Chapter XXI: Part II: , Showing Predominance of Malarial Element . . . . 617 (20)

PREDISPOSING CAUSES.--It may be stated, generally, that whatever impairs the health or reduces the strength of an individual, even temporarily, or acts depressingly on his nervous system, predisposes him to typhus fever. But there are among the predisposing causes some which exert a more special influence on its production than others. Among the more powerful of these is the overcrowding of human beings, with deficient ventilation. Indeed, there are some authors who consider that this has been in many cases alone sufficient to occasion the disease; and although this opinion, as it involves the admission that it may be generated de novo, is contested by others, there is great unanimity among authors in attaching great importance to it. Of the patients admitted into the London Fever Hospital with typhus fever, a large proportion came from the more crowded districts of the city. The disease has always been most prevalent in the poorer quarters of Glasgow, Dublin, and Edinburgh, and when epidemic in Philadelphia in 1836 it was confined to a portion of the town which has always been noted for the squalor and misery of its inhabitants. Among those admitted during that year to the Philadelphia Hospital were seven negroes, said by Gerhard to {342} be "the entire population of a cellar." It is probably largely due to the fact that the better social condition of the poor in this country prevents the degree of crowding which often exists in European cities that the disease is comparatively rare here. The effect of overcrowding is of course much increased by want of cleanliness, either of the person or of the clothes.

Poverty, not merely from its own depressing influences, but also from the fact that it leads to overcrowding, is a powerful predisposing cause of typhus fever. Insufficiency of food, which is one of its many consequences, by impairing his nutrition and thus diminishing his vital resistance, renders the individual more susceptible to the action of the specific cause. Gerhard says that of the patients seen by him in 1836 a very small proportion came from the better class of mechanics, and Tweedie[17] and Sir William Jenner[18] state that it is rare to meet with instances of the disease, except in the case of medical practitioners and students, among those in comfortable circumstances. Bateman[19] goes so far as to assert that "deficiency of nutriment is the principal source of epidemic fever;" and there is certainly a remarkable coincidence in time between outbreaks of this fever and seasons of want and distress. But, as Murchison has shown, destitution is not essential to the production of typhus, for the Dundee epidemic of 1865 was due to overcrowding of the town, brought about by the inhabitants of the surrounding country flocking into it in consequence of labor being unusually abundant and wages good.

[Footnote 17: _Lectures on the Distinctive Character, Pathology, and Treatment of Continued Fevers_, by Alexander Tweedie, M.D., F.R.S., London, 1842; and _Clinical Reports on Fever_, by same author, London, 1830.]

[Footnote 18: _On the Identity or Non-Identity of Typhoid and Typhus Fevers_, by William Jenner, M.D., London, 1880; also _Lancet_, November 15, 1879.]

[Footnote 19: _A Succinct Account of Typhus or Contagious Fever of this Country_, by Thomas Bateman, M.D., F.R.S., London, 1820.]

Similar in its action to the above cause is intemperance. Not only is the habitual drunkard more likely to suffer from typhus fever than the temperate man, but a single debauch has been followed by an attack in individuals who had previously resisted the contagion. On the other hand, the most rigid temperance will not afford in all cases a complete immunity from its effects. The debility left by an illness is also a condition favoring the occurrence of an attack of the disease in those who are exposed to its exciting cause. Fatigue of all kinds renders the body less able to resist the causes of disease, and typhus fever is not an exception to the general rule. Overworked nurses are specially liable to contract it. The depressing emotions also favor its occurrence. It has been observed during epidemics that those who exhibit an excessive fear of the contagion are much more likely to suffer from it than the cheerful and courageous.

No age enjoys an immunity from the disease. In fact, it is probable that all ages are equally liable to it. Buchanan[20] has seen it at the London Fever Hospital in an infant a fortnight old and in a man of eighty, and attributes the prevailing opinion that children rarely suffer from it to the fact that they are not often taken to hospitals, but are retained in their own homes for treatment. Gerhard[21] says that no children in the asylum attached to the Philadelphia Hospital were {343} attacked with the disease during the prevalence of the epidemic there, but the distance of the asylum from the wards in which the cases were treated was probably the reason of their escaping. In the few cases which have come under my own observation the patients were young men, varying in age from twenty-five to thirty-five. The sexes also suffer from it equally. In some epidemics there may be a preponderance of one sex over the other, but in others the reverse has been the case.

[Footnote 20: _A System of Medicine_, edited by J. Russell Reynolds, M.D., F.R.C.P., etc., vol. i., article "Typhus Fever," London, 1866.]

[Footnote 21: _Loc. cit._]

Occupation, except so far as it brings the individual into immediate contact with the sick, as in the case of physicians, nurses, and clergymen, does not predispose to the disease. There would seem also to be no difference in the susceptibility of the different races to the contagion. Acclimatization affords no protection from the disease, as it does in the case of typhoid fever, and change of the habits of life does not appear to exercise any influence upon the liability to it. On the other hand, the susceptibility of different individuals, and of the same individual at different times, varies considerably. Thus, while in many persons a single exposure to the contagion is followed by an attack, in the case of an engineer mentioned by Murchison it did not occur until after fifteen years of continuous service at the London Fever Hospital. A person who has once suffered from typhus fever is not likely to contract it again, but this protection is not complete, as there are a few well-attested instances of a second attack on record.

The disease prevails most frequently during the winter and early spring, principally because the cold weather of these seasons leads to the closing of windows and all other avenues of ventilation, thus intensifying its exciting cause. Still, some epidemics of great severity have occurred in the warmer months of the year, as, for instance, the one described by Gerhard. It is also doubtful if there is any relation between variations in temperature and the amount of moisture in the air and the prevalence of epidemics of typhus fever, although Hirsch regards a low and damp situation as powerfully predisposing to the endemic and epidemic prevalence of the disease. It is usually met with in towns on the sea-coast or on navigable rivers, but it has also been observed frequently in country districts, and even in regions at a considerable elevation above the level of the sea.

EXCITING CAUSE.--The principal if not the only exciting cause of typhus fever is a specific contagion developed in the bodies of the infected and transmitted from them to the healthy by actual contact, by fomites, or through the atmosphere. The nature of this contagion is unknown. A careful study of its peculiarities seems to justify the opinion that it depends upon the presence of a minute organism in the emanations given off by the sick, which is capable of indefinitely multiplying itself in the human body. But this is only an hypothesis, which rests principally upon the analogy between typhus and some other diseases, as, for instance, relapsing fever and diphtheria, in which such a growth is thought to have been discovered, and upon the fact that the contagious principle whatever it may be, is destroyed by a temperature over 204° F.

The evidence in favor of the contagiousness of typhus fever is conclusive, and may be briefly stated as follows: When it breaks out in a community the disease not only attacks those persons who have been subjected to the same influence as the sick--as, for instance, members of {344} their own families, occupants of the same house, etc.--but also those who have come from healthy localities to visit them. In fever hospitals it is rare for any member of the household who has not already had the fever to escape an attack, and the probability of his suffering is in direct proportion to the intimacy of his relations with the patients. Thus, the nurses are far more likely to be attacked than servants whose duties do not take them into the wards, except those employed in the laundry, who are so often affected by it that Murchison says it is difficult to find women who are willing to take the position. The spread of the disease may often be promptly arrested by the complete isolation of the first few cases, while free intercourse between the sick and the well is invariably followed by its extension, not only in the locality in which it first appeared, but to other localities. But the strongest argument in favor of its contagiousness is found in the fact that patients taken into a previously healthy place have frequently become the starting-point of an epidemic. In this way the disease has often been introduced by Irish immigrants into the cities on our seaboard, and even into some of our interior towns.

Actual contact is not necessary for the communication of typhus fever from the sick to the well. The contagion may be transmitted through the atmosphere. How far it will be transmitted in this way will depend upon many circumstances. In a spacious and well-ventilated ward it is probable that the presence of one or two patients with this disease does not seriously endanger the safety of the other patients, and that the only persons who run much risk of contracting it are the physicians and nurses, who are often compelled in the performance of their duties to inhale the emanations from the bodies of the sick. At the Pennsylvania Hospital, where cases of this disease are occasionally admitted, it has been usual to isolate them by placing them in a room a few feet distant only from the dining-room of the men's medical ward and separated from the ward by a short corridor. The steward of the hospital informs me that during his connection with it, which extends over a period of more than sixty years, he has never known the disease to extend to other persons, except on two occasions. One of these was during the epidemic described by Da Costa, when an unusual number of cases was received, and when one resident physician and two nurses contracted the disease. On the other occasion, which happened during my own term of service in the spring of 1881, a young Danish sailor appeared to have taken the disease from two British seamen. As it was ascertained positively that he had not entered the room in which these two seamen were isolated, and as his bed in the ward was one of the farthest removed from the room, and he had not therefore been more or as much exposed to the contagion as the other patients, it was difficult to understand why he alone of all of them should have suffered from it. The explanation was, however, found in the fact that he had been taken over to the women's ward to act as interpreter for a countrywoman who was not known at the time to be suffering from typhus fever, and that he had remained there some time in conversation with her. Murchison and Buchanan both assert also that typhus fever has never extended from the London Fever Hospital to the inmates of adjacent houses, even when it was itself one of a row of houses. If, on the other hand, several patients with typhus fever are placed in a crowded and ill-ventilated ward, the contagion will then be found to have {345} acquired so much more virulence that few of the other patients will escape its effects.

There is also no question that typhus fever may be communicated by fomites. Numerous instances are on record in which the disease has been communicated by the wearing apparel and bed-clothes of patients, and we have already called attention to the frequency with which laundry-women in fever hospitals are attacked by it. The clothes of persons who are themselves free from the disease, but who have been in close attendance upon the sick for some time, are often also the medium of communication. Indeed, Murchison goes so far as to say that men who have not changed their clothes and "who have been living in close, ill-ventilated apartments and on short allowance, may at length have their garments so impregnated with the poison of typhus as to communicate it to others without being themselves the subjects of it," even if they have not been brought in contact with fever patients. The disease was communicated in this way, he thinks, in the famous Black Assize in 1750 by several prisoners to the court that tried them, although they were themselves free from it. On the other hand, with proper precautions there is little danger of the disease being conveyed by physicians to their own families or to other patients.

Some difference of opinion exists as to the stage at which typhus is most contagious. Many authors believe that it is more infectious during convalescence than at any other time, and base this opinion upon the fact that the removal of fever patients to the convalescent ward is very often followed by the occurrence of the disease among its other occupants; but this is probably due, as Murchison suggests, to the patients being allowed at this time to wear their own clothing, which has not been thoroughly disinfected. It is much more likely that the disease is more contagious during the stage when the febrile symptoms are most marked than during either the stage of convalescence or that of invasion. It would appear also, from the observations of Dr. Gerhard and others, that dead bodies do not readily communicate the contagion or that the contagious principle is easily counteracted after death. Still, there are several well-authenticated cases on record in which individuals have unquestionably contracted the disease from dissecting the bodies of patients dead from this cause.

A question of great interest naturally arises here, as to whether or not typhus fever ever occurs except as the consequence of exposure to a previous case of the disease. Is it, in other words, ever generated de novo? Authorities are divided upon this point, many contending that an independent origin is impossible, and others that it may occasionally arise in this way. Among the latter is Murchison, who adduces in support of the position he takes several instances in which poverty, with overcrowding and deficient ventilation, appears to have been the only cause of extensive outbreaks of the disease, as in the case of the Black Assize already alluded to. These cases the opposite party explain by assuming that the germs of the disease are capable of lying dormant for a long time until roused into activity by favoring circumstances. If the disease is caused, as we have shown there is good reason to believe it is, by the presence of a minute organism, this view does not seem to be untenable. Pasteur has demonstrated that the germs of the splenic fever of some of the lower {346} animals may be deprived of their virulence by cultivation in appropriate liquids. If their virulence is diminished under certain circumstances, the assumption does not seem unwarrantable that under others it may be increased, and if we may draw this conclusion in regard to one form of microscopic growth, we may do the same for others; and the hypothesis is therefore not an unreasonable one that the typhus germ needs the atmosphere engendered by overcrowding for it to acquire the power to produce the disease.

PERIOD OF INCUBATION.--The period of incubation of typhus fever appears to vary considerably in length, but is usually about twelve days. In some cases the interval between exposure to the contagion and the occurrence of the first symptoms of the disease is asserted to have been considerably longer, and in one instance as long as thirty-one days; but it is probable that there has been in most, if not in all, of these cases a second exposure which has been overlooked. On the other hand, it is said to have followed at once upon exposure, as in cases reported by Gerhard, in one of which a nurse inhaled the breath of a patient whom he was shaving, and in an hour afterward was taken with cephalalgia and ringing in the ears, which were immediately succeeded by the other symptoms of typhus. In this and other similar cases which are on record it is difficult to exclude the possibility of a previous infection. In a case, however, reported by Murchison there would seem to be no reason to suspect that any such previous infection could have taken place, as the patient, the matron of an orphan asylum where there was no typhus, was taken ill immediately after opening a bundle of clothes which a child had brought with her from a fever hospital, and which had not been thoroughly disinfected.

SYMPTOMATOLOGY.--It will facilitate the study of typhus fever to give, in the first place, as most of the systematic writers on fever have done, a brief clinical sketch of the disease as it ordinarily occurs, and then afterward to consider its leading symptoms in greater detail.

GENERAL DESCRIPTION.--An attack of typhus fever is sometimes preceded for a few days by prodromata, such as a feeling of malaise, indisposition to exertion, pain in the head and limbs, anorexia, and vertigo; but it oftener begins abruptly with a slight chill, or more rarely with a decided rigor. This is followed in a short time by headache, by a marked rise of temperature, and by an increased frequency of pulse and respiration. Nausea is also occasionally present, and less frequently vomiting. The tongue is at first moist and covered with a thin whitish fur, but soon becomes dryish, and its coating is apt to assume a brownish appearance in a day or two. With these symptoms there are loss of appetite, great thirst, constipation, a dull, heavy expression of countenance, a dark, dusky hue of the face, and injection of the conjunctivæ. Mental confusion is early observed, so that, although the patient may be able to answer questions correctly when thoroughly roused, it is readily seen that his mind is working with difficulty. The sleep is very often disturbed by dreams, so that he awakes from it unrefreshed. Prostration and loss of muscular power are so decided from the very beginning of the disease that the patient is obliged usually to take to his bed at once, and it is much rarer to meet with walking cases of the disease than in typhoid fever. The urine is dense, scanty, and high-colored.

{347} Usually, about the fourth day of the disease the characteristic eruption of typhus fever makes its appearance. It consists of numerous spots of irregular form with ill-defined margins and of a dark red or purplish color, occurring singly or in groups, and varying in size from that of a pin's point to two or three lines in diameter. They disappear at first under pressure, but in twenty-four hours become persistent, and in severe cases may be converted later into petechiæ. Besides this eruption there is another which consists of a faint, irregular dusky red, subcuticular mottling. The two eruptions together constitute the mulberry rash of Jenner, and have been variously described by different authors under the name of measly or morbilliform rash.

As the disease advances the prostration becomes greater and the pulse grows weaker. The tongue becomes dry and brown and trembles when protruded. Later, it is so dry and contracted that it can scarcely be put out of the mouth. Sordes collect about the teeth and lips, and the surface exhales a peculiar odor. The headache grows more severe or gives place to delirium, which may at first be active and violent, and then pass into the low and muttering form, or the delirium may be of the latter variety from the start. The sleeplessness of the early stages may continue, and the condition known as coma vigil not infrequently supervenes. The delirium is usually followed by stupor, which is more or less profound in accordance with the severity of the case, and which is accompanied by all the symptoms which characterize the so-called typhoid state, such as subsultus tendinum, picking at the bed-clothes, slipping down in bed, retention or incontinence of urine, and sloughing of the parts exposed to pressure. In this condition the temperature, although usually still considerably above normal, is lower than during the first week of the disease.

Meanwhile, the issue remains in doubt, and may continue uncertain for several days before any improvement in the symptoms can be observed, or, the stupor passing into coma, the case may speedily terminate in death. When death is the result, it usually takes place about the close of the second week or a little later, but it may occur earlier in consequence of the violence of the fever, or, when due to a complication, may be postponed until after the end of the third week. Fortunately, however, recovery is the rule in this disease. The beginning of convalescence is often as abrupt as that of the attack itself. The temperature will often be found to have fallen to the normal or below the normal, the pulse and respiration to have returned to a healthy condition, and all confusion of the intellect to have disappeared in the course of a few hours. Occasionally, however, its approach is more gradual, and a slight fall in temperature and a corresponding improvement in the other symptoms may be observed before it actually occurs. Diarrhoea, an excessive secretion of urine, with a tendency to the deposition of urates, and moderate sweating, often take place simultaneously with the cessation of the fever, and were formerly regarded as critical discharges. The return to health is usually rapid, and very rarely retarded by the occurrence of complications or relapses, as in typhoid fever. The disease itself leaves no tendency to any other disease.

DESCRIPTION OF SPECIAL SYMPTOMS.--The appearance of a patient with typhus fever is pathognomonic, and is often alone sufficient to enable {348} a physician or nurse familiar with it to recognize the disease when brought in contact with it. The surface generally is congested; the face is flushed, and in bad cases dusky red or even livid in hue; the expression is dull and vacant, except during delirium, when it may be wild or even fierce; the conjunctivæ are injected, the eyes watery, and the teeth encrusted with sordes. The skin is generally hot and dry, except toward the close of bad cases, when it may be cool and bathed in a profuse sweat.

The symptoms connected with the nervous system are among the most characteristic of the disease, and of them none is more marked than prostration. It shows itself early, the patient usually taking to his bed immediately after his seizure or within a few days of it. It is much rarer than in typhoid fever to meet with walking cases of typhus, but Buchanan[22] mentions that patients with the rash already out upon them do occasionally present themselves at the out-door department of the London Fever Hospital. It generally increases as the disease progresses, and is often accompanied by a tendency to syncope. It may attain such a degree that the patient is unable to turn himself in bed or to help himself in any way. Among the most distressing sensations which attend this condition of excessive feebleness is a feeling as if he were sinking into the earth with nothing to support him. Headache is also an early symptom. It is often observed among the prodromata of the disease, and when these are absent supervenes directly after the chill. It is usually frontal, but may be diffused. It is generally dull and heavy, but is sometimes acute, and may be accompanied by a tendency to vertigo, increased by sitting up, and by pains in the back and limbs. It becomes more severe with the progress of the disease until the occurrence of delirium, when it is, as a rule, less complained of. With the headache there is generally some dulness of intellect, except in mild cases. This may be slight at first, and may continue so throughout the whole course of the attack, exhibiting itself principally in some confusion as to dates. In more severe cases it is much more marked, and may finally pass into actual stupor. On the other hand, it may be entirely absent, even in severe attacks, as in a case reported by Da Costa and in some cases recently observed by myself. It is usually soon replaced by delirium, which may be low and muttering or wild and noisy, the former being the more common. Delirium is said to occur most frequently among the educated classes and those oppressed with care and anxiety, but is not rare among those who occupy a lower position in the social scale, especially the intemperate. It is, as a rule, most marked at night, and in mild cases may occur only at that time or upon waking in the morning. When the delirium is active the patient may shout and scream, or leave his bed and attempt to throw himself from the window, being endowed apparently for the moment with strength sufficient to enable him to commit these acts of violence. After the paroxysm is over he sinks back in bed exhausted. The confusion of intellect or delirium continues in bad cases until death supervenes or until the establishment of convalescence. Indeed, the mental disturbance does not always end with the latter, and it is not rare for feebleness of intellect to persist for some time after the patient has in other respects regained his usual health, and in a few cases insanity has followed an attack of typhus fever. Among the most {349} formidable of the symptoms of typhus are convulsions, which are fortunately of infrequent occurrence.

[Footnote 22: _Loc. cit._]

The patient generally suffers from wakefulness, except during the first few days. When sleep is obtained it may be unrefreshing or broken and disturbed by dreams. In other cases the opposite condition of somnolence may be present. Occasionally, after having apparently slept for hours, he may deny having been asleep at all. This condition, which constitutes the coma vigil of Chomel, is entirely distinct from that described by Jenner under the same name, in which the patient lies with his eyes wide open, gazing into vacuity, his mouth only partly closed, his face pale and devoid of expression, and which is invariably fatal. Muscular tremor is more or less present in all cases of the disease, and in bad cases may be a prominent symptom. The disease, when this symptom is marked, especially if there is at the same time low, muttering delirium and a moist skin, presents a considerable degree of resemblance to delirium tremens. There is very often intolerance of light, tinnitus aurium, and loss or perversion of the senses of taste and smell. Deafness is also not uncommon, and is regarded by many authors as a favorable symptom. In bad cases, in addition to subsultus tendinum, there are carphologia, incontinence or retention of the urine, and paralysis of the sphincter ani.

Some discrepancy is found to exist in the statements of different authors in regard to the temperature curves of typhus fever. They all agree, however, in assigning them certain characters, the knowledge of which is often of great assistance in diagnosis. One of these is a rapid rise of temperature immediately after the invasion of the disease. Wunderlich[23] asserts that he has observed a temperature of 104.9° F. on the evening of the first day, and Lebert has found it as high as 106.4° F. on that of the second. Such temperatures, occurring so early in the disease, must be infrequent, as Murchison has never met with them. Usually, the temperature attains its maximum on the third or fourth day. The maximum is about 104° or 105° F. Murchison says it scarcely ever reaches 106°, except in children, in whom it rarely is as high as 107°, but Lebert states that he has known it to be as high as 107.8°. On the other hand, it may never exceed 103°, even in fatal cases. When the maximum is attained early in the disease there may be for several days, or until defervescence takes place, very little variation in the evening temperatures, but, as a general rule, they are slightly less elevated in the second than in the first week. This usually occurs from the tenth to the fourteenth day, but it may be postponed until the eighteenth, or even until much later. In some cases on the day before the crisis a slight fall, and in others a considerable fall with a subsequent rise of temperature, are observed. Defervescence is often very rapid, the temperature falling five or six degrees in the course of twelve hours. A true lysis is rarely observed. The occurrence of a complication in the course of a disease will not only cause a decided rise of temperature and a modification of the temperature curve, but may also postpone defervescence beyond the usual time. Not infrequently the thermometer indicates subnormal morning temperatures with slight evening rises for several days after the crisis, unless complications arise, {350} when fever of the hectic type may occur. A very slight cause will also often produce a considerable, although temporary, elevation of temperature in this condition. The morning remissions are less decided than in typhoid fever, especially in the first week. As a rule, they do not exceed 1°, but Lebert lays stress upon the fact that in the same curve variations from 0.3° to 1.8° and from 0.6° to 2.1° often occur. Cases which terminate fatally are generally characterized by high fever, with absence of the morning remissions, which may continue uninterruptedly through the second and even the third week. During the death-agony there is frequently a rise of temperature of two or more degrees. A very high temperature in the first week is often the forerunner of severe cerebral symptoms in the second, and a fall of temperature unaccompanied by an improvement in the other symptoms is not always indicative of the approach of convalescence.

[Footnote 23: _On the Temperature in Disease_, New Sydenham Society's translation, London, 1871.]

Anorexia is generally present in typhus fever from the beginning of 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.