Chapter XIX: Part II: , Showing Predominance of Malarial Element . . . . 617 (18)

Typhus fever has a course which is so essentially different from {312} that of typhoid that in well-marked cases it would scarcely be possible to mistake one for the other. Cases, however, do occur which, in consequence of a very profuse and dark-colored eruption in the latter, or of the existence of abdominal symptoms in the former, present at first a good deal of difficulty in diagnosis. The invasion of the former is more abrupt and its duration shorter than in typhoid fever. The eruption is usually also much more copious, and appears in the former as early as the fourth, fifth, or sixth day, while that of the latter is rarely observed before the seventh day. The fever in the former is much more nearly continued in type than that of the latter. Defervescence occurs in the former by crisis; in the latter, by lysis. The expression of the physiognomy is different in the two diseases. In typhus there is a uniform dusky hue of the face, with injection of the conjunctivæ and contraction of the pupils. In typhoid fever the pupils are often widely dilated, the conjunctivæ clear, and the face pallid, with the exception of a circumscribed flush on each cheek. Diarrhoea is much less frequent in the former than in the latter, and when it does occur is not accompanied by ochrey-yellow stools. Epistaxis, tympanites, pain, and gurgling in the right iliac region, and intestinal hemorrhage, common symptoms in the latter, are very infrequently met with in the former. On the other hand, petechiæ and vibices, which are of almost constant occurrence in the former, are rarely met with in the latter. The circumstances also under which the two diseases are contracted are different. Typhus originates from overcrowding or is due to direct contagion. The origin of typhoid fever is often involved in more obscurity, but it can generally be traced either to a polluted water-supply or to defective drainage.

Relapsing fever, with due care, is not likely to be confounded with typhoid fever. The abrupt commencement of the former, the high fever, lasting for from five to seven days only, and terminating by crisis with a profuse sweat, and the period of complete apyrexia of a week's duration, followed by the relapse in which the temperature rises even higher than in the primary paroxysm, and which also terminates by crisis, form a chain of symptoms which has no counterpart in the latter. The mind in relapsing fever is usually clear, there being none of the hebetude and mental confusion commonly observed in typhoid fever. The rose-colored eruption is, moreover, wanting, and diarrhoea and tympanites are absent. On the other hand, jaundice and tenderness in the epigastric zone are more common than in typhoid fever.

Influenza sometimes, Murchison says, when epidemic, closely simulates typhoid fever, but as the two diseases occur in this country the resemblance between them is not often sufficiently strong to lead the careful observer astray. In both there are fever, prostration, sleeplessness, delirium and sweating, and occasionally deafness, diarrhoea, epistaxis, and a dry red tongue; but the onset of the attack in the former is more abrupt, its duration shorter, and subsequent convalescence more rapid than in typhoid fever. The prostration, too, is more decided in proportion to the degree of fever present. Coryza and bronchial catarrh are much more marked symptoms in the former than in the latter, while hyperæsthesia of the surface, which is present in almost every case of influenza, is only rarely met with in typhoid fever.

Remittent and typhoid fevers often prevail together in the malarious {313} districts of this country, and, as they present many points of resemblance, they are sometimes with difficulty distinguished from each other. They both may begin with nausea and vomiting; abdominal and cerebral symptoms are common to both, and so is enlargement of the spleen. The typhoid state may supervene in either, and in both the febrile movement is remittent in character. In remittent fever, however, the remissions are more marked, and are usually accompanied with more profuse sweating, than in typhoid fever. Jaundice and other symptoms of hepatic derangement are also more common, and the pains in the back and limbs are more frequent and more severe. The effect, too, of quinine in producing a permanent reduction of the temperature, is generally more decided. On the other hand, the rose-colored eruption of typhoid fever is never present in pure remittent fever. Occasionally, in cases of the variety of typhoid fever known as typho-malarial fever, the symptoms of the latter may be so prominent as entirely to mask those of the former. In such cases the discovery of a few rose-colored spots somewhere on the surface will clearly reveal the true nature of the disease.

Epidemic cerebro-spinal meningitis differs from typhoid fever by its more abrupt invasion, by the retraction of the head which rapidly supervenes, and by the appearance a short time afterward upon different parts of the body of petechiæ, which are not likely, even at first, to be mistaken for the rose-colored spots of typhoid fever. The fever has, moreover, no constant character, but is remarkable, on the contrary, for its great irregularity. The duration of the disease is in fatal cases much shorter, death taking place not infrequently within the first week, and occasionally as early as the second or third day. On the other hand, the duration in cases which recover may be even longer than in typhoid fever.

Simple continued fever may readily be mistaken in the beginning for typhoid fever, especially in those cases complicated by diarrhoea, but, as a general rule, the different character of the febrile movement, its more abrupt commencement and termination, and its shorter duration, together with the absence of the rose-colored eruption, will usually serve to distinguish it.

The eruptive fevers are always readily distinguishable at the period of invasion from typhoid fever, and the mistake of confounding them with the latter disease may generally be avoided by a close study of the character of the pyrexia. In the eruptive fevers the temperature rises abruptly, frequently attaining its maximum in the course of twenty-four hours, and sometimes in very much less time. There are also in all of them early symptoms which indicate pretty clearly their true nature, as, for instance, the sore throat of scarlatina, the naso-pulmonary catarrh of measles, and the rachialgia of small-pox. The uncertainty, moreover, is of short duration, as the characteristic eruption appears in all of them before the fourth day.

Acute tuberculosis of the lungs is the condition which in my experience has been the most difficult to distinguish from typhoid fever. Indeed, in some cases which have come under my observation physicians of recognized skill as diagnosticians have been unable to make the discrimination until after the death of the patient. Muscular prostration, a dry brown tongue, delirium, stupor, bronchitic râles, dyspnoea, and even cyanosis, are symptoms frequently met with in both diseases, so that when the {314} rose-colored eruption and enlargement of the spleen happen to be wanting in typhoid fever, or diarrhoea and tympany present in acute tuberculosis, as they may be, the distinction is often impossible. The diagnosis may, however, even in these cases, be sometimes made after a careful study of the temperature range, which in acute tuberculosis is irregular and rarely presents any resemblance to that which is typical of typhoid fever.

Acute tubercular meningitis has also many symptoms in common with typhoid fever, such as high fever, headache, vomiting, delirium, and stupor, but in the former disease the rose-colored eruption, epistaxis, enlargement of the spleen, and intestinal hemorrhage do not occur. Diarrhoea is also rare, and the abdomen, instead of being tympanitic, is flat, and in many cases even scaphoid. The headache, too, is much more acute than in typhoid fever, and is very apt to be associated with retraction of the head. Here, again, the frequent use of the thermometer will yield very important results in diagnosis, as the temperature range in tubercular meningitis is always irregular and does not present any resemblance to that usually observed in typhoid fever.

Several of the inflammations, especially when associated with the typhoid state, have so many symptoms in common with typhoid fever that they may very readily be mistaken for one another by a careless observer. I have known, for instance, the general disease to be entirely overlooked in a case of typhoid fever complicated by pneumonia, and, on the other hand, it has sometimes been supposed to be present in a case of pure typhoid pneumonia. Gastro-enteritis is another disease which is also occasionally confounded with typhoid fever. The diagnosis in these cases will rest principally upon the presence or absence of epistaxis, enlargement of the spleen, tympanites, the rose-colored eruption, and of a temperature range presenting some similarity to that usual in typhoid fever.

Trichiniasis is not likely to give rise to much difficulty in diagnosis, for although vomiting, diarrhoea, and the typhoid state occur in it as well as in typhoid fever, the former disease may usually be recognized by the severe muscular pains and the local oedema which are constant accompaniments of it, and by the absence of the characteristic symptoms of the latter.

PROGNOSIS.--There is no other disease in which the physician should be more careful in making a positive prognosis than in typhoid fever. On the one hand, accidents of a fatal character frequently occur in cases which are apparently progressing favorably, and, on the other, recovery has often taken place after all hope of it had been abandoned. But, although it is impossible to foretell with absolute certainty the result in any particular case, there are certain symptoms which furnish very important indications for prognosis, and the proper appreciation of which will generally enable us to arrive at a correct conclusion as regards the gravity of the disease. Prominent among these is the character of the pyrexia. A fever characterized by high temperature should always give occasion for great anxiety. This is very fully shown by the statistics of the hospital at Basle. Thus of those patients in whom the temperature did not reach 104°, only 9.6 per cent. died; of those in which it reached or exceeded 104°, 29.1 per cent. died; and, finally, of those in whose axilla the temperature rose to or above 105.8°, more than half died. {315} Wunderlich has arrived at very nearly the same conclusions, for he says that the prognosis is very unfavorable when the temperature rises to 106.16°, that the deaths are almost twice as numerous as the recoveries when it rises to 107.06°, and that recoveries are rare when it rises to 107.24°. Murchison has, however, known recovery to follow a temperature of 108°. The highest temperature recorded in any of my cases was 106° F. In this case, which proved fatal, the temperature reached 105° F. five times. In three other cases, in all of which recovery took place, a temperature of 105.5° F. was observed. In twelve cases the temperature reached 105° F. on more than one occasion. Six of these ended fatally; in the others the patients recovered.

The prognosis is more unfavorable in a fever in which the temperature is continuously high, and in which the morning remissions are slight or wanting, than in one in which the daily fluctuations are greater, even though the temperature may reach a higher point during the evening exacerbations in the latter variety than is attained at any time in the former. Occasional remissions, even if produced by quinia or other remedies, are to be regarded as favorable omens, as they indicate that the fever tends to subside. A high morning temperature ought, therefore, to give rise to more alarm than a high evening temperature. The prognosis is grave when the morning temperature rises to 104° or is persistently above 103°. Murchison says that recovery is rare after a morning temperature of 105°. Fiedler[91] saw, with a single exception, all patients die whose temperature in the morning rose to or exceeded 106.25°, while of those whose temperature in the morning rose to 105.44°, if only on one day, more than half died. Any marked deviation from the usual temperature range in the course of the fever is unfavorable. A rapid rise of temperature indicates increased danger: it may be due to the occurrence of a complication or of some other cause acting unfavorably upon the patient. A sudden and decided fall should excite even more alarm, as it is generally the consequence of a free intestinal hemorrhage. A temporary abatement of the fever, with amelioration of the other symptoms, occurring between the tenth and twentieth days, and giving rise to the hope that convalescence is about to commence, but followed by a return of the symptoms in an aggravated form, is also unfavorable. Such cases, according to Chomel, Louis, Bartlett, and Murchison, almost invariably terminate fatally.

[Footnote 91: Quoted by Liebermeister.]

The prognosis is bad in cases in which coma or wild or violent delirium comes on early. A moderate amount of delirium, especially when it occurs only at night or upon wakening in the morning, and is readily dissipated by attracting the patient's attention, or stupor which disappears when he is thoroughly roused, is not unfavorable. Insomnia, subsultus tendinum, carphologia, slipping down in bed, incontinence of the urine or feces, and retention of urine, are all symptoms of bad omen. Rigidity of the limbs is also a bad symptom; Dr. Jackson reports six cases in which this symptom occurred, only one of which recovered. Excessive subsultus is especially unfavorable, as it is generally most marked in cases in which the ulcerations of the intestines are most extensive. Extreme deafness occurs in mild as well as severe cases; it is therefore without significance in prognosis.

{316} In estimating the importance, in a prognostic point of view, of these various nervous symptoms, it is important to bear in mind that a degree of fever which produces no disturbance of the mental functions in a phlegmatic person will give rise to active delirium and other marked cerebral symptoms in a person of an excitable temperament.

A change in the character of the pulse and of the action of the heart is often the earliest indication of the approach of danger in typhoid fever, and both pulse and heart should therefore be carefully examined at every visit. The first change is usually a diminution in the intensity of the first sound of the heart. This is significant, as it is frequently the earliest premonition of cardiac failure, to which a large proportion of the deaths in typhoid fever is due. A pulse of 120 and over, especially if it is at the same time feeble, is also unfavorable. The important part which the frequency of the pulse plays in the prognosis is shown by the following observations made by Liebermeister at the hospital in Basle: Of 63 cases in which the pulse rose to or above 120, 40 were fatal, or nearly two-thirds. Among these 63 were 37 in which it did not rise to 140; of these, 19 were fatal, or about one-half; in 26 it rose above 140; of these, 21, or about four-fifths, were fatal. In 12 patients it rose above 150; of these, 11 died. Of those in which the pulse rose to 160, the only case that ended in recovery was that of a girl twenty-one years old suffering from an imperfectly developed typhoid. Intermittence of the pulse is unfavorable, especially, according to Hayem,[92] when it occurs during the first week of the disease. In convalescence intermittence is not to be regarded as an unfavorable symptom. The prognosis is bad also in those cases in which, with excessive weakness of the pulse, there are other evidences of cardiac failure, as, for instance, congestion of the lungs, cyanosis of the surface, coldness of the extremities. A very frequent pulse is not so unfavorable in a child as in an adult, or in a person of a nervous temperament as in one of a different disposition.

[Footnote 92: _Loc. cit._]

Other unfavorable symptoms are a dry, brown tongue, excessive tympanites with great abdominal tenderness, severe diarrhoea, vomiting when it occurs late in the disease, intestinal hemorrhage, and colliquative sweats. The delusion sometimes observed in very severe cases, in which the patient declares that he is not ill, is a very bad sign, many authors, and among them Louis, asserting that they have never known recovery to take place after it has been manifested. Peritonitis is a very serious complication, whether due to perforation or to some other cause. Still, it would appear not to be invariably fatal, since recovery has occurred in cases in which all the symptoms of this complication were present.

Favorable symptoms, on the other hand, are a gradual decrease of the temperature with increasing morning remissions, moistening and cleansing of the tongue, a lessening of the delirium, and other nervous symptoms, reappearance of an intelligent expression, recognition by the patient of friends and attendants, and a diminution of the diarrhoea. A copious eruption is also regarded by many as a favorable symptom. Cases in which constipation exists generally do well. Nathan Smith never knew a patient to die whose bowels were constipated throughout the attack.

The death-rate of typhoid fever is found to vary very considerably in different years and in the different seasons of the year, as will be seen {317} from the two following tables. Statistics as to the mortality of the disease to be reliable must therefore be based upon a large number of cases extending over a series of years.

The following table shows the number of cases admitted into the Pennsylvania Hospital during each of the twenty years ending Dec. 31, 1881, and the ratio of mortality among them:

TABLE NO. 1.

-------+------+------+------+------+--------+--------+-------+-------
| | | | | | | |Percen-
| | | | | | | |tage of
| | | | | | | | deaths
| | | | | | | | after
| | | | | | | |deduct-
| | | |Number| | | | ing
| | | | of | | | | cases
| | | |deaths| Average| | | fatal
| | | |within| stay | | | within
| | | | 48 |in cases| | | 48
| |Number|Number| hours| ending | Average| | hours
|Number| of | of | of | in | stay |Percen-| of
| of |recov-| dea- |admis-| recov- |in fatal|tage of| admis-
YEAR. |cases.|eries.| ths. | sion.| ery. | cases. |deaths.| sion.
-------+------+------+------+------+--------+--------+-------+-------
1862 | 89 | 68 | 21 | 7 | 54-1/3 | 8 | 23.6 | 17.7
1863 | 36 | 33 | 3 | 2 | 32-1/5 | 3-1/3 | 8.3 | 2.9
1864 | 43 | 35 | 8 | 1 | 38-1/2 | 8 | 18.6 | 16.3
1865 | 36 | 31 | 5 | 1 | 38-1/2 | 5-1/2 | 13.9 | 11.4
1866 | 23 | 17 | 6 | 0 | 45-2/3 | 9 | 26.0 |
1867 | 24 | 20 | 4 | 0 | 37-1/3 | 6-1/2 | 16.6 |
1868 | 27 | 23 | 4 | 0 | 44-3/4 | 10 | 14.8 |
1869 | 21 | 16 | 5 | 1 | 35-1/2 | 14 | 23.8 | 20.0
1870 | 24 | 19 | 5 | 1 | 47-1/2 | 11 | 20.8 | 17.4
1871 | 32 | 26 | 6 | 1 | 37-3/4 | 13-1/2 | 18.8 | 15.0
1872 | 21 | 16 | 5 | 3 | 37-1/2 | 4-1/2 | 23.8 | 11.1
1873 | 12 | 8 | 4 | 2 | 34 | 9 | 33.3 | 20.0
1874 | 16 | 12 | 4 | 0 | 54-1/2 | 9-3/4 | 25.0 |
1875 | 20 | 18 | 2 | 1 | 48 | 4-1/2 | 10.0 | 5.3
1876 | 30 | 21 | 9 | 2 | 45-1/2 | 11 | 30.0 | 25.0
1877 | 48 | 34 | 14 | 4 | 48-1/2 | 12-1/2 | 29.2 | 22.7
1878 | 8 | 5 | 3 | 0 | 49 | 5-2/3 | 37.5 |
1879 | 17 | 15 | 2 | 0 | 53-1/3 | 8 | 11.8 |
1880 | 40 | 35 | 5 | 2 | 47 | 10-1/2 | 12.5 | 8.0
1881 | 54 | 48 | 6 | 0 | 41-3/4 | 8 | 11.1 |
-------+------+------+------+------+--------+--------+-------+-------
Totals,| 621 | 500 | 121 | 28 | 43-1/2 | 8-3/4 | 19.5 | 15.7
-------+------+------+------+------+--------+--------+-------+-------

Out of the 621 cases admitted, 121 were fatal. This gives a death-rate of 19.5 per cent.; but if we deduct the 28 cases in which the patients died within forty-eight hours of their admission, it falls to 15.68 per cent., or about the same ratio as Murchison found to exist among the cases treated at the London Fever Hospital. Other observers have obtained slightly different results. Thus, the mortality was 11.16 per cent. in 197 cases analyzed by Dr. Hale, and 13.5 per cent. in 303 cases collected by Dr. James Jackson. Dr. Cayley[93] found the death-rate of the several hospitals in London to be 17.8 per cent., and Geissler[94] that it was in all the German hospitals 12.8 per cent. in 1877, and 13.5 per cent. in 1878. Flint had 18 deaths in 73 cases, or 24.4 per cent. According to Liebermeister, the ratio of mortality at the hospital at Basle during the twenty-two years from 1843 to 1864, or before the introduction of a {318} systematic anti-pyretic treatment, was 27.3 per cent., and only 8.2 per cent. during the six years immediately following its adoption. As the results obtained at the Pennsylvania Hospital are apparently not so favorable as those reported at some of the continental hospitals, it is only proper to state that a large proportion of the cases were severe, that many of them were far advanced in the disease when admitted, and that very few of the patients were under twenty-one years of age. These are all circumstances which influence very decidedly the prognosis in typhoid fever. In no other city are the laboring classes able to surround themselves with so many comforts as in Philadelphia. This fact, fortunate as it is in the main, often operates to the disadvantage of the patient by enabling his family to indulge for a time the reluctance which it naturally feels to part with a member when sick. In the case of the young this reluctance is so hard to overcome that children with acute affections are rarely brought to hospitals for treatment. There were also special causes for the large mortality in certain years. This was particularly the case in 1862, when a large number of soldiers fresh from the battlefields of Virginia, and suffering from the typho-malarial form of the disease, were admitted into the hospital. Many of them were moribund upon admission, and others, exhausted by the fatigue incident to transportation here and by previous hardships, soon succumbed to the disease.

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

[Footnote 94: _Schmidt's Jahrbuch_.]

Table 2 gives the number of cases, with the number of deaths occurring in each season, at the Pennsylvania Hospital during the last twenty years:

TABLE NO. 2.

-------------------------+---------+---------+---------+---------
| Spring. | Summer. | Autumn. | Winter.
-------------------------+---------+---------+---------+---------
Number of cases | 89 | 259 | 182 | 91
Recoveries | 73 | 191 | 163 | 73
Deaths | 16 | 68 | 19 | 18
Percentage of mortality | 18.0 | 26.2 | 10.4 | 19.8
-------------------------+---------+---------+---------+---------

It will be seen from this table that the highest death-rate occurred in the summer and the lowest in autumn, while there was only a slight difference between the death-rate of spring and that of winter. Murchison's experience, based on a much larger number of cases, has led him to conclude that while the disease is a little less fatal in autumn, the difference in the mortality at different seasons is very inconsiderable. Chomel believed that the percentage of deaths was highest in France during the winter months, and Bartlett held the same opinion as regards America. Epidemics of great severity have undoubtedly prevailed in winter, as the in Lowell, Mass., referred to by Bartlett, but there can be little doubt that the death-rate is highest in this country during the warm months of the year. Dr. Cleemann[95] found that the monthly average mortality in Philadelphia for the ten years from 1866 to 1875 was highest in August, and next highest in September, confessedly the two months of the year when the heat in this city is most exhausting. I feel very sure I have lost patients with typhoid fever in these months {319} and in July who would probably have recovered if the weather had been cooler. With a temperature often rising above 90° F. at midday, and sometimes for several days at a time never falling below 80°, all radiation of heat from the surface of the body is arrested, and death frequently occurs as the result of hyperpyrexia.

[Footnote 95: _Transactions of the College of Physicians of Philadelphia_, 3d S., vols. ii. and iii.]

The stage of the disease at which efficient treatment is begun has a manifest influence upon the result. This is strikingly shown by some observations of Jackson: 90 cases were admitted into the Massachusetts General Hospital during the first week--of these 7 died, or 1 in 12.85; 139 cases were admitted in the second week--of these 16 died, or 1 in 8.68; 46 cases were admitted in the third week--of these 10 died, or 1 in 4.60; and 21 cases were admitted in the fourth week, and of these 5 died, or 1 in 4.20. Convalescence also occurred much earlier in those who were admitted early.

Murchison found that in a large number of cases the death-rate varied at different ages as follows: Under ten years it was 11.36 per cent.; from ten to fourteen years it was 12.86 per cent.; from fifteen to nineteen years it was 15.48 per cent.; from twenty to twenty-nine years it was 20.46 per cent.; from thirty to thirty-nine years it was 25.90 per cent.; from forty to forty-nine years it was 25 per cent.; and above fifty years it was 34.94 per cent.

According to Liebermeister, among the 1743 patients treated for typhoid fever in the hospital at Basle from 1865 to 1870, inclusive, there were 130 who were more than forty years old; of these 39, or 30 per cent., died, while the mortality among the patients under forty amounted only to 11.8 per cent. Among the cases of typhoid fever in individuals over forty years of age collected by Uhle, more than half proved fatal. According to Friedrich,[96] there were, among 16,084 children treated in the Children's Hospital at Dresden, 275 cases of typhoid fever, of which 31, or not quite 11 per cent., proved fatal. Age, therefore, exercises a positive influence upon the mortality of typhoid fever. Its influence is less decided in this disease than in typhus, in which the death-rate does not reach 4 per cent. until after the age of twenty, when it rapidly rises from 12.34 per cent. until it reaches 57.03 per cent. in patients above fifty years of age. The comparatively slight mortality of typhoid fever among children is probably due to the fact that the temperature is less often continuously high in them than in adults, and that while hyperpyrexia is frequently present, it is generally better borne and less likely to produce paralysis of the heart. Liebermeister says that the only case which he has seen recover after the temperature had repeatedly risen to 107.5° F. was that of a girl fourteen years of age. It is also said that the intestinal lesions are not so severe, and the liability to complications and sequelæ less marked, in children.

[Footnote 96: Quoted by Liebermeister.]

Typhoid fever appears to be a slightly more fatal disease in women than in men, for while in some local epidemics the percentage of deaths is greater among the latter than among the former, the reverse is found to be the case when the records of a large hospital for a number of years are carefully examined. According to Murchison, the mortality at the London Fever Hospital was about 1 per cent. higher among the female than among the male patients, and about the same difference in the death-rate {320} of the two sexes has been reported by continental physicians. A greater disparity even than this has been observed by Liebermeister at the hospital at Basle, where the death-rate for women was 14.8 per cent., and only 12 per cent. for men. Murchison says that this excess of mortality among the former cannot be accounted for by the influence of child-bearing upon the course of the fever, since it is much more decided between the ages of five and fifteen than in the period of child-bearing.

The rich are not only as liable to contract typhoid fever as the poor, but the disease is also quite as fatal among them. Murchison found from the statistics of the London Fever Hospital that the mortality is not greater among the destitute than among the better class of patients, and expresses the opinion that in private practice enteric fever is probably more fatal among the upper classes than among the very poor. Chomel and Forget seem to have reached a similar conclusion.

All authors agree that the prognosis is unfavorable in corpulent persons, not only on account of the diminished power of resistance to disease generally which such persons exhibit, but also because the febrile movement is often intense in them, and the degenerative changes of the muscles and organs of the body which it induces are generally early developed and of high grade. Liebermeister goes so far as to say that even in the case of ill-nourished, anæmic, or chlorotic individuals the chances for life are better than in the corpulent. Murchison has also expressed the opinion that a large, muscular development is likewise an unfavorable element in prognosis, having seen the strong and robust succumb to the disease oftener than the feeble. The mortality from the disease appears to be greater in certain families than in others. This has been ascribed by some writers to peculiarities of constitution, but it may be due to other causes, as, for instance, difference in the intensity of the poison. The disease is also often very fatal among the intemperate, who usually bear the disease badly in consequence of the presence of various degenerations of one or more of the important organs of the body caused by the excessive indulgence in alcoholic stimulants; paralysis of the heart being not an infrequent cause of death among them.

Certain epidemics have been exceedingly fatal, while in others the percentage of deaths has been very small. There can be no doubt that in most of these cases there has been a difference in the virulence of the poison. Recent residence in an infected locality has been shown by Murchison and other writers to have a decided influence in increasing the fatality of the disease. Second attacks are, on the other hand, usually mild. Some diversity of opinion exists among authors in regard to the effect that pregnancy has upon the course of the disease. Murchison believes that it is a far less formidable complication than is usually thought, while Liebermeister, on the contrary, holds a directly opposite opinion. He also regards the prognosis as unfavorable when the disease occurs in childbed or a short time afterward. Individuals with disease of the heart, emphysema, or bronchial catarrh who contract typhoid fever are said to be more liable to paralysis of the heart than others, hence the existence of these diseases materially diminishes their chances of recovery.

TREATMENT.--Inasmuch as the spread and propagation of typhoid fever may be prevented to a great extent, if not entirely, by the {321} employment of judicious sanitary measures, it is proper, before entering upon the discussion of its curative treatment, to devote a few words to the prophylaxis of the disease.

Whether the physician accepts the theory so ably advocated by Murchison, that typhoid fever may arise from exposure to the products of the fermentation of healthy feces, or adopts the view now held by a large number of investigators, that the disease is never generated in the absence of the specific germ, he will admit the great importance of an efficient system of sewerage, with a thorough flushing of the sewers at regular and frequent intervals, for disposing of the fecal discharges of the population of all towns, no matter how inconsiderable in size. No less important is it that the drains of every dwelling should be well constructed and kept in good order. They should be trapped just before they empty into the sewer, and should be provided with the means of thorough ventilation between the trap and the walls of the house by a free communication with the outer air. The soil-pipe should be carried up three or four feet above the top of the house, and every water-closet, bath-tub, stationary washstand, and sink should have its own separate trap, and none of them should be placed in rooms unprovided with a window or with some other sufficient means of ventilation. Physicians should, as sanitarians, urge upon the authorities of all cities and towns the importance of deriving their water-supply from a source unpolluted by sewerage or by any other substances likely to be deleterious to health. They should also see that when water is stored in a tank inside of a house the overflow pipe does not communicate directly with the drain, since if this is allowed to occur the water may very soon become contaminated with sewer gas, and consequently unfit for internal use.

In the case of isolated country-houses and of small villages some other means of disposing of the fecal discharges of the inhabitants than by sewers has to be found. In the great majority of instances no better way presents itself than by the ordinary cesspool. Care should, however, be taken that this is so constructed and situated that there can be no filtration of its contents into wells from which water for drinking is obtained.

As the alvine dejections of the sick are beyond question the medium by which typhoid fever is most frequently communicated to others, the importance of thoroughly disinfecting them before they have acquired the power of imparting the disease cannot well be overestimated. Liebermeister recommends that the bottom of the bed-pan should be strewed, each time before being used, with a layer of sulphate of iron, and that immediately after a passage crude muriatic acid should be poured over the fecal mass, as much as one-third or one-half of the bulk of the latter being used. He also urges, whenever it is practicable, that the contents of the bed-pan should be emptied into trenches dug anew every two days and filled up when discarded, care being of course taken that they are not located anywhere in the vicinity of wells. Murchison seems to prefer carbolic acid to other chemical agents as a means of preventing fecal fermentation. For this purpose the liquid carbolic acid may be diluted with water in the proportion of 1 to 40 to 1 to 20, or it may be mixed with sand or sawdust. I have myself employed as a disinfectant with success the solution of the chlorides sold under the name of Platt's chlorides. As the discharges must in cities, in the great majority of instances, be emptied into {322} water-closets, these should be freely flushed with water after every time they are used; and it is well to impress upon the attendant on the sick the importance of doing this. The bed-linen of the patient and his clothes, if they are soiled by his discharges, should be removed as soon as possible, and subjected to a high degree of heat (248° F.) or soaked in a solution of the chlorides or of carbolic acid for several hours before being washed. If these precautions are observed, cases of typhoid fever may be treated in the wards of general hospitals without danger to the other patients.

In the doubt and obscurity which generally envelop the diagnosis of the disease when the physician is first called upon to treat it, it is impossible to lay down any positive rules for the management of typhoid fever at its commencement. But even in those cases which begin insidiously, if the patient is carefully examined enough of the early symptoms of typhoid fever will be detected to put the physician on his guard. The thermometer will show the existence of fever, which has a tendency to increase at night. There will generally be found to be a little diarrhoea, or at least an increased susceptibility to the action of purgative medicines; perhaps a little tympany and tenderness in the right iliac fossa, and moreover a prostration which is out of all proportion to the other symptoms.

These symptoms, it is true, are not infrequent concomitants of many diseases besides the one under consideration; but when their presence cannot be otherwise satisfactorily explained, especially if they have continued for several days, it is a safe rule in practice to regard the case as one of typhoid fever, and to regulate the treatment accordingly. The patient must be put to bed at once, and not allowed to leave it on any pretext, not even to empty his bladder, after the first week. This is a rule which should be rigidly enforced in every case, no matter how mild the symptoms may be. Its non-observance, either through the neglect of the physician or the ignorance or wilfulness of the patient, has been the cause of some disastrous results; in illustration of which it is only necessary to refer to the frequency with which perforation of the bowel occurs in walking cases of typhoid fever. Perfect quiet should be maintained in the sick room. Visitors should be excluded from it, and the attendants limited in number to those actually necessary to carry out the directions of the physician. All unnecessary talking is to be avoided, and especially conversation carried on in a low tone of voice, which is always annoying to the sick.

There is only one condition under which I should be disposed to break the rule of absolute quiet and rest laid down above, and that is when called upon to treat typhoid fever in the built-up portion of our large cities during the summer season. If the patient were still in the first week of the disease, if his circumstances were sufficiently affluent to enable him to surround himself with every comfort, and if it did not involve a journey of more than a few hours, I should unhesitatingly send him to the sea-coast. I have so often seen cases prove fatal in summer in consequence of the great heat of the city--a heat, too, which is sometimes almost as great at night as in the day-time--that I should feel that I was giving him an additional chance of life by sending him where the heat was, at least occasionally, tempered by cool breezes from the ocean. During the late war numbers of soldiers were frequently sent in the early stages of {323} typhoid fever from the camps in the South to their homes or hospitals in the North, and it is fair to say that they did at least as well as those who remained behind. But when the journey may be accomplished by means of Pullman cars and the other appliances of modern travel the risk, and even discomfort, it involves to the patient is reduced to the minimum.

As the disease is usually one of long duration, the patient being rarely able to leave his bed under four weeks, and more frequently being obliged to keep it for a much longer time, the sick room should, wherever practicable, be large, airy, and provided with an open fireplace, which is a much more efficient means of securing thorough ventilation than an open window, while it is not liable to the objection sometimes applicable to the latter of causing a direct draught upon the patient. It is well, however, for the physician to remember that the danger from this source is very much exaggerated by the laity, and that patients in the febrile stage of typhoid fever do not readily take cold. Still, the same end may generally be attained without the least risk to the patient by opening a window in an adjoining room. The temperature of the sick room should be steadily maintained at between 65° and 68° F.

The careful regulation of the diet is also a point of great importance in the management of typhoid fever; for in this disease there are not merely the high fever and other exhausting symptoms, speedily inducing excessive prostration, loss of strength, and emaciation, common to many fevers, but there is also the peculiar ulceration of the bowels, which gives rise to danger of its own and demands special consideration in treatment. The food must therefore be not only nourishing, but also readily digestible, and not likely to create irritation in its passage through the intestines. All solid food should therefore be excluded from the dietary of the patient as long as the fever lasts. Indeed, it is better to continue this prohibition even after the subsidence of the fever if rose-colored spots are still to be seen on the abdomen or elsewhere, or if there exists a tendency to diarrhoea or any other symptom indicating that the disease has not fully run its course. Having myself seen some rather disastrous results from a too early return to solid food, I have been accustomed in my own practice to interdict its use until at least two weeks after the beginning of convalescence. Jaccoud also lays much stress upon this point, saying that the early administration of meat always gives rise to fever, to which, from its cause, he gives the name of febris carnis. On the other hand, Flint[97] and Peabody have recently advocated the giving of solid food immediately after the cessation of fever, in the belief that recovery is thereby promoted. Milk as an article of diet is unquestionably to be preferred to all others in typhoid fever. It is open, it is true, to the objection of occasionally forming tough curds in the stomach, but this may generally be prevented by giving the milk in small quantities at a time, diluted with lime-water or barley-water or mixed with some farinaceous substance. No positive general rule can be laid down as to the amount to be given. This will be found to vary not only in different cases, but also in the same case at different times. Indeed, in those cases which begin abruptly with symptoms of gastro-intestinal irritation, if it is forced upon the patient in large quantities it is not only usually rejected, but also causes an aggravation of the symptoms, while after {324} this irritation is allayed it will be digested without difficulty. As a general rule, most adult patients will be able to take from a quart and a half to two quarts of milk daily, given in quantities of from four to six ounces every two or three hours. It should be remembered, however, that if more is taken than can be assimilated it will act as an irritant and increase the diarrhoea. If, therefore, the stools contain undigested milk, the quantity should be diminished. Patients are occasionally met with, but not in as great number as is often asserted, with whom milk habitually disagrees. In these cases it must of course be replaced in whole or in part by some other article of food. Under these circumstances some one of the liquid preparations of beef may be given with advantage, although it may be objected to them also that they sometimes occasion an increase of diarrhoea. Beef-tea or beef-essence, made from the fresh meat whenever this can be obtained, is to be preferred to all others; but when it cannot, that made from the preparations of Johnston or Brand is the best substitute. When the stomach is very irritable, Valentine's meat-juice, in consequence of the smaller bulk in which it is given, often answers an admirable purpose.

[Footnote 97: _Medical News_, Mch. 29 and Apl. 5, 1884.]

Various farinaceous substances, such as farina, corn-starch, and arrowroot, are also occasionally given in typhoid fever, and, although the last named would seem to be indicated in cases in which diarrhoea is a prominent symptom, their tendency to cause flatulence is so great that their use in the acute stage of the fever has not found favor among physicians generally. In convalescence, on the other hand, they are generally perfectly well borne.

The subject of the administration of alcoholic stimulants in typhoid fever may be conveniently considered in this connection. Some difference of opinion exists in regard to the quantity in which they should be given, and indeed in regard to the necessity for their use at all in many cases, as, for instance, in those of young persons whose health and habits had been good previously to the attack. I have myself treated several such cases without alcohol, and have not been able to perceive that their duration was longer and the result less favorable than in cases in which it was given in the usual amount. It is, moreover, not necessary to prescribe it always, even in very severe cases, at the beginning of an attack. When given at this time, it not infrequently does harm by increasing the fever. It should be reserved, therefore, until the action of the heart grows feeble and the first sound becomes indistinct. It is not possible to lay down any general rule as to the amount to be given, even in severe attacks. This will vary in different cases, and to a certain extent will be determined by the effects it produces. If the pulse grows stronger and the delirium diminishes under its use, it is doing good and should be continued; if, on the other hand, there is increase of delirium and restlessness, the quantity should be diminished.

In cases in which only a gentle stimulus is required wine in the form of wine-whey will often be found to meet the indication fully. Generally, however, it will be necessary to have recourse to whiskey or brandy. The choice between these may usually be left to the patient's fancy; brandy is, however, to be preferred in cases in which diarrhoea is a prominent symptom. These stimulants should be given in small quantities frequently repeated. In many cases a dessertspoonful every two or three hours, {325} either diluted with water or, when the stomach is irritable, with carbonic acid water or given in the form of milk punch, will be sufficient. In others a tablespoonful every two hours, or even at shorter intervals, will be required, but it will rarely be necessary to exceed eight ounces a day for more than a few days at a time.

Although the physician will not often be called upon at the present day to encounter and combat the prejudice so common formerly against the free administration of water in the febrile condition, he will frequently find nurses and others not sufficiently alive to the importance of supplying it when the patient, having fallen into the typhoid state, ceases to ask for it. The high temperature which is generally present in this condition, and the rapid combustion of tissue which it causes, make a full supply of liquid an urgent necessity which it is dangerous to disregard. Water is the best of all diuretics, and it is important in this disease, as indeed it is in many others, that the functions of the kidneys should be kept active, so that the products of the combustion of the tissues may be eliminated with their secretion. Care, however, should of course be taken, as pointed out by Da Costa,[98] that water is not given in such quantity that the desire for and capability of digesting food is destroyed by it.

[Footnote 98: Preface to Wilson's _Treatise on the Continued Fevers_.]

In the few cases which begin abruptly with symptoms simulating those of a so-called bilious attack the practitioner will usually content himself with the administration of medicines calculated to allay the irritability of the stomach and bowels. For this purpose I have found the bicarbonate of potassa in solution, to which lemon-juice is added at the moment it is taken, so as to produce an extemporaneous effervescing draught, often an admirable remedy. In other cases I have used with advantage small doses of calomel or blue mass, followed, if necessary, by a gentle saline purge. When the symptoms have occurred soon after a hearty meal, or when there is evidence that the stomach is overloaded, it will occasionally be necessary to have recourse to an emetic. Usually, the indications for treatment at the beginning of an attack are much less definite, and even in the class of cases just referred to they become so after the subsidence of the gastro-intestinal symptoms. Indeed, the treatment in the larger number of cases must be purely symptomatic until the nature of the disease has fully declared itself. The presence of fever will suggest the use of the neutral mixture, effervescing draught, or spirit of Mindererus, combined, if there is decided tendency to evening exacerbations, with sulphate of quinia in full doses. If there is much diarrhoea, Hope's camphor mixture or opium in some other form may be given; if delirium is a prominent symptom, ice or cloths wrung out of cold water should be kept constantly applied to the head.

But even after all doubt in regard to the diagnosis has been dispelled and the existence of typhoid fever has been recognized, the treatment most in favor with physicians is in large measure symptomatic in character. It is true that various specific treatments, to which fuller reference will be made hereafter, have been lately proposed, but the results obtained by them up to the present time where they have been fairly tested are not so favorable as to induce the body of the profession to adopt them to the exclusion of all other methods. It is certain that no remedy or plan of {326} treatment has yet been discovered which has the power of cutting the disease short, although this power has been claimed at different times for several. Thus, at one time quinia in very large doses was believed to possess it, at another venesection, and at another cold baths. But experience has shown that these and other perturbating remedies often do harm, and there is good reason to believe that the apparent good which has followed their use in a comparatively small number of instances may be better explained by supposing that an error of diagnosis has been made than by attributing to them the power of arresting the progress of the disease. Medicines are, however, by no means useless in the treatment of typhoid fever. There is no question that the disease is not only generally conducted to a favorable issue, but that its duration is often materially shortened, by their judicious use. It is evident, however, that the treatment must vary with the severity of the attack. In a few cases it is scarcely necessary to interfere with the course of the disease by the administration of medicines. In others, on the contrary, it is necessary to act promptly and energetically in order to save life.