the attack, and may persist until its close. It is not, however,
usually attended by the same repugnance for food as in other fevers.
Patients can generally be persuaded at first to take nourishment.
Indeed, Dr. Gerhard asserts that the negroes who fell under his care
in 1832 frequently asked for solid food. Nausea and vomiting are rare
symptoms; the latter may occur late in the disease, and then, not
infrequently, is caused by irritation of the brain. Thirst is present
in all cases. In the later stages of the disease, when the senses are
blunted, water may not be asked for, although urgently called for by
the condition of the system. The bowels are, as a rule, constipated in
this disease. The exceptions to this rule are, however, more numerous
than is usually thought. Wood[24] says that he has frequently seen
diarrhoea in typhus fever when it occurs in recently-arrived
immigrants. Da Costa[25] mentions that it has occurred in several of
the cases which have come under his care, and Buchanan[26] says that
he has observed it in at least one-third of the patients admitted into
the London Fever Hospital in recent years. When there is no diarrhoea
the stools are of normal color and consistence. When it exists they
are watery and usually dark greenish in color, and never present the
peculiar ochrey-yellow appearance seen in typhoid fever. They are said
to be alkaline in reaction. Tympanites is rare in typhus fever. It may
be present in cases in which there is diarrhoea, and may then be
associated with gurgling in the bowels, but rarely attains the degree
common in typhoid fever. Gurgling when present is, moreover, not
confined to the right ileo-cæcal region, but may be produced in
different parts of the abdomen by pressure. There may also be
tenderness in the epigastric and hepatic regions, but the enlargement
of the spleen so constantly observed in typhoid is generally wholly
wanting in this fever.
[Footnote 24: _Loc. cit._]
[Footnote 25: _Loc. cit._]
[Footnote 26: _Loc. cit._]
The tongue in the beginning of the disease is covered with a thin
whitish fur and is moist, and may continue so throughout in mild
attacks. Generally, however, it soon becomes dryish, and in bad cases
absolutely dry, and is tremulous when put out of the mouth, while its
coating becomes thicker and brownish, and finally brown, or even black
and cracked. It is rare to see the tongue itself fissured as in
typhoid fever. Less frequently it remains red, smooth, and glazed
throughout the attack. Occasionally the tongue is contracted in bulk,
and it may {351} then, in consequence of its dryness and that of the
mouth, be impossible to protrude it. Sordes frequently collect about
the gums and lips in severe cases.
The pulse is usually increased in frequency in typhus fever, and
varies from 100 to 120, but in many cases it never rises above 90, and
in very severe cases it may be as high as 150. This increase is
observed from the beginning, and generally bears some proportion to
the severity of the fever; but toward the close, when the prostration
is great, the pulse may continue frequent even after a fall in
temperature has taken place, and is always more frequent when the
patient is sitting up than when he is lying down. Occasionally,
however, a very slow pulse is associated with symptoms of great
severity. When this association occurs the prognosis is grave. In the
young and robust the pulse may be full and bounding, but it is more
often compressible or small and weak. It is not so often dicrotic as
in typhoid fever. There is sometimes, according to Lyons, a singular
want of uniformity in the force and volume of the arterial pulse in
different parts of the system, and there may be but one pulsation at
the wrist for two of the heart. A very sudden fall in the frequency of
the pulse without an improvement in the other symptoms is not a
favorable indication, as it may be due to impaired innervation or to
degenerative changes in the muscular tissue of the heart. Usually the
beginning of convalescence is marked by a gradual fall of the pulse.
Later it may fall to 50 or below it, and continue slow for some time,
just as it does in typhoid fever.
The heart shares in the general enfeeblement of the system. In severe
attacks the impulse soon becomes weak and diffused, and may be
entirely absent for some time even in cases which eventually terminate
in recovery. Stokes long ago called attention to an alteration in the
systolic sound of the heart which he taught indicated the urgent
necessity for the administration of stimulants. This sound is observed
in the progress of the disease to become shorter and less distinct,
and finally inaudible, while the second sound is unaffected. This
modification of the heart-sounds is always an accompaniment of great
prostration. Occasionally the first sound is replaced by a functional
murmur.
The characteristic eruption of the disease is generally preceded by
the fainter subcuticular mottling already alluded to, and usually
appears between the fourth and seventh days, but it has been observed
as early as the third day, and, on the other hand, its appearance is
said by Wood to have been delayed until the thirteenth. It consists of
minute spots with ill-defined margins, varying in size from that of
the point of a pin to two or three lines in diameter, irregular in
shape, slightly elevated above the skin at first only, and occurring
singly or in groups. They are pinkish in color, and disappear readily
under pressure when first observed. They may then, as Gerhard and
others have pointed out, present a considerable resemblance to the
rose-colored spots of typhoid fever. In the course of twenty-four
hours they become brownish, and later, when the attack is a severe
one, livid in color. In malignant or even severe cases they are
frequently converted into true petechiæ. They do not appear in
successive crops, but usually require a couple of days for their full
development. Their duration is variable. In mild attacks they may
disappear in the course of a few days, but in bad cases often {352}
persist until after convalescence, and are recognizable after death.
They are confined to no part of the body, but appear usually earliest
and most abundantly upon the folds of the axilla and upon the abdomen.
Occasionally, however, they are first observed upon the wrists, and in
some cases are more numerous upon the arms and legs than upon the
body. They are rarely found upon the neck and face, but in children
the latter may be so much covered by them that the disease may be
readily mistaken for measles. They present some resemblance to
flea-bites, but the latter may be easily distinguished from them by
the minute discoloration in the centre left by the puncture of the
insect. The eruption is oftenest wanting in young subjects. It is
usually, but not invariably, most copious in severe attacks, but cases
have ended fatally in which it was wholly wanting from beginning to
end. Its color is also to a certain extent an index of the severity of
the attack; the darker and more livid it is, the graver the prognosis.
In malignant cases or those complicated by scurvy, in addition to the
petechiæ above referred to, purpura spots and vibices are not
infrequently observed. Some authors assert that the eruption is
followed by a slight desquamation of the cuticle, but this is denied
by others. Sudamina occasionally occur, but they are much rarer than
in typhoid fever. The blue spots described by the French under the
name of tâches bleuâtres are also sometimes met with.
A very disagreeable odor is exhaled from the bodies of typhus-fever
patients after the first week. Although readily recognizable by those
who have once perceived it, it is difficult to describe. Gerhard spoke
of it as pungent, ammoniacal, and offensive, especially in fat,
plethoric individuals, and believed that those patients who presented
this symptom in the highest degree were most likely to communicate the
disease to others. Murchison has also expressed the opinion that the
typhus poison is associated with this odoriferous substance. Others
have compared the odor to the smell given off by rotten straw, the
urine of mice, and various other substances. Wood says that he has
often perceived the same odor in badly-ventilated rooms in which a
number of people have been shut up together for some time.
The sensibility of the skin in cases in which the stupor is not so
great as to render the patients insensible to all external impressions
is said by some writers to be much increased. There is also
occasionally so much tenderness in the epigastric region as to give
the impression at first to the attendant that there is inflammation of
the stomach or liver.
Pulmonary complications are quite frequent in typhus fever, and, as
they often come on insidiously and give no evidence of their presence
by cough, expectoration, or even more hurried breathing, that is often
seen in uncomplicated cases, it is well to make it a rule to examine
the chest of every patient with this disease. To do this thoroughly it
is not necessary to make him sit up, which, where great prostration
exists, is often attended with danger. If he be turned gently upon his
side the auscultator will usually have no difficulty in ascertaining
the precise condition of his lungs.
The respiration is usually much more frequent in this disease than in
health. Even in cases in which there is no disease of the lungs it is
often as high as 30, and in cases in which there is such a
complication it may be 60. Its frequency is generally proportional to
the severity of {353} the fever. On the other hand, in grave cases in
which cerebral symptoms are predominant it may be reduced in frequency
much below the normal. When coma or profound stupor exists, it may
become jerking and spasmodic, or even simulate the stertorous
respiration of apoplexy. Bronchitis, if not of such constant
occurrence as in typhoid fever, is certainly not rare. It usually
occurs early in the attack, and makes itself known by the presence of
sonorous and sibilant râles, which give place later to mucous râles.
Expectoration is often absent in these cases; where it exists the
sputa are either mucous or muco-purulent. In mild cases no further
lesion of the lungs occurs. When the attack is more severe hypostatic
congestion is very likely to supervene. This is a condition which is
often attended with danger, and which frequently, as has been said
already, escapes recognition unless the chest be thoroughly examined,
when dullness on percussion, feeble respiration, and subcrepitant
râles may readily be detected. Occasionally the physical signs
indicate the existence of pneumonia. This, when it occurs in the
course of this disease, is always of low grade, and is attended by the
expectoration of mucus streaked with blood.
The breath of the typhus-fever patient has a very disagreeable odor,
not unlike that given off from the body, and is said by Murchison to
contain an increased amount of ammonia.
According to Parkes,[27] the changes in the urine are those usual in
ordinary pyrexia. During the fever it is generally diminished in
quantity, dark in color, and of high specific gravity. It contains an
increased amount of urea and of uric acid, the latter of which is not
infrequently spontaneously precipitated. Sulphuric acid is also in
excess. On the other hand, the chlorides are diminished in amount or
entirely absent. This diminution cannot be ascribed to a decrease in
the quantity ingested, for when they are administered with the food
they are not found to be eliminated by the kidney. The amount of
phosphoric acid does not appear to be affected by the disease. The
urine is acid in reaction at first, but its acidity soon diminishes,
and it may become alkaline toward the close of bad cases. It may also
contain albumen, or even blood, the former being present oftenest in
cases characterized by high temperature. According to Da Costa,
tube-casts are more often present than absent in severe cases. Those
seen by this observer were either coated with rather opaque epithelial
cells, many of which were finely granular or covered with granules,
which, when tested with reagents, were sparingly soluble in acetic
acid, and which with very high magnifying powers did not present the
round shape of oil, and were probably the urinary salts collected in
the tube-casts. The crisis is sometimes marked by a copious deposit of
urates. During convalescence the urine is usually increased in
quantity, is pale and limpid, and of low specific gravity, and is
found to contain the chlorides in gradually increasing quantity.
[Footnote 27: _The Composition of the Urine, etc._, by Edmund A.
Parkes, M.D., London, 1860.]
VARIETIES.--Many of the varieties of typhus fever recognized by
authors--as, for example, jail fever, ship fever, camp fever, and
hospital fever--really differ in nothing but name and the
circumstances under which the disease has arisen. Others are mere
modifications of it, due to the predominance of one symptom or of a
certain set of symptoms or to the intercurrence of a particular
complication, and likewise do not {354} need a full description here.
To this latter class belong the inflammatory typhus, the nervous or
ataxic typhus, the adynamic typhus, and the ataxo-adynamic typhus of
Murchison. The first variety occurs in young and robust subjects, and,
it is also said, in persons of the upper class. It is characterized by
high fever, intense headache, and active delirium. In the second
variety the nervous symptoms, such as delirium, somnolence, stupor,
and muscular tremblings, are the most prominent. The most marked
feature of the third variety is the excessive prostration, which is
shown in the feebleness of the heart's action and the loss of muscular
strength and of control over the sphincters. In this form the eruption
is dark colored. Purpura spots and vibices also are very apt to
appear, and even hemorrhages from the gums, nose, or other parts to
occur. In the ataxo-adynamic form the symptoms of the ataxic and those
of the adynamic form are found united. In addition to these there are
certain other varieties, arising from differences in degree. These
differences are sometimes owing to diversities in the constitution and
habits of the patient, sometimes to variations in the character of the
epidemic, and are sometimes not readily explainable. One of these is
the mild form, in which the symptoms are those of moderate fever, and
in which the disease may run its course in seven days. In this form
the temperature may never rise above 102° F., the eruption be absent
or very scanty, and the characteristic stupor or dulness be wholly
wanting. Unless complications arise recovery invariably takes place. A
walking form of typhus fever, as has already been said, is much rarer
than of typhoid, but it does sometimes occur, Dr. Buchanan having
often seen the eruption out upon patients who have walked to the
London Fever Hospital to seek admission. In this form the disease,
however, does not always run a mild course, as alarming prostration is
very apt to come on later in its course. Another variety, the abortive
form, has been described by authors. In this an individual, in due
time after exposure to the contagion, may present all the
characteristic symptoms of typhus fever, but the disease, instead of
running its usual course, may terminate abruptly with a critical
discharge of some kind. This form occurs during epidemics, and is
analogous to the abortive attack of scarlet fever or some other
diseases which are occasionally met with. On the other hand, a very
severe form, the typhus siderans of authors, also sometimes occurs. In
this variety the temperature rises rapidly, and soon attains its
maximum; there are frequent pulse and respiration, severe headache,
and early delirium and stupor. The mortality in this form is very
great. Very frequently death takes place so rapidly as often to leave
the physician in some doubt as to the nature of the disease in those
cases in which exposure to the contagion cannot be positively traced.
COMPLICATIONS AND SEQUELÆ.--The complications of typhus fever often
exercise a decided influence upon the course of the disease, for they
not only retard convalescence, but are often the immediate cause of
death. Their early detection, therefore, becomes a matter of the
greatest importance. They will be found to vary in different years,
one epidemic being characterized by complications which are entirely
wanting in the next. Among the commonest of them are several different
conditions of the respiratory organs. Bronchitis, if not quite so
frequent as in typhoid fever, occurs in a large number of cases. It
may come on at any stage {355} of the disease, either immediately
after the beginning of the attack or in its course, or not until
convalescence. In cases accompanied by prostration mucus may
accumulate in the bronchial tubes, and be the cause of the patient's
death by preventing the due aëration of the blood. It would seem to be
an especially frequent complication in Ireland, and it is rather
surprising that so acute an observer as Graves appears not to have
been aware of its real relation to typhus, and speaks of it as if it
were a predisposing cause. "Nothing can be more remarkable," he says,
"than the facility with which a simple cold, which in England would be
perfectly devoid of danger, runs into maculated typhus in Ireland, and
that, too, under circumstances quite free from even the suspicion of
contagion; in truth, except when fever is epidemic, taking cold is its
most usual cause." A much more serious complication than bronchitis is
the form of pneumonia already alluded to as liable to occur in the
course of typhus. This may often occur so insidiously that it may be
considerably advanced before its presence is even suspected; hence the
necessity for examining carefully the lungs of every patient with this
disease who comes under our care. Generally, however, it makes itself
known by giving rise to rapid breathing and great lividity of the
surface, but, as has already been said, both of these symptoms may
exist in cases in which there is no chest complication. This
pneumonia, if it does not immediately prove fatal, may, by becoming
chronic, retard the convalescence. It occasionally is followed by
gangrene, and sometimes by phthisis, which may then run a very rapid
course. Phthisis is, however, a much less frequent sequela of typhus
than of typhoid fever. Pleurisy may also complicate typhus fever, but
it is much more rarely met with than pneumonia.
Perhaps next in frequency to pneumonia and bronchitis are diseases of
the kidneys. These are very serious complications, whether they
antedate the fever or have occurred in its course. Careful examination
of the urine will generally lead to the discovery of a small amount of
albuminuria in bad cases, but this is fortunately, in the majority of
them, only temporary. The urine should, however, always be re-examined
before the discharge of the patient, as there is good reason to
believe that many otherwise inexplicable cases of chronic albuminuria
have originated in an attack of typhus. The presence of albumen and of
casts in the urine of a patient apparently convalescent from this
disease should therefore make us careful in our prognosis as to his
future health. The occurrence of diarrhoea may also very seriously
affect the patient's chances of recovery. Dysentery has also been
observed in certain epidemics in Ireland, and is not infrequent when
the disease breaks out in besieged towns or when it occurs in summer.
In grave cases or those complicated with scurvy the blood may be so
broken down as to escape readily from the vessels. Under these
circumstances, in addition to the purpura spots beneath the skin, we
may have epistaxis, hæmoptysis, hæmatemesis, intestinal hemorrhage, or
hemorrhage from any other part. Erysipelas, too, may be a troublesome
complication, for not only does it exhaust the strength, but, when it
invades the mucous membrane of the larynx, as it sometimes does, it
may prove rapidly fatal by producing oedema of the glottis.
Degeneration of the muscular structure of the heart may also take
place. This gives rise to a slow and feeble pulse and to a disposition
to syncope. Bed-sores are not so frequent as in typhoid fever. They
{356} do, however, sometimes occur, as does also gangrene of the toes
and of other parts not subjected to pressure.
Less common complications are jaundice, peri- and endo-carditis,
meningitis, local and general paralyses, cancrum oris, a diffuse
cellular inflammation ending in purulent infiltration, and
inflammatory swellings of the glands, or buboes. The salivary
glands--and especially the parotid gland--are very apt to be affected
by this inflammatory swelling. This occurs rapidly, is very tender,
and in most cases soon runs on to suppuration, although it
occasionally in children spontaneously subsides. It may occur at any
time during the course of the fever, or not until convalescence, and
sometimes affects the glands of both sides of the face. These buboes
form a connecting link between typhus fever and the Oriental plague,
and Murchison says that the distinguished Egyptian physician Clot Bey,
on seeing some cases of the former disease complicated with parotid
swellings, declared that in Egypt they would be regarded as examples
of the latter.
Many of the above-named complications may occur also as sequelæ, and
in addition to these we may have pyæmia, giving rise to purulent
collections in the joints and phlegmasia alba dolens. The last named
is not in itself serious. Its chief danger is from the breaking down
of the clot and the subsequent occurrence of embolism.
Menstruation is said not to be uncommon in the early stages of typhus
fever, and may be so profuse as to greatly increase the prostration or
even to cause death. According to Murchison, miscarriage does not
inevitably occur when pregnant women are attacked with the disease,
and if it does occur it is not necessarily fatal to either mother or
child.
POST-MORTEM APPEARANCES.--Emaciation when death has occurred early in
the course of the disease, and is due solely to the violence of the
fever, is usually not well marked, but in those cases which have been
protracted through the intercurrence of complications it may sometimes
reach an extreme degree. Bed-sores, except under the circumstances
just mentioned, are also rare. Rigor mortis is generally not well
developed, and is of short duration. In a few cases it would seem,
however, to have been well marked. The typhus maculæ are persistent
after death, and so are any purpura spots and vibices which may have
been present during life, but the subcuticular mottling usually
disappears. The skin of the dependent portions of the body is
discolored by the settling of blood in it, and putrefactive changes
are apt to set in rapidly.
The only constant lesion observed is a profound alteration of the
blood, which is darker in color and abnormally fluid. If clots are
found at all, they are large, soft, and friable. The fibrin is
diminished in amount. In the early part of the disease the red
blood-corpuscles are said to be slightly increased in number, but
later they are diminished, and under the microscope are observed to be
crenated and not to form themselves readily into rouleaux. The white
corpuscles are increased in number. No accurate chemical examination
of the blood appears to have been made. Many of the post-mortem
appearances which have been described as characteristics of typhus
fever are really the consequence of this abnormal condition of the
blood.