TYPHUS

FEVER (from Gr. ri 4 os,

See also:

• SMOKE (from O. Eng. smeocan, to smoke, reek, cf. Dutch meek, Ger. Schmauch, probably allied to Gr. vol9caiv)

smoke or mist, in allusion to the stupor of the disease)  , an acute infectious disease of highly contagious nature, lasting for about fourteen days, and characterized mainly by great prostration of strength,severe nervous symptoms, and a peculiar eruption on the skin . It has received numerous other names, such as pestilential, putrid, jail, hospital fever, exanthematic typhus, &c . It appears to have been known for many centuries as a destructive malady, frequently appearing in epidemic form, in all countries in 'Europe, under the conditions to be afterwards referred to . The best accounts of the disease are those given by old English writers, who narrate its ravages in towns and describe many " black assizes," in which it was communicated by prisoners brought into court to the judges, jurymen, court officials, &c., with fatal effect . Typhus fever would seem to have been observed in almost all parts of the world; but it has most frequently prevailed in temperate or cold climates . The conditions concerned in its production include both the predisposing and the exciting . Of the former the most powerful are those influences which lower the health of a community, especially overcrowding and poverty . Hence this fever is most frequently found to affect the poor of large cities and towns, or to appear where large numbers of persons are living crowded together in unfavourable hygienic conditions, as has often been seen in prisons, workhouses, &c . Armies in the field are also liable to suffer from this disease; for instance, during the Crimean War it caused an enormous mortality among the French troops . Recently, however, an important change of view of the connexion of typhus fever has arisen . Professor Matthew Hay (Journal of Public Health, September 1907) attributes the spread of typhus fever to fleas . His observations are based on the epidemic in Aberdeen .

He sums up his conclusions in the following manner: (1) Every

case in hospital examined by Professor Hay and his assistants was flea bitten, and those of the staff who complained of flea bites were attacked . Care was exercised to distinguish between flea bites and petechiae . (2) Where a patient was apparently free from bites it was found he had been in contact with verminous families . (3) The disease did not spread in clean houses with clean inhabitants, even when a typhus patient remained in the dwelling during his entire illness . (4) All nurses or wards-maids who were attacked were in contact with the patients when they were first admitted . No nurse, wards-maid or doctor who had been in close contact with the cases when cleaned contracted the disease: (5) An ambulance driver who complained of being pestered by fleas contracted typhus fever, but when the ambulance staff were adequately protected from fleas no other cases developed . Typhus is now regarded as certainly due to the action of some specific micro-organism (see PARASITIC DISEASES), but the bacteriology is still imperfect . In 1891 Jaroslav Hlava, of Prague, found in the blood of 20 out of 33 cases of typhus a well-defined organism which he termed the strepto-bacillus . Lewaschew in 1892 found in the blood and spleen of typhus patients small round highly refractive actively-moving bodies lying between the corpuscles . Sometimes these bodies were flagellate . Dubieff and Bruhl also found a diplococcus in the blood which they named the diplococcus exanthematicus . The course of typhus fever is characterized by certain well-marked stages .

1 . The

stage of incubation, or the period elapsing between the reception of the fever poison into the system and the manifestation of the special evidence of the disease, is believed to vary from a week to ten days . During this time, beyond feelings of languor, no particular symptoms are exhibited . 2 . The invasion of the fever is in general well marked and severe, in the form of a distinct rigor, or of feelings of chilliness lasting for hours, and a sense of illness and prostration, together with headache of a distressing character and sleeplessness . Feverish symptoms soon appear and the temperature of the body rises to a considerable height (103°–105°F.), at which it continues with little daily variation until about the period of the crisis . It is, however, of importance to observe certain points connected with the temperature during the progress of this fever . Thus about the seventh day the acme of the fever heat has been reached, and a slight subsidence (I° or less) of the temperature takes place in favourable cases, and no further subsequent rise beyond this lowered level occurs . When it is otherwise, the case often proves a severe one . Again, when the fever has advanced towards the end of the second week, slight falls of temperature are often observed, prior to the extensive descent which marks the attainment of the crisis . The pulse in HISTORY] typhus fever is rapid (1oo-12o or more) and at first full, but later on feeble . Its condition as indicating the strength of the heart's action is watched with anxiety .

The

tongue, at first coated with a white fur, soon becomes brown and dry, while sordes (dried mucus, &c.) accumulate upon the teeth; the appetite is gone; and intense thirst prevails . The bowels are as a rule constipated, and the urine is diminished in amount and high coloured . The physician may make out distinct enlargement of the spleen . 3 . The third stage is characterized by the appearance of the eruption, which generally shows itself about the fourth or fifth day or later, and consists of dark red (mulberry-coloured) spots or blotches varying in size from mere points to three or four lines in diameter, very slightly elevated above the skin, at first disappearing on pressure, but tending to become both darker in hue and more permanent . They appear chiefly on the abdomen, sides, back and limbs, and occasionally on the face . Besides this characteristic typhus rash, there is usually a general faint mottling all over the surface . The typhus rash is rarely absent and is a very important diagnostic of the disease . In the more severe and fatal forms of the fever the rash has all through a very dark colour, and slight subcutaneous haemorrhages (petechiae) are to be seen in abundance . After the appearance of the eruption the patient's condition seems to be easier, so far as regards the headache and discomfort which marked the outset of the symptoms; but this is also to be ascribed to the tendency to pass into the typhous stupor which supervenes about this time, and becomes more marked throughout the course of the second week . On the examination of the blood a marked leucocytosis is present This is considered to be diagnostic in doubtful cases when the rash is badly marked . The patient now lies on his back, with a dull dusky countenance, an apathetic or stupid expression, and contracted pupils .

All the febrile symptoms already mentioned are fully developed, and

delirium, usually of a low muttering kind, but sometimes wild and maniacal (delirium ferox), is present both by night and day . The peculiar condition to which the term " coma vigil " is applied, in which the patient, though quite unconscious, lies with eyes widely open, is regarded, especially if persisting for any length of time, as an unfavourable omen . Throughout the second week the symptoms continue unabated; but there is in addition great weakness, the pulse becoming very feeble, the breathing shallow and rapid, and often accompanied with bronchial sounds . 4 . A crisis or favourable change takes place about the end of the second or beginning of the third week (on an average the r4th day), and is marked by a more or less abrupt fall of the temperature and of the pulse, together with slight perspiration, a discharge of loaded urine, the return of moisture to the tongue, and by a change in the patient's look, which shows signs of returning intelligence . Although the sense of weakness is extreme, convalescence is in general steady and comparatively rapid . Typhus fever may, however, prove fatal during any stage of its progress and in the early convalescence, either from sudden failure of the heart's action—a condition which is specially apt to arise—from the supervention of some nervous symptoms, such as meningitis or of deepening coma, or from some other complication, such as bronchitis . Further, a fatal result sometimes takes place before the crisis from sheer exhaustion, particularly in the case of those whose physical or nervous energies have been lowered by hard work, inadequate nourishment and sleep, or intemperance . Occasionally troublesome sequelae remain for a greater or less length of time . Among these may be mentioned mental weakness or irritability, occasionally some form of paralysis, an inflamed condition of the lymphatic vessels of one leg (the swelled leg of fever), prolonged weakness and ill health, &c . Gradual improvement, however, may be confidently anticipated and even ultimately recovery . The mortality from typhus fever is estimated by Charles Murchison (183o-1879) and others as averaging about 18% of the cases, but it varies much according to the severity of type (particularly in epidemics), the previous health and habits of the individual, and very specially the age—the proportion of deaths being in striking relation to the advance of life .

Thus, while in

children under fifteen the death-rate is only 5 %, in persons over fifty it is about 46% . The treatment of typhus fever includes the prophylactic measures of attention to the sanitation of the more densely populated por-Treatment. tions of towns . Where typhus has broken out in a crowded district the prompt removal of the patients to a fever hospital and the thorough disinfection and cleansing of the infected houses are to be recommended . Where, however, a single case of accidentally caught typhus occurs in a member of a family inhabiting a well-aired house, the chance of it being communicated to others in the dwelling is small; nevertheless every precaution in the way of isolation and disinfection should be taken . The treatment of a typhus patient is conducted upon the same general principles as in typhoid . Complete isolation should be maintained throughout the illness, and due attention given to the ventilation and cleansing of the sick chamber . Open-air treatment when practicable greatly reduces the temperature . The main element in the treatment of this fever is good nursing, and especially509 the regular administration of nutriment, of which the best form is milk, although light plain soup may also be given . The food should be administered at stated intervals, not, as a rule, oftener than once in one and a half or two hours, and it will frequently be necessary to rouse the patient from his stupor for this purpose . Sometimes it is impossible to administer food by the mouth, in which case recourse must be had to nutrient enemata . Alcoholic stimulants are not often required, except in the case of elderly and weakly persons who have become greatly exhuasted by the attack and are threatening to collapse . When the pulse shows unsteadiness and undue rapidity, and the first sound of the heart is but indistinctly heard by the stethoscope, the prompt administration of stimulants (of which the best form is pure spirit) will often succeed in averting danger .

Should their use appear to increase the restlessness or delirium they should be discontinued and the diffusible (ammoniacal or ethereal) forms tried instead . Many other symptoms demand special treatment . The headache may be mitigated by removing the

hair and applying cold to the head . The sleeplessness, with or without delirium, may be combated by quietness, by a moderately darkened room (although a distinction between day and night should be made as regards the amount of admitted light), and by soothing and gentle dealing on the part of the nurse . Opiate and sedative medicines in any form, although recommended by many high authorities, must be given with great caution, as their use is often attended with danger in this fever, where coma is apt to supervene . When resorted to, probably the safest form is a combination of the bromide of potassium or ammonium with a guarded amount of chloral . Alarming effects sometimes follow the administration of opium . Occasionally the deep stupor calls for remedies to rouse the patient, and these may be employed in the form of mustard or cantharides to the surface (calves of legs, nape of neck, over region of heart, &c.), of the cold affusion, or of enemata containing turpentine . The height of the temperature may be a serious symptom, and antipyretic remedies appear to have but a slight influence over it as compared to that which they possess in typhoid fever, acute rheumatism, &c . Hugo Wilhelm von Ziemssen (1829–1902) strongly recommends baths in hyperpyrexia, the temperature of the bath being gradually reduced by the addition of ice . Cold sponging of the hands and feet and exposed parts, or cold to the head, may often considerably lower the temperature . Throughout the progress of a case the condition of the bladder requires special attention, owing to the patient's drowsiness, and the regular use of the catheter becomes, as a rule, necessary with the advance of the symptoms .