is not new. It is as old as the theory that the disease is generated
by a specific cause. The hypothesis that this is an alkaline poison
led many years ago to the use of the mineral acids, and it was only
after experience had shown that they were without power to cut the
disease short, or even to control many of its symptoms, that they
ceased in a measure to be prescribed. Calomel also, which was
occasionally resorted to formerly for its antiphlogistic effects upon
the intestinal lesions, has been lately recommended in Germany in the
treatment of typhoid fever on account of its supposed antidotal
properties. Seven and a half grains of the drug, and in some cases a
much larger dose, are given four times daily on alternate days as soon
as the nature of the disease is fully recognized. It is claimed for
this treatment that when it is begun early the rate of mortality and
the duration of the disease are much less under it than under any
other. Its advocates admit, however, that the latter is not always the
case--a variety in the action of the medicine which is attributed to a
difference in the way in which the poison of the disease has been
taken into the body. Salivation is rarely produced by the calomel. The
diarrhoea, which is at first increased by it, subsequently diminishes,
and the administration of each dose is followed by a decided although
temporary reduction of temperature.
A diminution in the rate of mortality is also said to have been
obtained by the administration of iodine in typhoid fever, although
the results of its use are on the whole less favorable than those of
calomel. Liebermeister recommends that three or four drops of a
solution of one part of iodine, two parts of iodide of potassium, and
ten parts of water should be given every two hours in a glass of
water.
--------------------------+---------+--------+--------------
| Number | Number | Percentage of
| treated.| died. | mortality.
--------------------------+---------+--------+--------------
Non-specifically treated | 377 | 69 | 18.3
Treated with calomel | 223 | 26 | 11.7
Treated with iodine | 239 | 35 | 14.6
--------------------------+---------+--------+--------------
Total | 839 | 130 | 15.5
--------------------------+---------+--------+--------------
The preceding table, which is taken from Liebermeister's article on
typhoid fever in _Ziemssen's Cyclopædia_, is based upon the results of
{337} treatment in 839 cases, a part of which were treated with
iodine, a part with calomel, and a part with neither, the rest of the
treatment being exactly alike in all of them, and consisting in the
employment of a partial antipyretic method.
James C. Wilson[108] has recently used with great success in the
treatment of typhoid fever the following prescription, which was
originally suggested by Roberts Bartholow: Rx. Tinct. Iodinii fl.
drachm ij.; Acid. Carbolici liq. fl. drachm j.--M. Of this, one, two,
or even three drops is given in a sherry-glassful of ice-water after
food every two or three hours during the day and night. In addition to
this prescription his patients were given a dose of calomel varying in
amount from seven and a half to ten grains, which was repeated on
every alternate night until three or four doses had been administered
in the course of the first six or eight days. Of sixteen cases so
treated, none proved fatal, although eight of them were severe, the
temperature reaching or exceeding 104° F. Da Costa[109] has used
carbolic acid in this disease, and has found it useful in controlling
the diarrhoea and in lowering the temperature, but suggests the use of
thymol in doses of from half a grain to one grain as a substitute, on
account of its greater acceptability to the stomach. C. G. Rothe[110]
recommends a mixture of carbolic acid, tincture of digitalis, tincture
of aconite, brandy, and tincture of iodine. Its use causes a decided
fall of temperature and diminution in the frequency of the pulse.
[Footnote 108: _Transactions of the College of Physicians of
Philadelphia_, 3d Series, vol. vi., Philadelphia, 1883, p. 221.]
[Footnote 109: _Ibid._, p. 234.]
[Footnote 110: _Deutsche Med. Wochenschr._, 1880.]
My own experience does not enable me to speak with positiveness of the
value of this plan of treatment. Indeed, it has been used in so few
cases, to the exclusion of all other remedies, that it is difficult to
decide how far the result attained in cases treated by them is due to
them, and how far to the other therapeutic means employed. With the
testimony of such competent observers as those above named it is only
proper that the treatment by iodine and carbolic acid should have a
further trial. More caution, it seems to me, is required in the use of
calomel. While it is probable that in a few cases the intestinal
lesions may be favorably modified by the purgation which it induces,
the indiscriminate use of the drug is, I am sure, calculated to do
more harm than good.
{338}
TYPHUS FEVER.
BY JAMES H. HUTCHINSON, M.D.
DEFINITION.--Typhus fever is an acute contagious disease, usually
occurring epidemically, lasting from ten to twenty days, and
characterized, among other symptoms, by an abrupt commencement, great
prostration, profound derangement of the nervous system, and a
peculiar eruption which appears between the third and eighth days, and
which, disappearing at first under pressure, soon becomes persistent,
and in severe cases may be converted into and be associated with true
petechiæ. When it proves fatal, it generally does so at or near the
end of the second week. The lesions found after death are not specific
in character, and consist mainly of a marked alteration of the blood,
congestions of internal organs, softening of the heart, and atrophy of
the brain.
SYNONYMS.--Petechial Typhus, Putrid or Malignant Fever, Camp, Jail,
Ship, or Hospital Fever, Spotted Fever, Irish Ague, Contagious Typhus,
Brain Fever, Adynamic or Ataxic Fever, Ochlotic Fever, Catarrhal
Typhus.
The term typhus was first applied by Sauvages in 1760, and afterward
by Cullen, to certain forms of fever, characterized by marked
prominence of the nervous symptoms, to distinguish them from another
group of cases to which they gave the name synochus, and is derived
from the Greek word [Greek: typhos], which literally means smoke, and
which is employed in the treatise on internal affections attributed to
Hippocrates for a similar purpose. According to Murchison,[1]
Hippocrates used the word to define a "confused state of the
intellect, with a tendency to stupor." The appellation typhus,
therefore, as indicating a very prominent symptom of the disease about
to be described, is perhaps the best that could be given to it. It has
been generally adopted by the physicians in England and in this
country to denote this disease, but on the Continent, and especially
in Germany, it is applied also to typhoid fever, the two fevers being
usually designated there as typhus petechialis and typhus abdominalis,
respectively.
[Footnote 1: _A Treatise on the Continued Fevers of Great Britain_, by
Charles Murchison, M.D., LL.D., F.R.S., etc., second edition, London,
1873.]
HISTORY.--As human want and misery and the evils which follow in the
train of war have never been wholly absent from the world, and as
these are the conditions which are now known to be favorable to the
spread, if not to the generation, of typhus fever, it is highly
probable that this disease was the cause of some of the epidemics to
which allusion is made by the sacred and profane writers of antiquity.
Yet their descriptions are too vague to justify us in assuming that
such was positively the {339} case. The records of the first fifteen
centuries of our own era are similarly wanting in details, for, with
the exception of a brief notice of an outbreak of the disease in the
monastery of La Cava, near Salerno, in the year 1083, by Corradi[2] it
may be said to have been practically undescribed before the year 1546,
when Fracastorius[3] published his work, _De Contagionibus et Morbis
Contagiosis_. From the description which this distinguished physician
gives there of the epidemics which prevailed in Verona in the years
1505 and 1508, there can be no doubt that the disease he had the
opportunity of observing was really typhus fever. Not only are the
principal symptoms succinctly described, but its contagiousness and
tendency to early prostration fully recognized. We learn also, from
the same work, that the disease, although previously unknown in Italy,
was one with which the physicians of Cyprus and the neighboring
islands were perfectly familiar. According to the same authority, it
again made its appearance in 1528 in Italy, and from there extended to
Germany.
[Footnote 2: In _Chron. Cavense Annali_, p. 1, 101, quoted in
_Handbuch der Historish-Geographischen Pathologie_, von Dr. August
Hirsch, Stuttgart, 1881.]
[Footnote 3: Quoted by Murchison.]
During the last half of the sixteenth century epidemics of typhus
fever would seem to have been of more frequent occurrence than before
it, since many of the medical authors of this period not only refer to
it very fully, but also give accurate descriptions of the disease.
There is also abundant evidence of the same kind that it frequently
prevailed epidemically in almost every part of Europe during the
seventeenth and eighteenth centuries, following generally in the wake
of famine and of war, and often attaining a high degree of virulence
in besieged towns. The histories of many of these epidemics are
exceedingly interesting, especially those of the so-called Black
Assizes which occurred at different times in several of the towns of
England, and which derived their name from the fact that the disease
was communicated from the prisoners on trial to the judges and other
persons in attendance upon the court; but to give these in detail
would be beyond the scope of this article. Although many of the
authors of these two centuries boldly advocated copious venesection as
the only rational method of treating the disease, there was a not
inconsiderable number who recognized its essentially typhoid nature,
its tendency to early prostration, and the fact that patients
suffering from it bear bleeding badly, as fully as is done by
physicians of the present day. They were also unquestionably quite
aware of the circumstances under which typhus fever generally arises,
for in 1735, Browne Langrish[4] wrote that it originated from "the
effluvia of human live bodies," and that its principal cause was
overcrowding with deficient ventilation, as a result of which "people
were made to inhale their own steams;" and a similar opinion was
expressed a few years later by Sir John Pringle,[5] J. Carmichael
Smyth,[6] and others.
[Footnote 4: _The Modern Theory and Practice of Physics_, by Browne
Langrish, p. 354, London, 1764.]
[Footnote 5: _Observations in Diseases of the Army_, London.]
[Footnote 6: Quoted by Murchison.]
Epidemics of typhus fever have frequently occurred in various parts of
Europe during the present century, although they have, on the whole,
shown a greater tendency than before to confine themselves to the
place in which they first appeared. The most severe of these began in
1846, and after committing great ravages in Ireland extended to
England, and {340} subsequently to the Continent. The disease proved
much more fatal than the sword in the armies of Napoleon in the towns
besieged by him in the early part of this century, and was the cause
of an immense loss of life in the Russian and French armies in the
Crimea after the fall of Sebastopol.
In our own country typhus fever has appeared several times during the
present century, but the outbreaks have rarely attained the magnitude
of epidemics, such as are seen in Europe, and have usually been
distinctly traceable to importation from abroad. It was first met
with, according to Wood,[7] in New England in 1807 and in Philadelphia
in 1812, continuing to lurk, this author says, in the lanes and alleys
of that city until the winter of 1820-21, when, as a student of
medicine, he had an opportunity of studying it. Another outbreak of
the disease occurred in the same city in 1836, and is the subject of
an admirable paper by the late Wm. S. Gerhard.[8] Since then epidemics
of moderate severity have repeatedly occurred at different times in
several of the American cities, and have been described, among others,
by Flint, Da Costa,[9] and Loomis. A large number of cases of typhus
fever (1723), with 572 deaths, were reported to the Surgeon-General's
office during the late Civil War, but doubt has been thrown upon the
correctness of the diagnosis of many of these cases by Clymer[10] and
Woodward,[11] and by other army surgeons, who, as the result of their
investigations of this subject, have reached the conclusion that
typhus did not prevail as an epidemic, however limited, among our
soldiers at dépôts for returned prisoners of war. A like immunity from
this scourge may be assumed to have been enjoyed by the Confederate
forces, since Joseph Jones,[12] one of the most eminent of their
medical officers, has stated positively that no case of true typhus
fever came under his observation during the war in any army, in any
field hospital, general hospital, or military prison, and that the
experience of all of his associates whose opinions on this question he
was able to obtain, either personally or by letter, was the same. It
is therefore most probable that the cases entered upon the sick
reports of both armies as typhus fever were in almost every case, if
not in all, cases of typhoid fever occurring in scorbutic subjects.
[Footnote 7: _A Treatise on the Practice of Medicine_, by George B.
Wood, M.D., etc., Philada., 1855.]
[Footnote 8: _The American Journal of the Medical Sciences_, February
and August, 1837.]
[Footnote 9: _Ibid._, January, 1866.]
[Footnote 10: _The Science and Practice of Medicine_, by William
Aitken, M.D., Edin.; 3d Amer. ed., p. 462, Philadelphia, 1872.]
[Footnote 11: _Camp Diseases of the United States Armies_, by Joseph
Janvier Woodward, M.D., Philadelphia, 1863.]
[Footnote 12: _United States Sanitary Commission's Memoirs--Medical_,
p. 600, New York, 1867.]
From the foregoing sketch of its history it is evident that typhus
fever has prevailed from time to time in almost all the countries of
Europe. Indeed, it is probable that no one of them has wholly escaped
its ravages, while in others--as, for example, Ireland--it has been
more or less constantly present until within the last few years, when
its visitations have been less frequent as well as less severe. Even
in countries which are popularly supposed to enjoy an immunity from it
there is evidence of an incontrovertible character that it has
occasionally occurred. Such an immunity has been claimed for France,
but in the works of Riverius,[13] {341} Ambrose Paré,[14] and others
will be found descriptions of the disease which leave no doubt upon
the mind of their entire familiarity with it; and Hirsch, in his work
on _Historico-Geographical Pathology_, is able to give references to
several writers who describe outbreaks that have recently occurred
there. The disease has also been observed in Iceland. Typhus fever is
of much less frequent occurrence in the other divisions of the eastern
hemisphere than in Europe. According to Murchison, there are no
authentic records of its having been met in Africa, or, with the
exception of India, in Asia, such as it is seen in England and
Ireland. There are, however, reports of its occurrence in Asia Minor,
Syria, Persia, Egypt, Nubia, Tunis, and Algeria, which Hirsch,[15] on
the other hand, believes place the occasional presence of this disease
in these countries beyond doubt. The same difference of opinion exists
between these two distinguished observers in regard to the accounts
which have been published of typhus fever occurring in Mexico, Central
America, and South America, the latter holding that they are entirely
reliable, the former that the cases described in them were really
cases of malarial or typhoid fever. The disease has never been met
with on the continent of Australia, in New Zealand, or in the valley
of the Mississippi and the States bordering on the Pacific Ocean in
our own country.
[Footnote 13: _The Practice of Physick_, being chiefly a Translation
of the Works of Lazarus Riverius, London, 1678.]
[Footnote 14: _Traité de la Peste, de la Petite Verolle et Rougeolle_,
par Ambrose Paré, Paris, 1568.]
[Footnote 15: _Loc. cit._]
While Hirsch's researches go to show that the tropical zone has not
been so wholly exempt from the visitation of typhus fever as some
authors have asserted, they establish the fact that it is of much less
frequent occurrence there than in the colder portions of the temperate
zone, where the modes of life are certainly much more favorable to its
extension. Natives of warm climates are as liable to be attacked by it
as others upon coming to places where it is prevailing, and in the
Philadelphia epidemic of 1836, which Gerhard[16] has described,
negroes and mulattoes suffered from it more severely than the whites.
[Footnote 16: _Loc. cit._]
ETIOLOGY.--The etiology of typhus fever will be best studied under the
heads Predisposing and Exciting Causes.
PREDISPOSING CAUSES.--It may be stated, generally, that whatever
impairs the health or reduces the strength of an individual, even
temporarily, or acts depressingly on his nervous system, predisposes
him to typhus fever. But there are among the predisposing causes some
which exert a more special influence on its production than others.
Among the more powerful of these is the overcrowding of human beings,
with deficient ventilation. Indeed, there are some authors who
consider that this has been in many cases alone sufficient to occasion
the disease; and although this opinion, as it involves the admission
that it may be generated de novo, is contested by others, there is
great unanimity among authors in attaching great importance to it. Of
the patients admitted into the London Fever Hospital with typhus
fever, a large proportion came from the more crowded districts of the
city. The disease has always been most prevalent in the poorer
quarters of Glasgow, Dublin, and Edinburgh, and when epidemic in
Philadelphia in 1836 it was confined to a portion of the town which
has always been noted for the squalor and misery of its inhabitants.
Among those admitted during that year to the Philadelphia Hospital
were seven negroes, said by Gerhard to {342} be "the entire population
of a cellar." It is probably largely due to the fact that the better
social condition of the poor in this country prevents the degree of
crowding which often exists in European cities that the disease is
comparatively rare here. The effect of overcrowding is of course much
increased by want of cleanliness, either of the person or of the
clothes.
Poverty, not merely from its own depressing influences, but also from
the fact that it leads to overcrowding, is a powerful predisposing
cause of typhus fever. Insufficiency of food, which is one of its many
consequences, by impairing his nutrition and thus diminishing his
vital resistance, renders the individual more susceptible to the
action of the specific cause. Gerhard says that of the patients seen
by him in 1836 a very small proportion came from the better class of
mechanics, and Tweedie[17] and Sir William Jenner[18] state that it is
rare to meet with instances of the disease, except in the case of
medical practitioners and students, among those in comfortable
circumstances. Bateman[19] goes so far as to assert that "deficiency
of nutriment is the principal source of epidemic fever;" and there is
certainly a remarkable coincidence in time between outbreaks of this
fever and seasons of want and distress. But, as Murchison has shown,
destitution is not essential to the production of typhus, for the
Dundee epidemic of 1865 was due to overcrowding of the town, brought
about by the inhabitants of the surrounding country flocking into it
in consequence of labor being unusually abundant and wages good.
[Footnote 17: _Lectures on the Distinctive Character, Pathology, and
Treatment of Continued Fevers_, by Alexander Tweedie, M.D., F.R.S.,
London, 1842; and _Clinical Reports on Fever_, by same author, London,
1830.]
[Footnote 18: _On the Identity or Non-Identity of Typhoid and Typhus
Fevers_, by William Jenner, M.D., London, 1880; also _Lancet_,
November 15, 1879.]
[Footnote 19: _A Succinct Account of Typhus or Contagious Fever of
this Country_, by Thomas Bateman, M.D., F.R.S., London, 1820.]
Similar in its action to the above cause is intemperance. Not only is
the habitual drunkard more likely to suffer from typhus fever than the
temperate man, but a single debauch has been followed by an attack in
individuals who had previously resisted the contagion. On the other
hand, the most rigid temperance will not afford in all cases a
complete immunity from its effects. The debility left by an illness is
also a condition favoring the occurrence of an attack of the disease
in those who are exposed to its exciting cause. Fatigue of all kinds
renders the body less able to resist the causes of disease, and typhus
fever is not an exception to the general rule. Overworked nurses are
specially liable to contract it. The depressing emotions also favor
its occurrence. It has been observed during epidemics that those who
exhibit an excessive fear of the contagion are much more likely to
suffer from it than the cheerful and courageous.
No age enjoys an immunity from the disease. In fact, it is probable
that all ages are equally liable to it. Buchanan[20] has seen it at
the London Fever Hospital in an infant a fortnight old and in a man of
eighty, and attributes the prevailing opinion that children rarely
suffer from it to the fact that they are not often taken to hospitals,
but are retained in their own homes for treatment. Gerhard[21] says
that no children in the asylum attached to the Philadelphia Hospital
were {343} attacked with the disease during the prevalence of the
epidemic there, but the distance of the asylum from the wards in which
the cases were treated was probably the reason of their escaping. In
the few cases which have come under my own observation the patients
were young men, varying in age from twenty-five to thirty-five. The
sexes also suffer from it equally. In some epidemics there may be a
preponderance of one sex over the other, but in others the reverse has
been the case.
[Footnote 20: _A System of Medicine_, edited by J. Russell Reynolds,
M.D., F.R.C.P., etc., vol. i., article "Typhus Fever," London, 1866.]
[Footnote 21: _Loc. cit._]
Occupation, except so far as it brings the individual into immediate
contact with the sick, as in the case of physicians, nurses, and
clergymen, does not predispose to the disease. There would seem also
to be no difference in the susceptibility of the different races to
the contagion. Acclimatization affords no protection from the disease,
as it does in the case of typhoid fever, and change of the habits of
life does not appear to exercise any influence upon the liability to
it. On the other hand, the susceptibility of different individuals,
and of the same individual at different times, varies considerably.
Thus, while in many persons a single exposure to the contagion is
followed by an attack, in the case of an engineer mentioned by
Murchison it did not occur until after fifteen years of continuous
service at the London Fever Hospital. A person who has once suffered
from typhus fever is not likely to contract it again, but this
protection is not complete, as there are a few well-attested instances
of a second attack on record.
The disease prevails most frequently during the winter and early
spring, principally because the cold weather of these seasons leads to
the closing of windows and all other avenues of ventilation, thus
intensifying its exciting cause. Still, some epidemics of great
severity have occurred in the warmer months of the year, as, for
instance, the one described by Gerhard. It is also doubtful if there
is any relation between variations in temperature and the amount of
moisture in the air and the prevalence of epidemics of typhus fever,
although Hirsch regards a low and damp situation as powerfully
predisposing to the endemic and epidemic prevalence of the disease. It
is usually met with in towns on the sea-coast or on navigable rivers,
but it has also been observed frequently in country districts, and
even in regions at a considerable elevation above the level of the
sea.