearance of the fever, if he wishes to avoid the
thousand and one ambuscades set by the retreating enemy.
Now, what has happened when recovery begins? One would suppose that
either the bacilli had poisoned themselves, exhausted the supplies of
nourishment in the body of the patient, so that the fever had "burnt
itself out," as we used to say, or that the tissues had rallied from the
attack and destroyed or thrown out the invaders. But, on the contrary,
we find that our convalescent patient, even after he is up and walking
about, is still full of the bacilli.
To put it very crudely, what has really happened is that the body has
succeeded in forming such antidotes against the poison of the bacilli
that, although they may be present in enormous numbers, they can no
longer produce any injurious effect. In other words, it has acquired
immunity against this particular germ and its toxin. In fact, one of our
newest and most reliable tests for the disease consists in a curious
"clumping" or paralyzing power over cultures of the _Bacillus typhosus_,
shown by a drop of the patient's blood, even as early as the seventh or
eighth day of the illness. And, while it is an immensely difficult and
complicated subject, we are justified in saying that this immunity is
not merely a substance formed in the body, the stock of which will
shortly become exhausted, but a faculty acquired by the body-cells,
which they will retain, like other results of education, for years, and
even for life. When once the body has learned the wrestling trick of
throwing and vanquishing a particular germ or bacillus, it no longer
has much to dread from that germ. This is why the same individual is
seldom attacked the second time by scarlet fever, measles, typhoid, and
smallpox.
While, however, the individual may be entirely immune to the germs of a
given disease, he may carry them in his body in enormous numbers, and
infect others while escaping himself.
This is peculiarly true of typhoid, and we are beginning to extend our
sanitary care over recovered patients, not merely to the end of acute
illness, but for the period of at least a month after they have
apparently recovered. Several most disquieting cases are on record of
so-called "typhoid carriers," or individuals who, having recovered from
the disease itself, carried and spread the infection wherever they went
for months and even years afterward. This, however, is probably a rare
state of affairs, though a recent German health bulletin reports the
discovery of some twenty cases during the past year. The lair of the
bacilli is believed to be the gall-bladder.
As to treatment, it may be broadly stated that all authorities and
schools are for once practically agreed:--
First, that we have no known specific drug for the cure of the disease.
Second, that we are content to take a leaf out of nature's book, and
follow--so to speak--her instinctive methods: first of all, by putting
the patient to bed the moment that a reasonable suspicion of the disease
is formed; this conserves his strength, and greatly diminishes the
danger of serious complications; cases of "walking typhoid" have among
the highest death-rates; second, by meeting the great instinctive
symptom of fever patients since the world began, thirst, encouraging the
patient to drink large quantities of water, taking care, of course, that
the water is pure and sterile. The days when we kept fever patients
wrapped up to their necks in woolen blankets in hot, stuffy rooms, and
rigorously limited the amount of water that they drank--in other words,
fought against nature in the treatment of disease--have passed. A
typhoid-fever patient now is not only given all he wants to drink, but
encouraged to take more, and some authorities recommend an intake of at
least three or four quarts, and, better, six and eight quarts a day.
This internal bath helps not only to allay the temperature, but to make
good the enormous loss by perspiration from the fevered skin, and to
flush the toxins out of the body.
Third, by liberal and regular feeding chiefly with some liquid or
semi-liquid food, of which milk is the commonest form. The old attitude
of mind represented by the proverb, "Feed a cold and starve a fever,"
has completely disappeared. One of the fathers of modern medicine asked
on his death-bed, thirty years ago, that his epitaph should be, "He fed
fevers."
Fourth. We respond to the other great thirst of fever patients, for
coolness, by sponge baths and tub baths, whenever the temperature rises
above a certain degree.
Simple as these methods sound, they are extremely troublesome to put
into execution, and require the greatest skill and judgment in their
carrying out. But intelligent persistence in the careful elaboration of
these methods of nature has resulted in already cutting the death-rate
in two,--from fifteen or twenty per cent to less than ten per cent,--and
where the full rigor of the tub bath is carried out it has been brought
down to as low as five per cent.
Meanwhile the bacteriologists are steadily at work on a vaccine or
antitoxin. Wright, of the English Army Medical Staff, has already
secured a serum, which has given remarkable results in protecting
regiments sent out to South Africa and other infected regions.
Chantemesse has imported some six hundred successive cases treated with
an antitoxin, whose mortality was only about a third of the ordinary
hospital rate, and the future is full of promise.