typhus fever is a specific contagion developed in the bodies of the
infected and transmitted from them to the healthy by actual contact,
by fomites, or through the atmosphere. The nature of this contagion is
unknown. A careful study of its peculiarities seems to justify the
opinion that it depends upon the presence of a minute organism in the
emanations given off by the sick, which is capable of indefinitely
multiplying itself in the human body. But this is only an hypothesis,
which rests principally upon the analogy between typhus and some other
diseases, as, for instance, relapsing fever and diphtheria, in which
such a growth is thought to have been discovered, and upon the fact
that the contagious principle whatever it may be, is destroyed by a
temperature over 204° F.
The evidence in favor of the contagiousness of typhus fever is
conclusive, and may be briefly stated as follows: When it breaks out
in a community the disease not only attacks those persons who have
been subjected to the same influence as the sick--as, for instance,
members of {344} their own families, occupants of the same house,
etc.--but also those who have come from healthy localities to visit
them. In fever hospitals it is rare for any member of the household
who has not already had the fever to escape an attack, and the
probability of his suffering is in direct proportion to the intimacy
of his relations with the patients. Thus, the nurses are far more
likely to be attacked than servants whose duties do not take them into
the wards, except those employed in the laundry, who are so often
affected by it that Murchison says it is difficult to find women who
are willing to take the position. The spread of the disease may often
be promptly arrested by the complete isolation of the first few cases,
while free intercourse between the sick and the well is invariably
followed by its extension, not only in the locality in which it first
appeared, but to other localities. But the strongest argument in favor
of its contagiousness is found in the fact that patients taken into a
previously healthy place have frequently become the starting-point of
an epidemic. In this way the disease has often been introduced by
Irish immigrants into the cities on our seaboard, and even into some
of our interior towns.
Actual contact is not necessary for the communication of typhus fever
from the sick to the well. The contagion may be transmitted through
the atmosphere. How far it will be transmitted in this way will depend
upon many circumstances. In a spacious and well-ventilated ward it is
probable that the presence of one or two patients with this disease
does not seriously endanger the safety of the other patients, and that
the only persons who run much risk of contracting it are the
physicians and nurses, who are often compelled in the performance of
their duties to inhale the emanations from the bodies of the sick. At
the Pennsylvania Hospital, where cases of this disease are
occasionally admitted, it has been usual to isolate them by placing
them in a room a few feet distant only from the dining-room of the
men's medical ward and separated from the ward by a short corridor.
The steward of the hospital informs me that during his connection with
it, which extends over a period of more than sixty years, he has never
known the disease to extend to other persons, except on two occasions.
One of these was during the epidemic described by Da Costa, when an
unusual number of cases was received, and when one resident physician
and two nurses contracted the disease. On the other occasion, which
happened during my own term of service in the spring of 1881, a young
Danish sailor appeared to have taken the disease from two British
seamen. As it was ascertained positively that he had not entered the
room in which these two seamen were isolated, and as his bed in the
ward was one of the farthest removed from the room, and he had not
therefore been more or as much exposed to the contagion as the other
patients, it was difficult to understand why he alone of all of them
should have suffered from it. The explanation was, however, found in
the fact that he had been taken over to the women's ward to act as
interpreter for a countrywoman who was not known at the time to be
suffering from typhus fever, and that he had remained there some time
in conversation with her. Murchison and Buchanan both assert also that
typhus fever has never extended from the London Fever Hospital to the
inmates of adjacent houses, even when it was itself one of a row of
houses. If, on the other hand, several patients with typhus fever are
placed in a crowded and ill-ventilated ward, the contagion will then
be found to have {345} acquired so much more virulence that few of the
other patients will escape its effects.
There is also no question that typhus fever may be communicated by
fomites. Numerous instances are on record in which the disease has
been communicated by the wearing apparel and bed-clothes of patients,
and we have already called attention to the frequency with which
laundry-women in fever hospitals are attacked by it. The clothes of
persons who are themselves free from the disease, but who have been in
close attendance upon the sick for some time, are often also the
medium of communication. Indeed, Murchison goes so far as to say that
men who have not changed their clothes and "who have been living in
close, ill-ventilated apartments and on short allowance, may at length
have their garments so impregnated with the poison of typhus as to
communicate it to others without being themselves the subjects of it,"
even if they have not been brought in contact with fever patients. The
disease was communicated in this way, he thinks, in the famous Black
Assize in 1750 by several prisoners to the court that tried them,
although they were themselves free from it. On the other hand, with
proper precautions there is little danger of the disease being
conveyed by physicians to their own families or to other patients.
Some difference of opinion exists as to the stage at which typhus is
most contagious. Many authors believe that it is more infectious
during convalescence than at any other time, and base this opinion
upon the fact that the removal of fever patients to the convalescent
ward is very often followed by the occurrence of the disease among its
other occupants; but this is probably due, as Murchison suggests, to
the patients being allowed at this time to wear their own clothing,
which has not been thoroughly disinfected. It is much more likely that
the disease is more contagious during the stage when the febrile
symptoms are most marked than during either the stage of convalescence
or that of invasion. It would appear also, from the observations of
Dr. Gerhard and others, that dead bodies do not readily communicate
the contagion or that the contagious principle is easily counteracted
after death. Still, there are several well-authenticated cases on
record in which individuals have unquestionably contracted the disease
from dissecting the bodies of patients dead from this cause.
A question of great interest naturally arises here, as to whether or
not typhus fever ever occurs except as the consequence of exposure to
a previous case of the disease. Is it, in other words, ever generated
de novo? Authorities are divided upon this point, many contending that
an independent origin is impossible, and others that it may
occasionally arise in this way. Among the latter is Murchison, who
adduces in support of the position he takes several instances in which
poverty, with overcrowding and deficient ventilation, appears to have
been the only cause of extensive outbreaks of the disease, as in the
case of the Black Assize already alluded to. These cases the opposite
party explain by assuming that the germs of the disease are capable of
lying dormant for a long time until roused into activity by favoring
circumstances. If the disease is caused, as we have shown there is
good reason to believe it is, by the presence of a minute organism,
this view does not seem to be untenable. Pasteur has demonstrated that
the germs of the splenic fever of some of the lower {346} animals may
be deprived of their virulence by cultivation in appropriate liquids.
If their virulence is diminished under certain circumstances, the
assumption does not seem unwarrantable that under others it may be
increased, and if we may draw this conclusion in regard to one form of
microscopic growth, we may do the same for others; and the hypothesis
is therefore not an unreasonable one that the typhus germ needs the
atmosphere engendered by overcrowding for it to acquire the power to
produce the disease.
PERIOD OF INCUBATION.--The period of incubation of typhus fever
appears to vary considerably in length, but is usually about twelve
days. In some cases the interval between exposure to the contagion and
the occurrence of the first symptoms of the disease is asserted to
have been considerably longer, and in one instance as long as
thirty-one days; but it is probable that there has been in most, if
not in all, of these cases a second exposure which has been
overlooked. On the other hand, it is said to have followed at once
upon exposure, as in cases reported by Gerhard, in one of which a
nurse inhaled the breath of a patient whom he was shaving, and in an
hour afterward was taken with cephalalgia and ringing in the ears,
which were immediately succeeded by the other symptoms of typhus. In
this and other similar cases which are on record it is difficult to
exclude the possibility of a previous infection. In a case, however,
reported by Murchison there would seem to be no reason to suspect that
any such previous infection could have taken place, as the patient,
the matron of an orphan asylum where there was no typhus, was taken
ill immediately after opening a bundle of clothes which a child had
brought with her from a fever hospital, and which had not been
thoroughly disinfected.
SYMPTOMATOLOGY.--It will facilitate the study of typhus fever to give,
in the first place, as most of the systematic writers on fever have
done, a brief clinical sketch of the disease as it ordinarily occurs,
and then afterward to consider its leading symptoms in greater detail.
GENERAL DESCRIPTION.--An attack of typhus fever is sometimes preceded
for a few days by prodromata, such as a feeling of malaise,
indisposition to exertion, pain in the head and limbs, anorexia, and
vertigo; but it oftener begins abruptly with a slight chill, or more
rarely with a decided rigor. This is followed in a short time by
headache, by a marked rise of temperature, and by an increased
frequency of pulse and respiration. Nausea is also occasionally
present, and less frequently vomiting. The tongue is at first moist
and covered with a thin whitish fur, but soon becomes dryish, and its
coating is apt to assume a brownish appearance in a day or two. With
these symptoms there are loss of appetite, great thirst, constipation,
a dull, heavy expression of countenance, a dark, dusky hue of the
face, and injection of the conjunctivæ. Mental confusion is early
observed, so that, although the patient may be able to answer
questions correctly when thoroughly roused, it is readily seen that
his mind is working with difficulty. The sleep is very often disturbed
by dreams, so that he awakes from it unrefreshed. Prostration and loss
of muscular power are so decided from the very beginning of the
disease that the patient is obliged usually to take to his bed at
once, and it is much rarer to meet with walking cases of the disease
than in typhoid fever. The urine is dense, scanty, and high-colored.
{347} Usually, about the fourth day of the disease the characteristic
eruption of typhus fever makes its appearance. It consists of numerous
spots of irregular form with ill-defined margins and of a dark red or
purplish color, occurring singly or in groups, and varying in size
from that of a pin's point to two or three lines in diameter. They
disappear at first under pressure, but in twenty-four hours become
persistent, and in severe cases may be converted later into petechiæ.
Besides this eruption there is another which consists of a faint,
irregular dusky red, subcuticular mottling. The two eruptions together
constitute the mulberry rash of Jenner, and have been variously
described by different authors under the name of measly or
morbilliform rash.
As the disease advances the prostration becomes greater and the pulse
grows weaker. The tongue becomes dry and brown and trembles when
protruded. Later, it is so dry and contracted that it can scarcely be
put out of the mouth. Sordes collect about the teeth and lips, and the
surface exhales a peculiar odor. The headache grows more severe or
gives place to delirium, which may at first be active and violent, and
then pass into the low and muttering form, or the delirium may be of
the latter variety from the start. The sleeplessness of the early
stages may continue, and the condition known as coma vigil not
infrequently supervenes. The delirium is usually followed by stupor,
which is more or less profound in accordance with the severity of the
case, and which is accompanied by all the symptoms which characterize
the so-called typhoid state, such as subsultus tendinum, picking at
the bed-clothes, slipping down in bed, retention or incontinence of
urine, and sloughing of the parts exposed to pressure. In this
condition the temperature, although usually still considerably above
normal, is lower than during the first week of the disease.
Meanwhile, the issue remains in doubt, and may continue uncertain for
several days before any improvement in the symptoms can be observed,
or, the stupor passing into coma, the case may speedily terminate in
death. When death is the result, it usually takes place about the
close of the second week or a little later, but it may occur earlier
in consequence of the violence of the fever, or, when due to a
complication, may be postponed until after the end of the third week.
Fortunately, however, recovery is the rule in this disease. The
beginning of convalescence is often as abrupt as that of the attack
itself. The temperature will often be found to have fallen to the
normal or below the normal, the pulse and respiration to have returned
to a healthy condition, and all confusion of the intellect to have
disappeared in the course of a few hours. Occasionally, however, its
approach is more gradual, and a slight fall in temperature and a
corresponding improvement in the other symptoms may be observed before
it actually occurs. Diarrhoea, an excessive secretion of urine, with a
tendency to the deposition of urates, and moderate sweating, often
take place simultaneously with the cessation of the fever, and were
formerly regarded as critical discharges. The return to health is
usually rapid, and very rarely retarded by the occurrence of
complications or relapses, as in typhoid fever. The disease itself
leaves no tendency to any other disease.
DESCRIPTION OF SPECIAL SYMPTOMS.--The appearance of a patient with
typhus fever is pathognomonic, and is often alone sufficient to enable
{348} a physician or nurse familiar with it to recognize the disease
when brought in contact with it. The surface generally is congested;
the face is flushed, and in bad cases dusky red or even livid in hue;
the expression is dull and vacant, except during delirium, when it may
be wild or even fierce; the conjunctivæ are injected, the eyes watery,
and the teeth encrusted with sordes. The skin is generally hot and
dry, except toward the close of bad cases, when it may be cool and
bathed in a profuse sweat.
The symptoms connected with the nervous system are among the most
characteristic of the disease, and of them none is more marked than
prostration. It shows itself early, the patient usually taking to his
bed immediately after his seizure or within a few days of it. It is
much rarer than in typhoid fever to meet with walking cases of typhus,
but Buchanan[22] mentions that patients with the rash already out upon
them do occasionally present themselves at the out-door department of
the London Fever Hospital. It generally increases as the disease
progresses, and is often accompanied by a tendency to syncope. It may
attain such a degree that the patient is unable to turn himself in bed
or to help himself in any way. Among the most distressing sensations
which attend this condition of excessive feebleness is a feeling as if
he were sinking into the earth with nothing to support him. Headache
is also an early symptom. It is often observed among the prodromata of
the disease, and when these are absent supervenes directly after the
chill. It is usually frontal, but may be diffused. It is generally
dull and heavy, but is sometimes acute, and may be accompanied by a
tendency to vertigo, increased by sitting up, and by pains in the back
and limbs. It becomes more severe with the progress of the disease
until the occurrence of delirium, when it is, as a rule, less
complained of. With the headache there is generally some dulness of
intellect, except in mild cases. This may be slight at first, and may
continue so throughout the whole course of the attack, exhibiting
itself principally in some confusion as to dates. In more severe cases
it is much more marked, and may finally pass into actual stupor. On
the other hand, it may be entirely absent, even in severe attacks, as
in a case reported by Da Costa and in some cases recently observed by
myself. It is usually soon replaced by delirium, which may be low and
muttering or wild and noisy, the former being the more common.
Delirium is said to occur most frequently among the educated classes
and those oppressed with care and anxiety, but is not rare among those
who occupy a lower position in the social scale, especially the
intemperate. It is, as a rule, most marked at night, and in mild cases
may occur only at that time or upon waking in the morning. When the
delirium is active the patient may shout and scream, or leave his bed
and attempt to throw himself from the window, being endowed apparently
for the moment with strength sufficient to enable him to commit these
acts of violence. After the paroxysm is over he sinks back in bed
exhausted. The confusion of intellect or delirium continues in bad
cases until death supervenes or until the establishment of
convalescence. Indeed, the mental disturbance does not always end with
the latter, and it is not rare for feebleness of intellect to persist
for some time after the patient has in other respects regained his
usual health, and in a few cases insanity has followed an attack of
typhus fever. Among the most {349} formidable of the symptoms of
typhus are convulsions, which are fortunately of infrequent
occurrence.
[Footnote 22: _Loc. cit._]
The patient generally suffers from wakefulness, except during the
first few days. When sleep is obtained it may be unrefreshing or
broken and disturbed by dreams. In other cases the opposite condition
of somnolence may be present. Occasionally, after having apparently
slept for hours, he may deny having been asleep at all. This
condition, which constitutes the coma vigil of Chomel, is entirely
distinct from that described by Jenner under the same name, in which
the patient lies with his eyes wide open, gazing into vacuity, his
mouth only partly closed, his face pale and devoid of expression, and
which is invariably fatal. Muscular tremor is more or less present in
all cases of the disease, and in bad cases may be a prominent symptom.
The disease, when this symptom is marked, especially if there is at
the same time low, muttering delirium and a moist skin, presents a
considerable degree of resemblance to delirium tremens. There is very
often intolerance of light, tinnitus aurium, and loss or perversion of
the senses of taste and smell. Deafness is also not uncommon, and is
regarded by many authors as a favorable symptom. In bad cases, in
addition to subsultus tendinum, there are carphologia, incontinence or
retention of the urine, and paralysis of the sphincter ani.
Some discrepancy is found to exist in the statements of different
authors in regard to the temperature curves of typhus fever. They all
agree, however, in assigning them certain characters, the knowledge of
which is often of great assistance in diagnosis. One of these is a
rapid rise of temperature immediately after the invasion of the
disease. Wunderlich[23] asserts that he has observed a temperature of
104.9° F. on the evening of the first day, and Lebert has found it as
high as 106.4° F. on that of the second. Such temperatures, occurring
so early in the disease, must be infrequent, as Murchison has never
met with them. Usually, the temperature attains its maximum on the
third or fourth day. The maximum is about 104° or 105° F. Murchison
says it scarcely ever reaches 106°, except in children, in whom it
rarely is as high as 107°, but Lebert states that he has known it to
be as high as 107.8°. On the other hand, it may never exceed 103°,
even in fatal cases. When the maximum is attained early in the disease
there may be for several days, or until defervescence takes place,
very little variation in the evening temperatures, but, as a general
rule, they are slightly less elevated in the second than in the first
week. This usually occurs from the tenth to the fourteenth day, but it
may be postponed until the eighteenth, or even until much later. In
some cases on the day before the crisis a slight fall, and in others a
considerable fall with a subsequent rise of temperature, are observed.
Defervescence is often very rapid, the temperature falling five or six
degrees in the course of twelve hours. A true lysis is rarely
observed. The occurrence of a complication in the course of a disease
will not only cause a decided rise of temperature and a modification
of the temperature curve, but may also postpone defervescence beyond
the usual time. Not infrequently the thermometer indicates subnormal
morning temperatures with slight evening rises for several days after
the crisis, unless complications arise, {350} when fever of the hectic
type may occur. A very slight cause will also often produce a
considerable, although temporary, elevation of temperature in this
condition. The morning remissions are less decided than in typhoid
fever, especially in the first week. As a rule, they do not exceed 1°,
but Lebert lays stress upon the fact that in the same curve variations
from 0.3° to 1.8° and from 0.6° to 2.1° often occur. Cases which
terminate fatally are generally characterized by high fever, with
absence of the morning remissions, which may continue uninterruptedly
through the second and even the third week. During the death-agony
there is frequently a rise of temperature of two or more degrees. A
very high temperature in the first week is often the forerunner of
severe cerebral symptoms in the second, and a fall of temperature
unaccompanied by an improvement in the other symptoms is not always
indicative of the approach of convalescence.
[Footnote 23: _On the Temperature in Disease_, New Sydenham Society's
translation, London, 1871.]