lesions of laryngitis, bronchitis, pneumonia, hypostatic congestion of
the {357} lungs, and pleurisy have all been observed after death from
typhus fever. Usually, the traces of previous inflammation of the
larynx are but slight; in a few cases, however, ulceration has been
found, but the ulcers are stated to be always minute and superficial.
Ulcers are also occasionally found in the bronchi, and frequently
indicate by their appearance the pre-existence of a much higher grade
of inflammation. The bronchial mucous membrane is, however, oftener
merely reddened and softened and covered with a tenacious frothy
secretion. True pneumonia is of infrequent occurrence as compared with
that of hypostatic congestion of the lungs, but it nevertheless does
occur, and may be of either the catarrhal or croupous variety. When
pleurisy exists, it is usually accompanied, according to Murchison, by
purulent effusion into the pleural cavity. On the other hand, Lebert
says the variety of inflammation of the pleura oftenest met with is
the plastic. The intestines present no constant lesion. Gerhard says
that in fifty examinations there was but in one case, and that
doubtful in diagnosis, the slightest deviation from the natural
appearance of the glands of Peyer. In a few cases the Peyer's patches
have been found more prominent than usual, but not more so than they
are in measles and in some other diseases. Lebert alone of recent
authors makes a contrary statement. In an epidemic at Breslau, he
says, the solitary glands, as well as the patches of Peyer, were the
seat of small, isolated, and superficial ulcers, which were usually
situated in the vicinity of the ileo-cæcal valve. The mesenteric
glands are generally unaffected, but in the Breslau epidemic just
referred to they were not infrequently found moderately swollen. In
cases in which dysentery has occurred as a complication the
characteristic appearances of the disease will of course be observed,
as well as those of typhus fever. The spleen is generally softened and
slightly enlarged. The enlargement is not, however, always present, as
Gerhard found it in one only out of every five or six of the cases
which he examined. Extravasations of blood into its structure are
occasionally met with. The liver is usually congested, somewhat
enlarged, and frequently under the microscope presents the appearances
of commencing fatty degeneration. The kidneys often present
unmistakable signs of renal disease in the swollen granular and more
or less fatty condition of their gland-cells according to the duration
of the disease. The muscles are darker in color than in health. Under
the microscope they are found to have undergone the peculiar granular
or waxy degeneration described by Zenker, and which have been fully
referred to in the article on typhoid fever. Extravasations of blood
are occasionally found in them, which may soften and form
pseudo-abscesses.
Other post-mortem appearances which are met with less frequently than
those above detailed are inflammation, and even ulceration, of the
mucous membrane, of the bladder, inflammation of the salivary gland,
peritonitis, and congestion of the pancreas and of the stomach.
The muscular tissue of the heart is generally softened and easily
torn. It is not, however, as stated by some authors, invariably so,
for in several cases in which it was examined by Da Costa it had
undergone this change in one case only, in which there was no reason
to suspect previous disease of the heart. The alteration is similar in
kind to that which takes place in the voluntary muscles. An effusion
of serum, which may be of a deep-red color from the transudation of
the coloring matter of the blood, is {358} sometimes found in the
pericardial sac, as are ecchymotic patches upon the surface of the
heart. The endocardium may be stained from the imbibition of blood. On
the other hand, endo- and peri-carditis are excessively rare.
Notwithstanding the severity of the cerebral symptoms in typhus fever,
there are few or no important changes found in the brain or its
membranes after death. The sinuses are occasionally filled with dark
fluid blood, and the appearances of congestion of the brain are
sometimes present. In other cases there may be an increased amount of
serum beneath the arachnoid and into the lateral ventricles, but not
more than is often seen after death from other causes. Very rarely a
slight film of hemorrhage has been found in the cavity of the
arachnoid, and sometimes also the evidences of non-inflammatory
softening of the brain. Actual inflammation of the meninges has only
been detected in a very few cases. There may also be congestion of the
spinal membranes, increase of the spinal fluid, and softening of the
cord itself. The ganglia of the sympathetic system appear to undergo a
form of granular degeneration.
DIAGNOSIS.--The diseases which most closely resemble typhus fever are
typhoid fever, measles, meningitis, and typhoid pneumonia.
The circumstances under which typhoid and typhus fever occur are
different. Typhoid is never generated by overcrowding, and if
contagious at all is much less so than typhus. Prostration occurs much
earlier and is usually much more marked in the latter. The eruption in
the former does not appear until the eighth day, and comes out in
successive crops, and usually disappears under pressure as long as it
lasts, and therefore may be easily distinguished from that of the
latter. The duration of typhus is from ten to twenty days; that of
typhoid is rarely less than twenty-one. Nevertheless, cases are
occasionally met with in which it is impossible to arrive at a correct
conclusion as to their nature unless some light is thrown upon it by
the existence of other and more characteristic cases in the same house
or neighborhood. I have recently had under my care a case which
eventually proved to be typhoid fever, but which I and many others who
saw it at first believed to be typhus in consequence of the presence
of an abundant eruption, which did not disappear under pressure, and
was finally converted into petechiæ.
The eruption of typhus is sometimes found upon the face, especially in
children, and then presents a considerable similarity to that of
measles, which, however, usually appears a little earlier. There is,
moreover, rarely the same amount of prostration or stupor in the
latter disease, which is also attended by coryza and more bronchial
catarrh than is often present in the former. The eruptions in the two
diseases differ. In measles it is crescentic in shape, and is more
elevated than in typhus. It is also brighter in color, disappears
under pressure, except in malignant cases, as long as it lasts, and is
followed by free desquamation of the cuticle, which is not often
observed in typhus. The temperature may be high in the former, but it
usually falls upon the sixth day.
In meningitis the headache is much more severe, and does not disappear
upon the occurrence of delirium. It may be so severe as to cause the
patient to cry out. The senses are painfully acute. There are
intolerance of light and sound, and some hypersensitiveness of the
surface, {359} strabismus, inequality of the pupils or some other
local paralysis, and retraction of the head. Nausea and vomiting are
more common than in typhus, while the utter prostration of the latter
disease is wholly wanting, and so is of course the characteristic
eruption. The tâche meningitique is wanting in the latter, but too
much reliance should not be placed upon either the presence or absence
of this sign. The diagnosis is only likely to be difficult in those
cases of typhus in which the delirium is active. In that form of
typhus in which the symptoms simulate those of delirium tremens some
difficulty may also be experienced in making a diagnosis, especially
if the patient be a drunkard. In delirium tremens it will be
remembered, however, that there is little or no elevation of
temperature, that the skin is bathed in perspiration, the tongue
moist, and the characteristic eruption absent. Typhoid pneumonia can
be distinguished from pneumonia complicating typhus fever by the
presence of the eruption in the latter.
Other diseases which have occasionally been mistaken for typhus fever
are remittent fever, Bright's disease, giving rise to uræmia and
purpura. It does not seem likely that even the severest forms of
malarial fever should ever present such a resemblance to typhus fever
as to make the differential diagnosis a matter of difficulty; but it
would appear from the history of the latter disease given by Murchison
that such a mistake has occurred in some of the Spanish American
countries. The enlargement of the spleen and liver is much less marked
than in remittent fever, and the remissions of temperature are much
less decided. Uræmia may at times present a good deal of resemblance
to the condition often seen in typhus fever after the supervention of
coma or stupor, but the history of the case, the absence of fever and
of eruption in the former, will generally enable us to distinguish
between the two conditions. It should be remembered, however, that
Bright's disease may occur in the course of typhus fever. Purpura may
generally be recognized by the absence of fever and by the occurrence
of hemorrhages from the nose, gums, and bowels.
PROGNOSIS.--The age, habits of life, and previous condition of health,
as well as the character of the prevailing epidemic, must all be fully
considered before making a prognosis in any special case. The disease
usually runs a much milder course in children and young people than in
adults past thirty years of age. After this age the mortality
progressively increases, and in advanced life it becomes very high,
being often as much as 50 per cent. or over. Sex does not of itself
exercise much influence upon the course of typhus fever, for, although
a few more men than women die of it, this appears to be attributable
to the greater prevalence of drinking among the former. Previous
intemperance acts unfavorably by producing a degeneration of the
tissues of the body, thus rendering the patient less able to withstand
the effects of the disease. Drunkards have therefore always furnished
a large proportion of the fatal cases. The mortality among patients
who are unfortunate enough to take typhus fever as they are
convalescing from other diseases is usually also very great. This has
often been observed in general hospitals in which cases of fever as
well as those of other forms of disease are admitted. Fat, lymphatic,
or muscular people more frequently die of it than those of a different
conformation. Gerhard found it especially {360} fatal among negroes in
the epidemic of 1836, and Buchanan seems to have had a similar
experience at the London Fever Hospital. It is a fact noticed by
English writers that people of the better class, although seldom
attacked by typhus, often suffer severely from it. The mortality is
always high among those patients who previously to contracting the
disease have been for some time deprived of sufficient food, or have
been overworked, or who have been the subjects of mental anxiety,
worry, or any other depressing emotion. It is high also among those
who in the beginning of the disease have exhausted their strength in
the vain effort to resist the disposition to go to bed. The chances of
recovery are, on the other hand, very much improved by the removal of
patients from crowded, ill-ventilated houses to the wards of a
spacious, airy hospital.
Unfavorable symptoms are a profuse dark-colored eruption associated
with purpura spots and vibices, general lividity of the surface, great
injection of the pupils, and a dusky hue of the countenance; extreme
prostration; an excessively frequent and feeble pulse, especially if
it is at the same time irregular or intermittent; absence of the
cardiac impulse and of the systolic sound; hurried and spasmodic or
abnormally slow respiration; great dryness and retraction of the
tongue; excessive prominence of the nervous symptoms, such as
headache, delirium, whether active or muttering; unequal or pin-hole
contraction of the pupils; strabismus or other local paralysis;
sleeplessness; muscular tremblings; subsultus tendinum; carphology;
protracted hiccough; retention of the urine; relaxation of the
sphincters of the bladder and rectum; coma and especially coma vigil,
and convulsions; continued high temperature, rising instead of falling
after the tenth day, especially if it is associated with coldness of
the extremities and of the breath; a profuse perspiration without a
general improvement in the symptoms; diminution in the quantity of the
urine, or the presence in it of albumen, blood, or casts; vomiting;
and diarrhoea. Hope, however, should never be abandoned even in the
most unfavorable cases, as recovery has sometimes occurred when the
patient seemed almost in articulo mortis. Convulsions are said to be
invariably followed by death, and Graves regarded the presence of the
pin-hole contraction of the pupils as of very grave import.
Favorable symptoms are--reduction of the frequency of the pulse, a
fall of temperature, a diminution of the stupor or a resumption of
consciousness, and a return of appetite and of moisture to the tongue.
When the patient begins to improve he will often without assistance
turn upon his side after having lain for a long time upon his back,
and this change of position is sometimes the first indication of the
approach of convalescence.
The mortality varies of course in different epidemics. The cases which
have come under my own care being too few in number to draw deductions
from on this point, I must rely upon the experience of those whose
field of observation has been more extended than my own. According to
Murchison, out of 18,268 cases of typhus fever admitted into the
London Fever Hospital during twenty-three years, 3457 proved fatal,
making a mortality of 18.92 per cent., or 1 in 5.28. Deducting 686
cases fatal within forty-eight hours, the mortality falls to 15.76 per
cent., or 1 in 6.34. Included among the fatal cases is a large number
in which {361} the disease had run its course to a favorable
termination, and in which death was really due to sequelæ, such as
pneumonia, erysipelas, etc. Moreover, the death-rate in the hospital
is greater than in the community, because children, who rarely die of
typhus fever, are seldom brought to it; while, on the other hand, it
receives a large number of the infirm and aged inmates of the
metropolitan workhouses. Making allowance for these sources of
fallacy, Murchison believes that the actual mortality of typhus is not
more than 10 per cent. In Gerhard's cases the proportion of deaths
amongst the black was much greater than amongst the white men; thus,
of the whites 1 died in 4-2/3, of the blacks 1 in 2-19/28. Amongst the
women the reverse was true; thus, 1 white woman died in 4-3/5, but
only 1 colored woman in 6-1/2, nearly. Da Costa lost 6 out of 39
cases. In one of the fatal cases the diagnosis was doubtful; in
another there was a great deal of previous disease; in two others
death was due to complications--so that there were but two in which
the fatal result could fairly be attributed to the disease itself.
TREATMENT.--Typhus fever is an eminently preventible disease. It is
therefore proper that the description of its curative treatment should
be preceded by a few words in regard to its prophylaxis.
It is still an unsettled question whether or not typhus fever ever
occurs de novo, and although the recent discovery by Klebs and others
of bacillus peculiar to typhoid fever (the bacillus typhosus), and of
special bacilli in other analogous diseases, renders it highly
probable that typhus fever has also its own bacillus, and that
therefore it is not likely to arise except as the result of infection,
it must be admitted that it has often prevailed in localities into
which it has not been possible to trace its importation. Under these
circumstances it will be well to refer to those conditions which are
asserted by some authors to favor its spontaneous generation,
especially as these same conditions are certainly known to favor its
propagation. It will not be necessary to do this at any great length,
as they have all been fully described in discussing the etiology of
the disease. The most important of them is the overcrowding of human
beings, especially when combined with deficient ventilation,
destitution, and want of personal cleanliness. The knowledge of the
laws of hygiene is now so universally diffused that this combination
of conditions never occurs at the present time to anything like the
degree it often existed in the eighteenth century, and consequently
epidemics of this disease are not only less frequent, but are also
much milder in character, than formerly. Much work, however, still
remains for sanitarians in the improvement of the homes of the poor,
which even in this country are too often overcrowded and
ill-ventilated.
The extension of the disease in a community will almost always be
prevented by the prompt isolation of the first few cases. This can
often be thoroughly done, if the patient is in easy circumstances, by
placing him in an upper room, which should be stripped of its carpets,
curtains, and other unnecessary furniture; by cutting off all
communication between him and his attendants and the rest of the
household; and by the free use of disinfectants. The room should be
airy, and to ensure good ventilation a window should be left partly
open. This may be done during the febrile stage, even in winter,
without the risk of any injury to the patient. Among the poorer
classes, however, {362} isolation can rarely be effectually carried
out, and it is therefore much better to remove the patient to a
hospital. Upon the admission of such a patient to an institution of
this character his clothes should be at once disinfected. This may be
done by washing the underclothing in a disinfecting fluid, and then
exposing them to a free current of air, and by subjecting the outer
clothing to a very high temperature in an oven or to the fumes of
burning sulphur. Murchison believes that a neglect of this precaution
has often been the cause of the extension of the disease to other
inmates of the hospital, especially when the patient resumes during
his convalescence the same clothing he wore upon admission. If the
hospital is a general one, he should be placed, whenever practicable,
in a well-ventilated ward by himself or with other patients suffering
from the same disease. As this is not always possible, the number of
the other occupants of the ward should be reduced and their beds
placed as far away as possible from his. As the infectiousness of
typhus fever is very much lessened by free ventilation, this
precaution is often alone sufficient to prevent its extension to them.
It is also well, however, to supplement it by the use of
disinfectants. The diffusion of a solution of carbolic acid in the
atmosphere of the ward by means of the steam atomizer has not only
rendered the odor emanating from the patient less perceptible, but has
also appeared to diminish decidedly the risk of infection. As a still
further precaution the patient may be sponged with a weak solution of
carbolic acid or some other disinfectant. His nurses should be
selected, whenever practicable, from among those who have had the
disease themselves. They should never sleep in the sick room, lounge
about the patient's bed, or inhale his breath. They should be allowed
a certain amount of time every day for rest and recreation in the
fresh air, and should have a full supply of nourishing food. On the
other hand, they should be warned against the danger of
over-stimulation, which is often resorted to in the hope of warding
off the disease, and should be relieved as far as possible from
attendance upon other patients. It may be well here to say that the
nursing of a case of typhus fever should never be undertaken by the
relatives or friends of the patient, except as a matter of necessity.
Not only do the anxiety and distress they naturally feel unnerve them
and render them unfit to carry out the directions of the physician,
but they can rarely execute the many offices required in the sick room
with half the skill of a trained nurse or with so little annoyance to
the patient.
Before the patient is allowed to leave his ward he should have a warm
bath. If the disease has occurred in a private house, the room which
he has occupied should be thoroughly disinfected. This is best done by
replastering, repapering, and repainting it. In many cases, however,
it will be sufficient to fumigate it with burning sulphur, and then to
air it for several days. The bed and bedding should also be
disinfected, and, where this cannot be thoroughly done, the latter had
better be destroyed.
Of primary importance in the treatment of typhus fever is the
regulation of the diet. Although there are no ulcers in the bowels in
this as in typhoid fever, and although, consequently, there is not the
same imperative necessity in this as in the latter disease to restrict
the patient to liquid articles of food, experience has shown that such
articles are much more readily digested and assimilated than solids.
The diet {363} should consist, therefore, of milk, beef-tea, and
chicken or mutton broth. Of all of these, milk is incomparably the
best, and it should form, unless the patient manifest an unconquerable
repugnance to its use, a large part of the nourishment in every case.
Farinaceous articles of food are generally not well borne in this
fever, because the diminution in the secretion of the salivary glands
which almost always exists prevents their proper digestion. After the
third or fourth day nourishment should be given in small quantities at
short intervals, as every two hours, every hour, or even every half
hour when the prostration is extreme. It should be the aim of the
physician to give an adult at least two quarts of milk or their
equivalent daily.
It is sometimes necessary to put a delirious patient under some
restraint to prevent him from leaving his bed or doing some other act
of violence. Frequently a judicious nurse will be able to accomplish
this without the use of an undue amount of force, but at other times
it will be necessary to have recourse to mechanical means of
restraint. Usually, all that is necessary is to pass a folded sheet
across the patient's chest, the ends of which are fastened to the
sides of his bed.
It is now a universally accepted axiom among physicians that typhus
fever is a self-limited disease, and that any attempts to cut it short
is worse than useless. Not only do remedies which are employed for
this purpose often produce alarming prostration, but there can be no
doubt that they have in some cases been the cause of a fatal
termination, which under another plan of treatment would have been
averted. During the last century it was not uncommon to bleed, and to
bleed largely, in the beginning of an attack of typhus fever, but even
then there were physicians--as, for instance, O'Connell, Rogers,[28]
Pringle,[29] and Rutty[30]--who raised a warning voice against the
practice. Sir John Pringle goes so far as to say that "many have
recovered without bleeding, but few who have lost much blood." A very
similar opinion was also expressed by Baron Larrey in the early part
of this century. Indeed, it is very evident that the same difference
of opinion existed as to the employment of venesection in the
treatment of acute affections when these authors wrote as prevailed in
England and this country until within the last thirty years, and that
the disastrous results which occasionally follow the abstraction of
large amounts of blood from patients affected with fevers and
inflammations were as fully recognized then as now by many physicians.
This would seem effectually to dispose of the
change-of-type-in-disease theory which was generally accepted in the
first half of this century as sufficient to explain the fact which
could no longer be overlooked that this class of patients did much
better under a supporting than a depleting plan of treatment.
Purgatives were also at one time freely given for the purpose of
arresting the disease, but the results obtained from their use were
scarcely less unfavorable, and they are now never employed with this
view. The use of quinia in large doses has also been advocated for the
same purpose, but experience, while it has shown that it is a valuable
remedy, has demonstrated also that it does not possess {364} this
power. Exactly the same thing may be said of the cold-water treatment
of typhus fever. There is no evidence that it has ever shortened the
duration of the disease.
[Footnote 28: _An Essay on Epidemic Diseases_, p. 60, by Joseph
Rogers, M.D., Dublin, 1734.]
[Footnote 29: _Loc. cit._]
[Footnote 30: _A Chronological History of the Weather and Seasons, and
the Prevailing Diseases, in Dublin during the Space of Forty Years_,
by John Rutty, M.D., London, 1770.]