Typhus Fever.

Synonyms.—Famine Fever; Ship Fever; Jail Fever; Hospital Fever; and Putrid Fever.

Definition.—An acute, infectious fever, endemic and also epidemic, where great masses of people are congregated without regard to proper sanitation. It is characterized by a sudden invasion, high grade of fever, a peculiar rash, great nervous derangement, and terminates in from twelve to sixteen days by crisis.

History.—According to Murchison, to study the history of typhus fever would require an historic study of Europe for three hundred and fifty years, during which time severe epidemics have proven more destructive than war. Until the latter half of the present century but little attention was given to sanitation, in the army, on shipboard, in jails, prisons, or even in hospitals; hence the great loss of life; but the great improvement of modern sanitary regulations is rendering the disease less dreaded and far less fatal. Typhus fever is still epidemic in Ireland, England, Poland, Russia, Hungary, and Italy.

In 1807 the fever appeared in the New England States, and visited each in rapid succession. In 1812 it appeared in Philadelphia, and again in 1836, in 1865, and in 1883. New York was visited in 1881, 1882, and 1893 by epidemics of this fever. In all of these epidemics the, disease sustained its reputation as the deadly typhus. Since 1893 but few cases have been reported, and, with improved sanitation and the rigid quarantine regulations adopted by this country, typhus fever will soon have only an historic interest for the American physician.

Etiology.—The predisposing causes are, filth, poverty, and overcrowding, without due regard to cleanliness, especially in regard to the removal and destruction of human excreta.

Intemperance, one of the most fruitful causes of poverty, weakens and saps the vitality to such an extent that its victims readily' succumb to typhus. Poor food naturally makes poor blood, and poor blood is a soil where toxins flourish and multiply.

Exciting Cause.—The specific cause has not yet been isolated, although undoubtedly similar in character to that of other infectious diseases, and when once it finds entrance into the system of one susceptible to the poison or germ, it has the power of multiplying and reproducing the original toxin. Although highly contagious, the infection has but a short range and only those in close contact with the patient are apt to contract the disease; hence nurses and physicians are in special danger. "In the Crimean war—1854-56—during the height of the epidemic, in a single period of fifty-seven days, typhus fever attacked six hundred and three nurses in a total of eight hundred and forty in the service; and in the Russo-Turkish war, 60 per cent of the physicians Were attacked." Those who handle the soiled linen are peculiarly liable to the infection, as the linen retains the poison for a long period.

Pathology.—There are no characteristic lesions of the viscera. The blood is dark and diffluent, the result of the intense fever and rapid work of the poison. The liver is somewhat enlarged and softened, as are the kidneys and spleen, and each becomes dark-red in color. There is generally a bronchial catarrh, and many times hypostatic congestion of the lungs.

Extravasation into the pericardium gives it an ecchymotic appearance, which is also seen in the gastro-intestinal mucosa. The intestinal lesion is not characteristic as in typhoid fever, and while there may be hyperplasia of the lymph follicles, there is never ulceration as in the former. Peyer's plaques are also intact, although congested.

There is often granular engorgement, but the process stops short of suppuration. The muscular tissues are of a dark-red color, and the heart often shows granular degeneration, and is of the same dark-red color. There may be cerebral congestion, with effusion into the subarachnoid space and the ventricles. The coagulability of the blood is greatly diminished. The skin shows a characteristic rash, and ecchymotic spots are found on the more dependent parts after death.

Symptoms.—The period of incubation, the time from exposure to invasion, varies from three to twelve days, according to the intensity of the infectious material and the susceptibility of the patient. Although the onset is usually sudden, we may have during the last three or four days prior to the invasion the usual prodromal symptoms that accompany most fevers; viz., headache, languor, loss of appetite, aching of back and limbs, insomnia, and partial arrest of the secretions. These increase progressively until the chilly sensations or a rigor proclaim the invasion.

Invasion.—The chilly sensations continue for several hours or a sharp, short chill may announce the unwelcome guest. The patient complains of severe pain in his head, and the muscles seem sore as if bruised. There is now great prostration, and the patient is compelled to take to his bed. The temperature rises very rapidly, and by the end of twenty-four or forty-eight hours the temperature may register 104° or 105°. The pulse is rapid, full, and bounding, with throbbing of the carotids, although after the first forty-eight hours the pulse loses its strong impulse and becomes small and feeble, showing the influence of the toxin on the heart.

The face is characteristic. There is a dusky flush, with injected and contracted pupils. The skin is dry and pungent; the tongue is at first but slightly coated, but soon acquires a thick, dry, and brown coating. There is often nausea and vomiting during the first forty-eight hours. The pain in the head becomes intense, and the symptoms of meningitis are often present. The mind is early impressed, and delirium may occur as early as the second day, varying greatly in character, from the mild to the most intense. Usually, however, the patient becomes dull, and is impressed with difficulty, and stupor is an early feature.

Eruption.—From the third to the fifth day the eruption makes its appearance, at first on the abdomen, gradually encroaching upon the other parts of the body, although singularly sparing the face in most cases. The rash is characteristic, first appearing as bright red macules, disappearing on pressure, and soon changing to a dark, dingy red, becoming hemorrhagic in character, and petechia follows, the rash remaining after death.

There is no abatement of the fever with the appearance of the rash. By the end of the first week the fever is intense and uniform. Temperature 104°, 105°, or 106°. The tongue is dry and almost immobile; sordes appear on teeth and lips; the skin is hot, dry, and constricted; the urine is scanty and contains albumen. With the appearance of the eruption there is often retention of the urine. The patient lies upon his back, and tends to slip towards the foot of the bed. Although there is stupor, the eye may be open and the patient muttering; or the delirium may be very active. From the seventh to the fourteenth day the symptoms are quite uniform, showing great depression and much deprivation of the blood. There is increased suppression of muscular power, and an increase of involuntary action, as tremors, subsultus tendinum, and slight convulsive action.

The symptoms of the crisis have been thus described: "At the end of the thirteenth day a more serious exacerbation than any former one takes place; the heat is more glowing, the arteries pulsate more strongly, the brain is more affected, and the stupor passes into sopor. In twelve hours afterward, and on the fourteenth day, the parched skin shows a tendency to perspiration. In some cases slight epistaxis occurs, with relief to the head; the nostrils become moist; the tongue, at the point and edge, moist, clean, and red, and perspiration more copious and general.

"A free expectoration often takes place, especially if the chest has been affected. When the perspiration is salutary, it is uniform, not clammy, has a peculiar odor, and occurs during sleep. The stools are now copious, loose, and offensive; the urine plentiful, muddy, and slightly colored, and deposits a copious sediment. With these changes, or within a few hours afterward, the patient seems as if awakened from a dream, or from a state of intoxication. and, with the return of complete consciousness, all the severe symptoms abate." Convalescence is usually quite rapid and uneventful.

Complications.—The most frequent, and quite common complication, is bronchitis, which occurs from the third to the seventh day. There is a sense of constriction of the chest, hurried respiration, dry, hard, and harassing cough, with an aggravation of all the symptoms. There may be hypostatic congestion of the lungs, rendering the respiration more labored; the duskiness of face increases, showing imperfect aeration of the blood. Thus more work is thrown on the heart, which greatly endangers the patient's recovery.

Temperature.—As will be seen by studying the chart, the range of temperature in typhus fever is higher than in any other fever, frequently running for ten days at 105 or more. In the milder cases the high range does not occur, and after the seventh day there is a more rapid decline, convalescence commencing the eighth or tenth day.

Diagnosis.—The diagnosis is readily made. The known presence of an epidemic, the sudden invasion beginning with a rigor, the high grade of fever, the more intense disturbance of the nervous system, the dusky flush of the face, the characteristic petechial eruption occurring the third day, render the diagnosis comparatively easy. We diagnose it from typhoid by the long forming stage of the latter, the less intense febrile reaction, and also less disturbance of the nervous system, the absence of the intestinal lesion, the difference in character of the eruption, and. also the time of its appearance.

In sporadic cases, if not careful, we may mistake it for spinal-meningitis, although in the latter the head symptoms are more pronounced, with retraction of the head, marked tenderness on pressure over the cervical region, and an absence, on the third day, of the petechial rash.

Prognosis.—The prognosis depends upon several conditions,—the severity of the epidemic prevailing; the character of the complications; the vitality of the patient, the mortality being great where this is reduced; the age of the patient, but few children dying, while, after middle life, the mortality increases; the intensity of the lesion of the nervous system, and the severity of the blood lesion.

Race is also to be considered, the colored race succumb more rapidly than the white race. The mortality is given at from ten to thirty-five per cent, but with the sanitation now in vogue, and the use of remedies with which we have been successful in overcoming sthenic fevers, and the septic conditions, the mortality should not be large.

Treatment.—The prophylactic treatment should consist of disinfection, immediate isolation, and a persistent effort at cleanliness. There should be plenty of pure, fresh air in the sickroom.

In the treatment of this disease there are three conditions to overcome,—sepsis, high temperature, and wrongs of the nervous system; the two latter, no doubt, being- due to the first, sepsis.

The room, where possible, should be large, well ventilated, and the temperature, if in winter, not allowed over 68 degrees.

Veratrum.—Where there is a full, bounding pulse and throbbing of the carotids, veratrum, drachms .5 to drachms 1, to water 4 ounces, will be the indicated remedy. In connection with this, the wet-sheet pack may be used, if temperature be very high, 104° or 105°. Where the poison is intense, the extremities are cold, the patient is dull and drowsy, and the pulse feeble and oppressed, blankets wrung out of hot mustard-water, and placed about the patient, with a stimulating emetic of capsicum and lobelia, will give good results.

Belladonna will be called for where there is dullness and coma.

Gelsemium will be the remedy where there is great irritation and active delirium.

Hyoscyamus will also be used where the patient is restless and unable to sleep.

Echinacea.—This remedy should give a good account of itself in typhus fever. The furred tongue, the dusky hue, calls for the agent. Echinacea, drachms 1 to water 4 ounces, teaspoonful every hour. It should be continued with the proper sedative.

Baptisia.—The full tissues with purplish hue, as if the patient had been frozen, calls for baptisia.

Sodium Sulphite.—Where the tongue is broad, moist, and heavily coated with a dirty, pasty coating, a saturated solution of sodium sulphite, in tablespoonful doses, will not disappoint.

Potassium Chlorate is the remedy for bad odors, and where the tongue is moist, dirty, and the breath foul, potassium chlorate will be the remedy.

Hydrochloric Acid.—Where the tongue is dry, brown, or red, sordes on teeth and lips, nothing can take the place of hydrochloric acid, C. P., 20 drops, simple syrup and water 2 ounces each. Teaspoonful every two hours. This is one of the most severe forms of fever; but, with good nursing, the proper antiseptics, the proper wet-sheet packs, and the use of belladonna, gelsemium, and hyoscyamus for the nervous lesions, many will recover.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.