The prognosis is bad in cases in which coma or wild or viole_A system of practical medicine. By American authors. Vol. 1

delirium comes on early. A moderate amount of delirium, especially

when it occurs only at night or upon wakening in the morning, and is

readily dissipated by attracting the patient's attention, or stupor

which disappears when he is thoroughly roused, is not unfavorable.

Insomnia, subsultus tendinum, carphologia, slipping down in bed,

incontinence of the urine or feces, and retention of urine, are all

symptoms of bad omen. Rigidity of the limbs is also a bad symptom; Dr.

Jackson reports six cases in which this symptom occurred, only one of

which recovered. Excessive subsultus is especially unfavorable, as it

is generally most marked in cases in which the ulcerations of the

intestines are most extensive. Extreme deafness occurs in mild as well

as severe cases; it is therefore without significance in prognosis.

{316} In estimating the importance, in a prognostic point of view, of

these various nervous symptoms, it is important to bear in mind that a

degree of fever which produces no disturbance of the mental functions

in a phlegmatic person will give rise to active delirium and other

marked cerebral symptoms in a person of an excitable temperament.

A change in the character of the pulse and of the action of the heart

is often the earliest indication of the approach of danger in typhoid

fever, and both pulse and heart should therefore be carefully examined

at every visit. The first change is usually a diminution in the

intensity of the first sound of the heart. This is significant, as it

is frequently the earliest premonition of cardiac failure, to which a

large proportion of the deaths in typhoid fever is due. A pulse of 120

and over, especially if it is at the same time feeble, is also

unfavorable. The important part which the frequency of the pulse plays

in the prognosis is shown by the following observations made by

Liebermeister at the hospital in Basle: Of 63 cases in which the pulse

rose to or above 120, 40 were fatal, or nearly two-thirds. Among these

63 were 37 in which it did not rise to 140; of these, 19 were fatal,

or about one-half; in 26 it rose above 140; of these, 21, or about

four-fifths, were fatal. In 12 patients it rose above 150; of these,

11 died. Of those in which the pulse rose to 160, the only case that

ended in recovery was that of a girl twenty-one years old suffering

from an imperfectly developed typhoid. Intermittence of the pulse is

unfavorable, especially, according to Hayem,[92] when it occurs during

the first week of the disease. In convalescence intermittence is not

to be regarded as an unfavorable symptom. The prognosis is bad also in

those cases in which, with excessive weakness of the pulse, there are

other evidences of cardiac failure, as, for instance, congestion of

the lungs, cyanosis of the surface, coldness of the extremities. A

very frequent pulse is not so unfavorable in a child as in an adult,

or in a person of a nervous temperament as in one of a different

disposition.

[Footnote 92: _Loc. cit._]

Other unfavorable symptoms are a dry, brown tongue, excessive

tympanites with great abdominal tenderness, severe diarrhoea, vomiting

when it occurs late in the disease, intestinal hemorrhage, and

colliquative sweats. The delusion sometimes observed in very severe

cases, in which the patient declares that he is not ill, is a very bad

sign, many authors, and among them Louis, asserting that they have

never known recovery to take place after it has been manifested.

Peritonitis is a very serious complication, whether due to perforation

or to some other cause. Still, it would appear not to be invariably

fatal, since recovery has occurred in cases in which all the symptoms

of this complication were present.

Favorable symptoms, on the other hand, are a gradual decrease of the

temperature with increasing morning remissions, moistening and

cleansing of the tongue, a lessening of the delirium, and other

nervous symptoms, reappearance of an intelligent expression,

recognition by the patient of friends and attendants, and a diminution

of the diarrhoea. A copious eruption is also regarded by many as a

favorable symptom. Cases in which constipation exists generally do

well. Nathan Smith never knew a patient to die whose bowels were

constipated throughout the attack.

The death-rate of typhoid fever is found to vary very considerably in

different years and in the different seasons of the year, as will be

seen {317} from the two following tables. Statistics as to the

mortality of the disease to be reliable must therefore be based upon a

large number of cases extending over a series of years.

The following table shows the number of cases admitted into the

Pennsylvania Hospital during each of the twenty years ending Dec. 31,

1881, and the ratio of mortality among them:

TABLE NO. 1.

-------+------+------+------+------+--------+--------+-------+-------

| | | |Number| | | | ing

| | | | of | | | | cases

| | | | 48 |in cases| | | 48

|Number| of | of | of | in | stay |Percen-| of

-------+------+------+------+------+--------+--------+-------+-------

1862 | 89 | 68 | 21 | 7 | 54-1/3 | 8 | 23.6 | 17.7

1863 | 36 | 33 | 3 | 2 | 32-1/5 | 3-1/3 | 8.3 | 2.9

1864 | 43 | 35 | 8 | 1 | 38-1/2 | 8 | 18.6 | 16.3

1865 | 36 | 31 | 5 | 1 | 38-1/2 | 5-1/2 | 13.9 | 11.4

1866 | 23 | 17 | 6 | 0 | 45-2/3 | 9 | 26.0 |

1867 | 24 | 20 | 4 | 0 | 37-1/3 | 6-1/2 | 16.6 |

1868 | 27 | 23 | 4 | 0 | 44-3/4 | 10 | 14.8 |

1869 | 21 | 16 | 5 | 1 | 35-1/2 | 14 | 23.8 | 20.0

1870 | 24 | 19 | 5 | 1 | 47-1/2 | 11 | 20.8 | 17.4

1871 | 32 | 26 | 6 | 1 | 37-3/4 | 13-1/2 | 18.8 | 15.0

1872 | 21 | 16 | 5 | 3 | 37-1/2 | 4-1/2 | 23.8 | 11.1

1873 | 12 | 8 | 4 | 2 | 34 | 9 | 33.3 | 20.0

1874 | 16 | 12 | 4 | 0 | 54-1/2 | 9-3/4 | 25.0 |

1875 | 20 | 18 | 2 | 1 | 48 | 4-1/2 | 10.0 | 5.3

1876 | 30 | 21 | 9 | 2 | 45-1/2 | 11 | 30.0 | 25.0

1877 | 48 | 34 | 14 | 4 | 48-1/2 | 12-1/2 | 29.2 | 22.7

1878 | 8 | 5 | 3 | 0 | 49 | 5-2/3 | 37.5 |

1879 | 17 | 15 | 2 | 0 | 53-1/3 | 8 | 11.8 |

1880 | 40 | 35 | 5 | 2 | 47 | 10-1/2 | 12.5 | 8.0

1881 | 54 | 48 | 6 | 0 | 41-3/4 | 8 | 11.1 |

-------+------+------+------+------+--------+--------+-------+-------

Totals,| 621 | 500 | 121 | 28 | 43-1/2 | 8-3/4 | 19.5 | 15.7

-------+------+------+------+------+--------+--------+-------+-------

Out of the 621 cases admitted, 121 were fatal. This gives a death-rate

of 19.5 per cent.; but if we deduct the 28 cases in which the patients

died within forty-eight hours of their admission, it falls to 15.68

per cent., or about the same ratio as Murchison found to exist among

the cases treated at the London Fever Hospital. Other observers have

obtained slightly different results. Thus, the mortality was 11.16 per

cent. in 197 cases analyzed by Dr. Hale, and 13.5 per cent. in 303

cases collected by Dr. James Jackson. Dr. Cayley[93] found the

death-rate of the several hospitals in London to be 17.8 per cent.,

and Geissler[94] that it was in all the German hospitals 12.8 per

cent. in 1877, and 13.5 per cent. in 1878. Flint had 18 deaths in 73

cases, or 24.4 per cent. According to Liebermeister, the ratio of

mortality at the hospital at Basle during the twenty-two years from

1843 to 1864, or before the introduction of a {318} systematic

anti-pyretic treatment, was 27.3 per cent., and only 8.2 per cent.

during the six years immediately following its adoption. As the

results obtained at the Pennsylvania Hospital are apparently not so

favorable as those reported at some of the continental hospitals, it

is only proper to state that a large proportion of the cases were

severe, that many of them were far advanced in the disease when

admitted, and that very few of the patients were under twenty-one

years of age. These are all circumstances which influence very

decidedly the prognosis in typhoid fever. In no other city are the

laboring classes able to surround themselves with so many comforts as

in Philadelphia. This fact, fortunate as it is in the main, often

operates to the disadvantage of the patient by enabling his family to

indulge for a time the reluctance which it naturally feels to part

with a member when sick. In the case of the young this reluctance is

so hard to overcome that children with acute affections are rarely

brought to hospitals for treatment. There were also special causes for

the large mortality in certain years. This was particularly the case

in 1862, when a large number of soldiers fresh from the battlefields

of Virginia, and suffering from the typho-malarial form of the

disease, were admitted into the hospital. Many of them were moribund

upon admission, and others, exhausted by the fatigue incident to

transportation here and by previous hardships, soon succumbed to the

disease.

[Footnote 93: _Med. Times and Gaz._, 1880.]

[Footnote 94: _Schmidt's Jahrbuch_.]

Table 2 gives the number of cases, with the number of deaths occurring

in each season, at the Pennsylvania Hospital during the last twenty

years:

TABLE NO. 2.

-------------------------+---------+---------+---------+---------

| Spring. | Summer. | Autumn. | Winter.

-------------------------+---------+---------+---------+---------

Number of cases | 89 | 259 | 182 | 91

Recoveries | 73 | 191 | 163 | 73

Deaths | 16 | 68 | 19 | 18

Percentage of mortality | 18.0 | 26.2 | 10.4 | 19.8

-------------------------+---------+---------+---------+---------

It will be seen from this table that the highest death-rate occurred

in the summer and the lowest in autumn, while there was only a slight

difference between the death-rate of spring and that of winter.

Murchison's experience, based on a much larger number of cases, has

led him to conclude that while the disease is a little less fatal in

autumn, the difference in the mortality at different seasons is very

inconsiderable. Chomel believed that the percentage of deaths was

highest in France during the winter months, and Bartlett held the same

opinion as regards America. Epidemics of great severity have

undoubtedly prevailed in winter, as the in Lowell, Mass., referred to

by Bartlett, but there can be little doubt that the death-rate is

highest in this country during the warm months of the year. Dr.

Cleemann[95] found that the monthly average mortality in Philadelphia

for the ten years from 1866 to 1875 was highest in August, and next

highest in September, confessedly the two months of the year when the

heat in this city is most exhausting. I feel very sure I have lost

patients with typhoid fever in these months {319} and in July who

would probably have recovered if the weather had been cooler. With a

temperature often rising above 90° F. at midday, and sometimes for

several days at a time never falling below 80°, all radiation of heat

from the surface of the body is arrested, and death frequently occurs

as the result of hyperpyrexia.

[Footnote 95: _Transactions of the College of Physicians of

Philadelphia_, 3d S., vols. ii. and iii.]

The stage of the disease at which efficient treatment is begun has a

manifest influence upon the result. This is strikingly shown by some

observations of Jackson: 90 cases were admitted into the Massachusetts

General Hospital during the first week--of these 7 died, or 1 in

12.85; 139 cases were admitted in the second week--of these 16 died,

or 1 in 8.68; 46 cases were admitted in the third week--of these 10

died, or 1 in 4.60; and 21 cases were admitted in the fourth week, and

of these 5 died, or 1 in 4.20. Convalescence also occurred much

earlier in those who were admitted early.

Murchison found that in a large number of cases the death-rate varied

at different ages as follows: Under ten years it was 11.36 per cent.;

from ten to fourteen years it was 12.86 per cent.; from fifteen to

nineteen years it was 15.48 per cent.; from twenty to twenty-nine

years it was 20.46 per cent.; from thirty to thirty-nine years it was

25.90 per cent.; from forty to forty-nine years it was 25 per cent.;

and above fifty years it was 34.94 per cent.

According to Liebermeister, among the 1743 patients treated for

typhoid fever in the hospital at Basle from 1865 to 1870, inclusive,

there were 130 who were more than forty years old; of these 39, or 30

per cent., died, while the mortality among the patients under forty

amounted only to 11.8 per cent. Among the cases of typhoid fever in

individuals over forty years of age collected by Uhle, more than half

proved fatal. According to Friedrich,[96] there were, among 16,084

children treated in the Children's Hospital at Dresden, 275 cases of

typhoid fever, of which 31, or not quite 11 per cent., proved fatal.

Age, therefore, exercises a positive influence upon the mortality of

typhoid fever. Its influence is less decided in this disease than in

typhus, in which the death-rate does not reach 4 per cent. until after

the age of twenty, when it rapidly rises from 12.34 per cent. until it

reaches 57.03 per cent. in patients above fifty years of age. The

comparatively slight mortality of typhoid fever among children is

probably due to the fact that the temperature is less often

continuously high in them than in adults, and that while hyperpyrexia

is frequently present, it is generally better borne and less likely to

produce paralysis of the heart. Liebermeister says that the only case

which he has seen recover after the temperature had repeatedly risen

to 107.5° F. was that of a girl fourteen years of age. It is also said

that the intestinal lesions are not so severe, and the liability to

complications and sequelæ less marked, in children.

[Footnote 96: Quoted by Liebermeister.]

Typhoid fever appears to be a slightly more fatal disease in women

than in men, for while in some local epidemics the percentage of

deaths is greater among the latter than among the former, the reverse

is found to be the case when the records of a large hospital for a

number of years are carefully examined. According to Murchison, the

mortality at the London Fever Hospital was about 1 per cent. higher

among the female than among the male patients, and about the same

difference in the death-rate {320} of the two sexes has been reported

by continental physicians. A greater disparity even than this has been

observed by Liebermeister at the hospital at Basle, where the

death-rate for women was 14.8 per cent., and only 12 per cent. for

men. Murchison says that this excess of mortality among the former

cannot be accounted for by the influence of child-bearing upon the

course of the fever, since it is much more decided between the ages of

five and fifteen than in the period of child-bearing.

The rich are not only as liable to contract typhoid fever as the poor,

but the disease is also quite as fatal among them. Murchison found

from the statistics of the London Fever Hospital that the mortality is

not greater among the destitute than among the better class of

patients, and expresses the opinion that in private practice enteric

fever is probably more fatal among the upper classes than among the

very poor. Chomel and Forget seem to have reached a similar

conclusion.

All authors agree that the prognosis is unfavorable in corpulent

persons, not only on account of the diminished power of resistance to

disease generally which such persons exhibit, but also because the

febrile movement is often intense in them, and the degenerative

changes of the muscles and organs of the body which it induces are

generally early developed and of high grade. Liebermeister goes so far

as to say that even in the case of ill-nourished, anæmic, or chlorotic

individuals the chances for life are better than in the corpulent.

Murchison has also expressed the opinion that a large, muscular

development is likewise an unfavorable element in prognosis, having

seen the strong and robust succumb to the disease oftener than the

feeble. The mortality from the disease appears to be greater in

certain families than in others. This has been ascribed by some

writers to peculiarities of constitution, but it may be due to other

causes, as, for instance, difference in the intensity of the poison.

The disease is also often very fatal among the intemperate, who

usually bear the disease badly in consequence of the presence of

various degenerations of one or more of the important organs of the

body caused by the excessive indulgence in alcoholic stimulants;

paralysis of the heart being not an infrequent cause of death among

them.

Certain epidemics have been exceedingly fatal, while in others the

percentage of deaths has been very small. There can be no doubt that

in most of these cases there has been a difference in the virulence of

the poison. Recent residence in an infected locality has been shown by

Murchison and other writers to have a decided influence in increasing

the fatality of the disease. Second attacks are, on the other hand,

usually mild. Some diversity of opinion exists among authors in regard

to the effect that pregnancy has upon the course of the disease.

Murchison believes that it is a far less formidable complication than

is usually thought, while Liebermeister, on the contrary, holds a

directly opposite opinion. He also regards the prognosis as

unfavorable when the disease occurs in childbed or a short time

afterward. Individuals with disease of the heart, emphysema, or

bronchial catarrh who contract typhoid fever are said to be more

liable to paralysis of the heart than others, hence the existence of

these diseases materially diminishes their chances of recovery.

TREATMENT.--Inasmuch as the spread and propagation of typhoid fever

may be prevented to a great extent, if not entirely, by the {321}

employment of judicious sanitary measures, it is proper, before

entering upon the discussion of its curative treatment, to devote a

few words to the prophylaxis of the disease.

Whether the physician accepts the theory so ably advocated by

Murchison, that typhoid fever may arise from exposure to the products

of the fermentation of healthy feces, or adopts the view now held by a

large number of investigators, that the disease is never generated in

the absence of the specific germ, he will admit the great importance

of an efficient system of sewerage, with a thorough flushing of the

sewers at regular and frequent intervals, for disposing of the fecal

discharges of the population of all towns, no matter how

inconsiderable in size. No less important is it that the drains of

every dwelling should be well constructed and kept in good order. They

should be trapped just before they empty into the sewer, and should be

provided with the means of thorough ventilation between the trap and

the walls of the house by a free communication with the outer air. The

soil-pipe should be carried up three or four feet above the top of the

house, and every water-closet, bath-tub, stationary washstand, and

sink should have its own separate trap, and none of them should be

placed in rooms unprovided with a window or with some other sufficient

means of ventilation. Physicians should, as sanitarians, urge upon the

authorities of all cities and towns the importance of deriving their

water-supply from a source unpolluted by sewerage or by any other

substances likely to be deleterious to health. They should also see

that when water is stored in a tank inside of a house the overflow

pipe does not communicate directly with the drain, since if this is

allowed to occur the water may very soon become contaminated with

sewer gas, and consequently unfit for internal use.

In the case of isolated country-houses and of small villages some

other means of disposing of the fecal discharges of the inhabitants

than by sewers has to be found. In the great majority of instances no

better way presents itself than by the ordinary cesspool. Care should,

however, be taken that this is so constructed and situated that there

can be no filtration of its contents into wells from which water for

drinking is obtained.

As the alvine dejections of the sick are beyond question the medium by

which typhoid fever is most frequently communicated to others, the

importance of thoroughly disinfecting them before they have acquired

the power of imparting the disease cannot well be overestimated.

Liebermeister recommends that the bottom of the bed-pan should be

strewed, each time before being used, with a layer of sulphate of

iron, and that immediately after a passage crude muriatic acid should

be poured over the fecal mass, as much as one-third or one-half of the

bulk of the latter being used. He also urges, whenever it is

practicable, that the contents of the bed-pan should be emptied into

trenches dug anew every two days and filled up when discarded, care

being of course taken that they are not located anywhere in the

vicinity of wells. Murchison seems to prefer carbolic acid to other

chemical agents as a means of preventing fecal fermentation. For this

purpose the liquid carbolic acid may be diluted with water in the

proportion of 1 to 40 to 1 to 20, or it may be mixed with sand or

sawdust. I have myself employed as a disinfectant with success the

solution of the chlorides sold under the name of Platt's chlorides. As

the discharges must in cities, in the great majority of instances, be

emptied into {322} water-closets, these should be freely flushed with

water after every time they are used; and it is well to impress upon

the attendant on the sick the importance of doing this. The bed-linen

of the patient and his clothes, if they are soiled by his discharges,

should be removed as soon as possible, and subjected to a high degree

of heat (248° F.) or soaked in a solution of the chlorides or of

carbolic acid for several hours before being washed. If these

precautions are observed, cases of typhoid fever may be treated in the

wards of general hospitals without danger to the other patients.

In the doubt and obscurity which generally envelop the diagnosis of

the disease when the physician is first called upon to treat it, it is

impossible to lay down any positive rules for the management of

typhoid fever at its commencement. But even in those cases which begin

insidiously, if the patient is carefully examined enough of the early

symptoms of typhoid fever will be detected to put the physician on his

guard. The thermometer will show the existence of fever, which has a

tendency to increase at night. There will generally be found to be a

little diarrhoea, or at least an increased susceptibility to the

action of purgative medicines; perhaps a little tympany and tenderness

in the right iliac fossa, and moreover a prostration which is out of

all proportion to the other symptoms.

These symptoms, it is true, are not infrequent concomitants of many

diseases besides the one under consideration; but when their presence

cannot be otherwise satisfactorily explained, especially if they have

continued for several days, it is a safe rule in practice to regard

the case as one of typhoid fever, and to regulate the treatment

accordingly. The patient must be put to bed at once, and not allowed

to leave it on any pretext, not even to empty his bladder, after the

first week. This is a rule which should be rigidly enforced in every

case, no matter how mild the symptoms may be. Its non-observance,

either through the neglect of the physician or the ignorance or

wilfulness of the patient, has been the cause of some disastrous

results; in illustration of which it is only necessary to refer to the

frequency with which perforation of the bowel occurs in walking cases

of typhoid fever. Perfect quiet should be maintained in the sick room.

Visitors should be excluded from it, and the attendants limited in

number to those actually necessary to carry out the directions of the

physician. All unnecessary talking is to be avoided, and especially

conversation carried on in a low tone of voice, which is always

annoying to the sick.

The prognosis is bad in cases in which coma or wild or violent