A system of practical medicine. By American authors. Vol. 1

by Unknown

TYPHUS FEVER.

BY JAMES H. HUTCHINSON, M.D.

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DEFINITION.—Typhus fever is an acute contagious disease, usually occurring epidemically, lasting from ten to twenty days, and characterized, among other symptoms, by an abrupt commencement, great prostration, profound derangement of the nervous system, and a peculiar eruption which appears between the third and eighth days, and which, disappearing at first under pressure, soon becomes persistent, and in severe cases may be converted into and be associated with true petechiæ. When it proves fatal, it generally does so at or near the end of the second week. The lesions found after death are not specific in character, and consist mainly of a marked alteration of the blood, congestions of internal organs, softening of the heart, and atrophy of the brain.

SYNONYMS.—Petechial Typhus, Putrid or Malignant Fever, Camp, Jail, Ship, or Hospital Fever, Spotted Fever, Irish Ague, Contagious Typhus, Brain Fever, Adynamic or Ataxic Fever, Ochlotic Fever, Catarrhal Typhus.

The term typhus was first applied by Sauvages in 1760, and afterward by Cullen, to certain forms of fever, characterized by marked prominence of the nervous symptoms, to distinguish them from another group of cases to which they gave the name synochus, and is derived from the Greek word [Greek: typhos], which literally means smoke, and which is employed in the treatise on internal affections attributed to Hippocrates for a similar purpose. According to Murchison,¹ Hippocrates used the word to define a "confused state of the intellect, with a tendency to stupor." The appellation typhus, therefore, as indicating a very prominent symptom of the disease about to be described, is perhaps the best that could be given to it. It has been generally adopted by the physicians in England and in this country to denote this disease, but on the Continent, and especially in Germany, it is applied also to typhoid fever, the two fevers being usually designated there as typhus petechialis and typhus abdominalis, respectively.

¹ A Treatise on the Continued Fevers of Great Britain, by Charles Murchison, M.D., LL.D., F.R.S., etc., second edition, London, 1873.

HISTORY.—As human want and misery and the evils which follow in the train of war have never been wholly absent from the world, and as these are the conditions which are now known to be favorable to the spread, if not to the generation, of typhus fever, it is highly probable that this disease was the cause of some of the epidemics to which allusion is made by the sacred and profane writers of antiquity. Yet their descriptions are too vague to justify us in assuming that such was positively the case. The records of the first fifteen centuries of our own era are similarly wanting in details, for, with the exception of a brief notice of an outbreak of the disease in the monastery of La Cava, near Salerno, in the year 1083, by Corradi² it may be said to have been practically undescribed before the year 1546, when Fracastorius³ published his work, De Contagionibus et Morbis Contagiosis. From the description which this distinguished physician gives there of the epidemics which prevailed in Verona in the years 1505 and 1508, there can be no doubt that the disease he had the opportunity of observing was really typhus fever. Not only are the principal symptoms succinctly described, but its contagiousness and tendency to early prostration fully recognized. We learn also, from the same work, that the disease, although previously unknown in Italy, was one with which the physicians of Cyprus and the neighboring islands were perfectly familiar. According to the same authority, it again made its appearance in 1528 in Italy, and from there extended to Germany.

² In Chron. Cavense Annali, p. 1, 101, quoted in Handbuch der Historish-Geographischen Pathologie, von Dr. August Hirsch, Stuttgart, 1881.

³ Quoted by Murchison.

During the last half of the sixteenth century epidemics of typhus fever would seem to have been of more frequent occurrence than before it, since many of the medical authors of this period not only refer to it very fully, but also give accurate descriptions of the disease. There is also abundant evidence of the same kind that it frequently prevailed epidemically in almost every part of Europe during the seventeenth and eighteenth centuries, following generally in the wake of famine and of war, and often attaining a high degree of virulence in besieged towns. The histories of many of these epidemics are exceedingly interesting, especially those of the so-called Black Assizes which occurred at different times in several of the towns of England, and which derived their name from the fact that the disease was communicated from the prisoners on trial to the judges and other persons in attendance upon the court; but to give these in detail would be beyond the scope of this article. Although many of the authors of these two centuries boldly advocated copious venesection as the only rational method of treating the disease, there was a not inconsiderable number who recognized its essentially typhoid nature, its tendency to early prostration, and the fact that patients suffering from it bear bleeding badly, as fully as is done by physicians of the present day. They were also unquestionably quite aware of the circumstances under which typhus fever generally arises, for in 1735, Browne Langrish⁴ wrote that it originated from "the effluvia of human live bodies," and that its principal cause was overcrowding with deficient ventilation, as a result of which "people were made to inhale their own steams;" and a similar opinion was expressed a few years later by Sir John Pringle,⁵ J. Carmichael Smyth,⁶ and others.

⁴ The Modern Theory and Practice of Physics, by Browne Langrish, p. 354, London, 1764.

⁵ Observations in Diseases of the Army, London.

⁶ Quoted by Murchison.

Epidemics of typhus fever have frequently occurred in various parts of Europe during the present century, although they have, on the whole, shown a greater tendency than before to confine themselves to the place in which they first appeared. The most severe of these began in 1846, and after committing great ravages in Ireland extended to England, and subsequently to the Continent. The disease proved much more fatal than the sword in the armies of Napoleon in the towns besieged by him in the early part of this century, and was the cause of an immense loss of life in the Russian and French armies in the Crimea after the fall of Sebastopol.

In our own country typhus fever has appeared several times during the present century, but the outbreaks have rarely attained the magnitude of epidemics, such as are seen in Europe, and have usually been distinctly traceable to importation from abroad. It was first met with, according to Wood,⁷ in New England in 1807 and in Philadelphia in 1812, continuing to lurk, this author says, in the lanes and alleys of that city until the winter of 1820-21, when, as a student of medicine, he had an opportunity of studying it. Another outbreak of the disease occurred in the same city in 1836, and is the subject of an admirable paper by the late Wm. S. Gerhard.⁸ Since then epidemics of moderate severity have repeatedly occurred at different times in several of the American cities, and have been described, among others, by Flint, Da Costa,⁹ and Loomis. A large number of cases of typhus fever (1723), with 572 deaths, were reported to the Surgeon-General's office during the late Civil War, but doubt has been thrown upon the correctness of the diagnosis of many of these cases by Clymer¹⁰ and Woodward,¹¹ and by other army surgeons, who, as the result of their investigations of this subject, have reached the conclusion that typhus did not prevail as an epidemic, however limited, among our soldiers at dépôts for returned prisoners of war. A like immunity from this scourge may be assumed to have been enjoyed by the Confederate forces, since Joseph Jones,¹² one of the most eminent of their medical officers, has stated positively that no case of true typhus fever came under his observation during the war in any army, in any field hospital, general hospital, or military prison, and that the experience of all of his associates whose opinions on this question he was able to obtain, either personally or by letter, was the same. It is therefore most probable that the cases entered upon the sick reports of both armies as typhus fever were in almost every case, if not in all, cases of typhoid fever occurring in scorbutic subjects.

⁷ A Treatise on the Practice of Medicine, by George B. Wood, M.D., etc., Philada., 1855.

⁸ The American Journal of the Medical Sciences, February and August, 1837.

⁹ Ibid., January, 1866.

¹⁰ The Science and Practice of Medicine, by William Aitken, M.D., Edin.; 3d Amer. ed., p. 462, Philadelphia, 1872.

¹¹ Camp Diseases of the United States Armies, by Joseph Janvier Woodward, M.D., Philadelphia, 1863.

¹² United States Sanitary Commission's Memoirs—Medical, p. 600, New York, 1867.

From the foregoing sketch of its history it is evident that typhus fever has prevailed from time to time in almost all the countries of Europe. Indeed, it is probable that no one of them has wholly escaped its ravages, while in others—as, for example, Ireland—it has been more or less constantly present until within the last few years, when its visitations have been less frequent as well as less severe. Even in countries which are popularly supposed to enjoy an immunity from it there is evidence of an incontrovertible character that it has occasionally occurred. Such an immunity has been claimed for France, but in the works of Riverius,¹³ Ambrose Paré,¹⁴ and others will be found descriptions of the disease which leave no doubt upon the mind of their entire familiarity with it; and Hirsch, in his work on Historico-Geographical Pathology, is able to give references to several writers who describe outbreaks that have recently occurred there. The disease has also been observed in Iceland. Typhus fever is of much less frequent occurrence in the other divisions of the eastern hemisphere than in Europe. According to Murchison, there are no authentic records of its having been met in Africa, or, with the exception of India, in Asia, such as it is seen in England and Ireland. There are, however, reports of its occurrence in Asia Minor, Syria, Persia, Egypt, Nubia, Tunis, and Algeria, which Hirsch,¹⁵ on the other hand, believes place the occasional presence of this disease in these countries beyond doubt. The same difference of opinion exists between these two distinguished observers in regard to the accounts which have been published of typhus fever occurring in Mexico, Central America, and South America, the latter holding that they are entirely reliable, the former that the cases described in them were really cases of malarial or typhoid fever. The disease has never been met with on the continent of Australia, in New Zealand, or in the valley of the Mississippi and the States bordering on the Pacific Ocean in our own country.

¹³ The Practice of Physick, being chiefly a Translation of the Works of Lazarus Riverius, London, 1678.

¹⁴ Traité de la Peste, de la Petite Verolle et Rougeolle, par Ambrose Paré, Paris, 1568.

¹⁵ Loc. cit.

While Hirsch's researches go to show that the tropical zone has not been so wholly exempt from the visitation of typhus fever as some authors have asserted, they establish the fact that it is of much less frequent occurrence there than in the colder portions of the temperate zone, where the modes of life are certainly much more favorable to its extension. Natives of warm climates are as liable to be attacked by it as others upon coming to places where it is prevailing, and in the Philadelphia epidemic of 1836, which Gerhard¹⁶ has described, negroes and mulattoes suffered from it more severely than the whites.

¹⁶ Loc. cit.

ETIOLOGY.—The etiology of typhus fever will be best studied under the heads Predisposing and Exciting Causes.

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 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 Tweedie¹⁷ and Sir William Jenner¹⁸ 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. Bateman¹⁹ 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.

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.

¹⁸ On the Identity or Non-Identity of Typhoid and Typhus Fevers, by William Jenner, M.D., London, 1880; also Lancet, November 15, 1879.

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. Buchanan²⁰ 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. Gerhard²¹ says that no children in the asylum attached to the Philadelphia Hospital were 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.

²⁰ A System of Medicine, edited by J. Russell Reynolds, M.D., F.R.C.P., etc., vol. i., article "Typhus Fever," London, 1866.

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 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 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 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.

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 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 Buchanan²² 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 formidable of the symptoms of typhus are convulsions, which are fortunately of infrequent occurrence.

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. Wunderlich²³ 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, 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.

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. Wood²⁴ says that he has frequently seen diarrhoea in typhus fever when it occurs in recently-arrived immigrants. Da Costa²⁵ mentions that it has occurred in several of the cases which have come under his care, and Buchanan²⁶ 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.

²⁴ Loc. cit.

²⁵ Loc. cit.

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 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 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 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.

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 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 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 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.

POST-MORTEM APPEARANCES.—Emaciation when death has occurred early in the course of the disease, and is due solely to the violence of the fever, is usually not well marked, but in those cases which have been protracted through the intercurrence of complications it may sometimes reach an extreme degree. Bed-sores, except under the circumstances just mentioned, are also rare. Rigor mortis is generally not well developed, and is of short duration. In a few cases it would seem, however, to have been well marked. The typhus maculæ are persistent after death, and so are any purpura spots and vibices which may have been present during life, but the subcuticular mottling usually disappears. The skin of the dependent portions of the body is discolored by the settling of blood in it, and putrefactive changes are apt to set in rapidly.

The only constant lesion observed is a profound alteration of the blood, which is darker in color and abnormally fluid. If clots are found at all, they are large, soft, and friable. The fibrin is diminished in amount. In the early part of the disease the red blood-corpuscles are said to be slightly increased in number, but later they are diminished, and under the microscope are observed to be crenated and not to form themselves readily into rouleaux. The white corpuscles are increased in number. No accurate chemical examination of the blood appears to have been made. Many of the post-mortem appearances which have been described as characteristics of typhus fever are really the consequence of this abnormal condition of the blood.

The respiratory organs generally present evidences of disease; the lesions of laryngitis, bronchitis, pneumonia, hypostatic congestion of the lungs, and pleurisy have all been observed after death from typhus fever. Usually, the traces of previous inflammation of the larynx are but slight; in a few cases, however, ulceration has been found, but the ulcers are stated to be always minute and superficial. Ulcers are also occasionally found in the bronchi, and frequently indicate by their appearance the pre-existence of a much higher grade of inflammation. The bronchial mucous membrane is, however, oftener merely reddened and softened and covered with a tenacious frothy secretion. True pneumonia is of infrequent occurrence as compared with that of hypostatic congestion of the lungs, but it nevertheless does occur, and may be of either the catarrhal or croupous variety. When pleurisy exists, it is usually accompanied, according to Murchison, by purulent effusion into the pleural cavity. On the other hand, Lebert says the variety of inflammation of the pleura oftenest met with is the plastic. The intestines present no constant lesion. Gerhard says that in fifty examinations there was but in one case, and that doubtful in diagnosis, the slightest deviation from the natural appearance of the glands of Peyer. In a few cases the Peyer's patches have been found more prominent than usual, but not more so than they are in measles and in some other diseases. Lebert alone of recent authors makes a contrary statement. In an epidemic at Breslau, he says, the solitary glands, as well as the patches of Peyer, were the seat of small, isolated, and superficial ulcers, which were usually situated in the vicinity of the ileo-cæcal valve. The mesenteric glands are generally unaffected, but in the Breslau epidemic just referred to they were not infrequently found moderately swollen. In cases in which dysentery has occurred as a complication the characteristic appearances of the disease will of course be observed, as well as those of typhus fever. The spleen is generally softened and slightly enlarged. The enlargement is not, however, always present, as Gerhard found it in one only out of every five or six of the cases which he examined. Extravasations of blood into its structure are occasionally met with. The liver is usually congested, somewhat enlarged, and frequently under the microscope presents the appearances of commencing fatty degeneration. The kidneys often present unmistakable signs of renal disease in the swollen granular and more or less fatty condition of their gland-cells according to the duration of the disease. The muscles are darker in color than in health. Under the microscope they are found to have undergone the peculiar granular or waxy degeneration described by Zenker, and which have been fully referred to in the article on typhoid fever. Extravasations of blood are occasionally found in them, which may soften and form pseudo-abscesses.

Other post-mortem appearances which are met with less frequently than those above detailed are inflammation, and even ulceration, of the mucous membrane, of the bladder, inflammation of the salivary gland, peritonitis, and congestion of the pancreas and of the stomach.

The muscular tissue of the heart is generally softened and easily torn. It is not, however, as stated by some authors, invariably so, for in several cases in which it was examined by Da Costa it had undergone this change in one case only, in which there was no reason to suspect previous disease of the heart. The alteration is similar in kind to that which takes place in the voluntary muscles. An effusion of serum, which may be of a deep-red color from the transudation of the coloring matter of the blood, is sometimes found in the pericardial sac, as are ecchymotic patches upon the surface of the heart. The endocardium may be stained from the imbibition of blood. On the other hand, endo- and peri-carditis are excessively rare.

Notwithstanding the severity of the cerebral symptoms in typhus fever, there are few or no important changes found in the brain or its membranes after death. The sinuses are occasionally filled with dark fluid blood, and the appearances of congestion of the brain are sometimes present. In other cases there may be an increased amount of serum beneath the arachnoid and into the lateral ventricles, but not more than is often seen after death from other causes. Very rarely a slight film of hemorrhage has been found in the cavity of the arachnoid, and sometimes also the evidences of non-inflammatory softening of the brain. Actual inflammation of the meninges has only been detected in a very few cases. There may also be congestion of the spinal membranes, increase of the spinal fluid, and softening of the cord itself. The ganglia of the sympathetic system appear to undergo a form of granular degeneration.

DIAGNOSIS.—The diseases which most closely resemble typhus fever are typhoid fever, measles, meningitis, and typhoid pneumonia.

The circumstances under which typhoid and typhus fever occur are different. Typhoid is never generated by overcrowding, and if contagious at all is much less so than typhus. Prostration occurs much earlier and is usually much more marked in the latter. The eruption in the former does not appear until the eighth day, and comes out in successive crops, and usually disappears under pressure as long as it lasts, and therefore may be easily distinguished from that of the latter. The duration of typhus is from ten to twenty days; that of typhoid is rarely less than twenty-one. Nevertheless, cases are occasionally met with in which it is impossible to arrive at a correct conclusion as to their nature unless some light is thrown upon it by the existence of other and more characteristic cases in the same house or neighborhood. I have recently had under my care a case which eventually proved to be typhoid fever, but which I and many others who saw it at first believed to be typhus in consequence of the presence of an abundant eruption, which did not disappear under pressure, and was finally converted into petechiæ.

The eruption of typhus is sometimes found upon the face, especially in children, and then presents a considerable similarity to that of measles, which, however, usually appears a little earlier. There is, moreover, rarely the same amount of prostration or stupor in the latter disease, which is also attended by coryza and more bronchial catarrh than is often present in the former. The eruptions in the two diseases differ. In measles it is crescentic in shape, and is more elevated than in typhus. It is also brighter in color, disappears under pressure, except in malignant cases, as long as it lasts, and is followed by free desquamation of the cuticle, which is not often observed in typhus. The temperature may be high in the former, but it usually falls upon the sixth day.

In meningitis the headache is much more severe, and does not disappear upon the occurrence of delirium. It may be so severe as to cause the patient to cry out. The senses are painfully acute. There are intolerance of light and sound, and some hypersensitiveness of the surface, strabismus, inequality of the pupils or some other local paralysis, and retraction of the head. Nausea and vomiting are more common than in typhus, while the utter prostration of the latter disease is wholly wanting, and so is of course the characteristic eruption. The tâche meningitique is wanting in the latter, but too much reliance should not be placed upon either the presence or absence of this sign. The diagnosis is only likely to be difficult in those cases of typhus in which the delirium is active. In that form of typhus in which the symptoms simulate those of delirium tremens some difficulty may also be experienced in making a diagnosis, especially if the patient be a drunkard. In delirium tremens it will be remembered, however, that there is little or no elevation of temperature, that the skin is bathed in perspiration, the tongue moist, and the characteristic eruption absent. Typhoid pneumonia can be distinguished from pneumonia complicating typhus fever by the presence of the eruption in the latter.

Other diseases which have occasionally been mistaken for typhus fever are remittent fever, Bright's disease, giving rise to uræmia and purpura. It does not seem likely that even the severest forms of malarial fever should ever present such a resemblance to typhus fever as to make the differential diagnosis a matter of difficulty; but it would appear from the history of the latter disease given by Murchison that such a mistake has occurred in some of the Spanish American countries. The enlargement of the spleen and liver is much less marked than in remittent fever, and the remissions of temperature are much less decided. Uræmia may at times present a good deal of resemblance to the condition often seen in typhus fever after the supervention of coma or stupor, but the history of the case, the absence of fever and of eruption in the former, will generally enable us to distinguish between the two conditions. It should be remembered, however, that Bright's disease may occur in the course of typhus fever. Purpura may generally be recognized by the absence of fever and by the occurrence of hemorrhages from the nose, gums, and bowels.

PROGNOSIS.—The age, habits of life, and previous condition of health, as well as the character of the prevailing epidemic, must all be fully considered before making a prognosis in any special case. The disease usually runs a much milder course in children and young people than in adults past thirty years of age. After this age the mortality progressively increases, and in advanced life it becomes very high, being often as much as 50 per cent. or over. Sex does not of itself exercise much influence upon the course of typhus fever, for, although a few more men than women die of it, this appears to be attributable to the greater prevalence of drinking among the former. Previous intemperance acts unfavorably by producing a degeneration of the tissues of the body, thus rendering the patient less able to withstand the effects of the disease. Drunkards have therefore always furnished a large proportion of the fatal cases. The mortality among patients who are unfortunate enough to take typhus fever as they are convalescing from other diseases is usually also very great. This has often been observed in general hospitals in which cases of fever as well as those of other forms of disease are admitted. Fat, lymphatic, or muscular people more frequently die of it than those of a different conformation. Gerhard found it especially fatal among negroes in the epidemic of 1836, and Buchanan seems to have had a similar experience at the London Fever Hospital. It is a fact noticed by English writers that people of the better class, although seldom attacked by typhus, often suffer severely from it. The mortality is always high among those patients who previously to contracting the disease have been for some time deprived of sufficient food, or have been overworked, or who have been the subjects of mental anxiety, worry, or any other depressing emotion. It is high also among those who in the beginning of the disease have exhausted their strength in the vain effort to resist the disposition to go to bed. The chances of recovery are, on the other hand, very much improved by the removal of patients from crowded, ill-ventilated houses to the wards of a spacious, airy hospital.

Unfavorable symptoms are a profuse dark-colored eruption associated with purpura spots and vibices, general lividity of the surface, great injection of the pupils, and a dusky hue of the countenance; extreme prostration; an excessively frequent and feeble pulse, especially if it is at the same time irregular or intermittent; absence of the cardiac impulse and of the systolic sound; hurried and spasmodic or abnormally slow respiration; great dryness and retraction of the tongue; excessive prominence of the nervous symptoms, such as headache, delirium, whether active or muttering; unequal or pin-hole contraction of the pupils; strabismus or other local paralysis; sleeplessness; muscular tremblings; subsultus tendinum; carphology; protracted hiccough; retention of the urine; relaxation of the sphincters of the bladder and rectum; coma and especially coma vigil, and convulsions; continued high temperature, rising instead of falling after the tenth day, especially if it is associated with coldness of the extremities and of the breath; a profuse perspiration without a general improvement in the symptoms; diminution in the quantity of the urine, or the presence in it of albumen, blood, or casts; vomiting; and diarrhoea. Hope, however, should never be abandoned even in the most unfavorable cases, as recovery has sometimes occurred when the patient seemed almost in articulo mortis. Convulsions are said to be invariably followed by death, and Graves regarded the presence of the pin-hole contraction of the pupils as of very grave import.

Favorable symptoms are—reduction of the frequency of the pulse, a fall of temperature, a diminution of the stupor or a resumption of consciousness, and a return of appetite and of moisture to the tongue. When the patient begins to improve he will often without assistance turn upon his side after having lain for a long time upon his back, and this change of position is sometimes the first indication of the approach of convalescence.

The mortality varies of course in different epidemics. The cases which have come under my own care being too few in number to draw deductions from on this point, I must rely upon the experience of those whose field of observation has been more extended than my own. According to Murchison, out of 18,268 cases of typhus fever admitted into the London Fever Hospital during twenty-three years, 3457 proved fatal, making a mortality of 18.92 per cent., or 1 in 5.28. Deducting 686 cases fatal within forty-eight hours, the mortality falls to 15.76 per cent., or 1 in 6.34. Included among the fatal cases is a large number in which the disease had run its course to a favorable termination, and in which death was really due to sequelæ, such as pneumonia, erysipelas, etc. Moreover, the death-rate in the hospital is greater than in the community, because children, who rarely die of typhus fever, are seldom brought to it; while, on the other hand, it receives a large number of the infirm and aged inmates of the metropolitan workhouses. Making allowance for these sources of fallacy, Murchison believes that the actual mortality of typhus is not more than 10 per cent. In Gerhard's cases the proportion of deaths amongst the black was much greater than amongst the white men; thus, of the whites 1 died in 4²/3, of the blacks 1 in 2¹⁹/28. Amongst the women the reverse was true; thus, 1 white woman died in 4³/5, but only 1 colored woman in 6½, nearly. Da Costa lost 6 out of 39 cases. In one of the fatal cases the diagnosis was doubtful; in another there was a great deal of previous disease; in two others death was due to complications—so that there were but two in which the fatal result could fairly be attributed to the disease itself.

TREATMENT.—Typhus fever is an eminently preventible disease. It is therefore proper that the description of its curative treatment should be preceded by a few words in regard to its prophylaxis.

It is still an unsettled question whether or not typhus fever ever occurs de novo, and although the recent discovery by Klebs and others of bacillus peculiar to typhoid fever (the bacillus typhosus), and of special bacilli in other analogous diseases, renders it highly probable that typhus fever has also its own bacillus, and that therefore it is not likely to arise except as the result of infection, it must be admitted that it has often prevailed in localities into which it has not been possible to trace its importation. Under these circumstances it will be well to refer to those conditions which are asserted by some authors to favor its spontaneous generation, especially as these same conditions are certainly known to favor its propagation. It will not be necessary to do this at any great length, as they have all been fully described in discussing the etiology of the disease. The most important of them is the overcrowding of human beings, especially when combined with deficient ventilation, destitution, and want of personal cleanliness. The knowledge of the laws of hygiene is now so universally diffused that this combination of conditions never occurs at the present time to anything like the degree it often existed in the eighteenth century, and consequently epidemics of this disease are not only less frequent, but are also much milder in character, than formerly. Much work, however, still remains for sanitarians in the improvement of the homes of the poor, which even in this country are too often overcrowded and ill-ventilated.

The extension of the disease in a community will almost always be prevented by the prompt isolation of the first few cases. This can often be thoroughly done, if the patient is in easy circumstances, by placing him in an upper room, which should be stripped of its carpets, curtains, and other unnecessary furniture; by cutting off all communication between him and his attendants and the rest of the household; and by the free use of disinfectants. The room should be airy, and to ensure good ventilation a window should be left partly open. This may be done during the febrile stage, even in winter, without the risk of any injury to the patient. Among the poorer classes, however, isolation can rarely be effectually carried out, and it is therefore much better to remove the patient to a hospital. Upon the admission of such a patient to an institution of this character his clothes should be at once disinfected. This may be done by washing the underclothing in a disinfecting fluid, and then exposing them to a free current of air, and by subjecting the outer clothing to a very high temperature in an oven or to the fumes of burning sulphur. Murchison believes that a neglect of this precaution has often been the cause of the extension of the disease to other inmates of the hospital, especially when the patient resumes during his convalescence the same clothing he wore upon admission. If the hospital is a general one, he should be placed, whenever practicable, in a well-ventilated ward by himself or with other patients suffering from the same disease. As this is not always possible, the number of the other occupants of the ward should be reduced and their beds placed as far away as possible from his. As the infectiousness of typhus fever is very much lessened by free ventilation, this precaution is often alone sufficient to prevent its extension to them. It is also well, however, to supplement it by the use of disinfectants. The diffusion of a solution of carbolic acid in the atmosphere of the ward by means of the steam atomizer has not only rendered the odor emanating from the patient less perceptible, but has also appeared to diminish decidedly the risk of infection. As a still further precaution the patient may be sponged with a weak solution of carbolic acid or some other disinfectant. His nurses should be selected, whenever practicable, from among those who have had the disease themselves. They should never sleep in the sick room, lounge about the patient's bed, or inhale his breath. They should be allowed a certain amount of time every day for rest and recreation in the fresh air, and should have a full supply of nourishing food. On the other hand, they should be warned against the danger of over-stimulation, which is often resorted to in the hope of warding off the disease, and should be relieved as far as possible from attendance upon other patients. It may be well here to say that the nursing of a case of typhus fever should never be undertaken by the relatives or friends of the patient, except as a matter of necessity. Not only do the anxiety and distress they naturally feel unnerve them and render them unfit to carry out the directions of the physician, but they can rarely execute the many offices required in the sick room with half the skill of a trained nurse or with so little annoyance to the patient.

Before the patient is allowed to leave his ward he should have a warm bath. If the disease has occurred in a private house, the room which he has occupied should be thoroughly disinfected. This is best done by replastering, repapering, and repainting it. In many cases, however, it will be sufficient to fumigate it with burning sulphur, and then to air it for several days. The bed and bedding should also be disinfected, and, where this cannot be thoroughly done, the latter had better be destroyed.

Of primary importance in the treatment of typhus fever is the regulation of the diet. Although there are no ulcers in the bowels in this as in typhoid fever, and although, consequently, there is not the same imperative necessity in this as in the latter disease to restrict the patient to liquid articles of food, experience has shown that such articles are much more readily digested and assimilated than solids. The diet should consist, therefore, of milk, beef-tea, and chicken or mutton broth. Of all of these, milk is incomparably the best, and it should form, unless the patient manifest an unconquerable repugnance to its use, a large part of the nourishment in every case. Farinaceous articles of food are generally not well borne in this fever, because the diminution in the secretion of the salivary glands which almost always exists prevents their proper digestion. After the third or fourth day nourishment should be given in small quantities at short intervals, as every two hours, every hour, or even every half hour when the prostration is extreme. It should be the aim of the physician to give an adult at least two quarts of milk or their equivalent daily.

It is sometimes necessary to put a delirious patient under some restraint to prevent him from leaving his bed or doing some other act of violence. Frequently a judicious nurse will be able to accomplish this without the use of an undue amount of force, but at other times it will be necessary to have recourse to mechanical means of restraint. Usually, all that is necessary is to pass a folded sheet across the patient's chest, the ends of which are fastened to the sides of his bed.

It is now a universally accepted axiom among physicians that typhus fever is a self-limited disease, and that any attempts to cut it short is worse than useless. Not only do remedies which are employed for this purpose often produce alarming prostration, but there can be no doubt that they have in some cases been the cause of a fatal termination, which under another plan of treatment would have been averted. During the last century it was not uncommon to bleed, and to bleed largely, in the beginning of an attack of typhus fever, but even then there were physicians—as, for instance, O'Connell, Rogers,²⁸ Pringle,²⁹ and Rutty³⁰—who raised a warning voice against the practice. Sir John Pringle goes so far as to say that "many have recovered without bleeding, but few who have lost much blood." A very similar opinion was also expressed by Baron Larrey in the early part of this century. Indeed, it is very evident that the same difference of opinion existed as to the employment of venesection in the treatment of acute affections when these authors wrote as prevailed in England and this country until within the last thirty years, and that the disastrous results which occasionally follow the abstraction of large amounts of blood from patients affected with fevers and inflammations were as fully recognized then as now by many physicians. This would seem effectually to dispose of the change-of-type-in-disease theory which was generally accepted in the first half of this century as sufficient to explain the fact which could no longer be overlooked that this class of patients did much better under a supporting than a depleting plan of treatment. Purgatives were also at one time freely given for the purpose of arresting the disease, but the results obtained from their use were scarcely less unfavorable, and they are now never employed with this view. The use of quinia in large doses has also been advocated for the same purpose, but experience, while it has shown that it is a valuable remedy, has demonstrated also that it does not possess this power. Exactly the same thing may be said of the cold-water treatment of typhus fever. There is no evidence that it has ever shortened the duration of the disease.

²⁸ An Essay on Epidemic Diseases, p. 60, by Joseph Rogers, M.D., Dublin, 1734.

²⁹ Loc. cit.

³⁰ A Chronological History of the Weather and Seasons, and the Prevailing Diseases, in Dublin during the Space of Forty Years, by John Rutty, M.D., London, 1770.

If the physician is called to a case of typhus fever during the chill, before reaction has taken place, he will of course have recourse to diffusible stimulants and external warmth to aid in the establishment of this process. More frequently he is not sent for until after the chill has been succeeded by fever. His treatment will then, of course, vary with the condition of the patient. If his stomach is loaded with food, an emetic should be administered to him. If the bowels are constipated, a mild cathartic will often be of service, but after the bowels have been once well moved it is generally unnecessary to disturb them further. During the first day or two, while the fever is still moderate in degree, and during the uncertainty which then usually exists as to the diagnosis, it will be sufficient to prescribe the neutral mixture or the spirit of Mindererus in tablespoonful doses every two or three hours. Upon the third day more active remedies will generally be required to reduce the temperature. This is best done by the cold-water treatment in some form or other, or by the internal administration of antipyretic doses of quinia. The manner in which the cold water is to be used and the cases to which it is applicable must be left in a great measure to the judgment of the physician. In the form of the cold affusion it is now rarely resorted to, although Currie³¹ obtained most excellent results with it. It is calculated, however, to alarm a timid patient, and it is probably owing largely to this fact that it has fallen into disuse. The cold bath, packing in a cold wet sheet, and sponging with cold water are the more usual means of employing cold in the treatment of typhus fever at the present day. The cold bath is much used in Germany in the treatment of different forms of fever, and even of inflammation. It is also resorted to in this country, but it has never attained the same popularity here as abroad. The best way of using it is as follows: The patient as soon as his temperature rises above 103° F. should be placed in a bath having a temperature between 80° and 90°, and which, whenever practicable, should be brought to his bedside, as when he has to be carried to the bathroom he is sometimes not only alarmed and rendered very nervous by the operation, but may exhaust himself in his struggles to free himself from his attendants. After his immersion cold water should be gradually added until the temperature of the bath is between 60° and 70° F. The length of time he should be allowed to remain in the bath will of course depend upon circumstances. If shivering is produced by it, he should be at once removed from it and thoroughly dried and put back to bed. If no such symptoms are observed, he may be allowed to remain in it longer. As a general rule, a half hour is as long as will be necessary or safe for him to continue immersed at any one time. His temperature will usually continue to fall for some time after his removal from the bath, but in the course of a few hours it will be found to have risen again to 103° or over, when he should have another bath. In this way it may be necessary to repeat the baths from eight to twelve times a day. Some authors recommend that the patient should be placed at once in a bath having a temperature of 50° F., but this method of applying cold possesses no advantage over that above described, and is, like the cold affusion, very apt to excite alarm in the patient. The cold bath is not, however, well borne by all persons, and alarming symptoms, and even fatal collapse, have followed its use in the old and feeble. It is also contraindicated when the skin is covered with a profuse sweat or when the disease is complicated by an internal inflammation. When the means of giving a cold bath are not at hand, the cold pack will often be found a very efficient substitute for it. Sponging with cold water, although not so efficacious in reducing the temperature, has advantages over either of these methods of applying cold. In the first place, it is more agreeable to most patients and less calculated to excite alarm in those who are timid. Again, it may be more frequently repeated, and may be used in cases in which the cold bath is contraindicated. Occasionally alcohol or vinegar may be added with advantage to the water, with the view of increasing its refrigerant effects.

³¹ Medical Reports on the Effects of Water, Cold and Warm, as a Remedy in Fever and Febrile Diseases, by James Currie, M.D., F.R.S., London, 1805.

When quinia is given for the purpose of reducing the temperature in the treatment of typhus fever, it must be used in large doses, as much as ten or fifteen grains repeated once or twice in the course of twenty-four hours being required for this purpose. When given in these quantities it has the disadvantage of producing deafness and occasionally of increasing the headache. I have therefore contented myself in the cases which have fallen under my own care with giving it in more moderate quantities, in combination with one of the mineral acids, as, for instance, a couple of grains of quinia in solution with from eight to ten drops of dilute muriatic acid, repeated from four to six times a day. The mineral acids were originally recommended in the treatment of typhus fever in the belief that they neutralized the poison which caused the fever, and which was supposed to be ammonia or some of its compounds. Although this theory is now no longer entertained, there can be no doubt that the tendency in this disease to the accumulation of ammonia in the blood is prevented by their administration. Digitalis, aconite, or veratrum viride may also be given in appropriate doses if with a high temperature there coexists great frequency of the pulse. The first-named remedy is especially indicated if there is at the same time diminution of the secretion of urine.

As the disease progresses other symptoms present themselves for treatment. One of the most urgent of these is the prostration. This not only appears early, but is often extreme, and if not met by appropriate remedies will often of itself be sufficient to cause the death of the patient. As soon as it makes itself manifest stimulants must be prescribed. These are, however, not to be resorted to simply because the patient has typhus fever. Many cases do perfectly well without them. In the young and robust it is often unnecessary to have recourse to them. On the other hand, in the old, the feeble, and the intemperate they should be employed early. The rule laid down by Stokes, that they should be administered as soon as the first sound of the heart becomes indistinct and inaudible, may be adopted for our guidance in this respect. At first they should be given tentatively. If the delirium, headache, and other nervous symptoms are increased after their administration, it is best to withhold them. They should be continued, on the other hand, when under their use the delirium ceases or grows milder, the other nervous symptoms subside, and the patient falls into a refreshing sleep. The amount required to prevent fatal prostration will of course vary in each case. I have rarely myself found it necessary to prescribe more than half an ounce of whiskey or brandy every two hours, and frequently a very much smaller quantity has been found sufficient. Cases are, however, reported in which from twenty to twenty-four ounces daily have been given with asserted advantage.

Another symptom which often demands prompt relief is the headache. When not severe, it may be relieved by the application of cold to the head, either in the form of the ice-cap or by means of cloths frequently wrung out of cold water, and by the administration of moderate doses of potassium bromide; but when intense it requires more active treatment for its removal, such as the application of cups to the back of the neck or of leeches to the temples. General bleeding will accomplish the same result, but the good which is done by it is often more than counterbalanced by the prostration it induces. Sleeplessness is also sometimes the cause of a good deal of distress to the patient. When it occurs early in the disease and is caused by the headache, it will generally subside under the use of the remedies which are employed for the relief of the latter symptom; but when it comes on at a later period, it will often require special treatment. There is some doubt as to the propriety of giving opium under these circumstances, but Murchison, Gerhard, and others assert that it may be given not only without injury, but with positive advantage to the patient. Graves was in the habit of combining it with a small quantity of tartar emetic in the condition in which the sleeplessness is associated with active delirium. If, on the other hand, the delirium is of a low muttering character, it should be given with a diffusible stimulant.

In this condition I have often found a pill containing a small quantity each of opium and camphor, frequently repeated, to answer an admirable purpose, not only in procuring for the patient the needed repose, but also in diminishing the restlessness, jactitation, and subsultus tendinum. Opium should, however, not be used at all or used very carefully in cases in which there is congestion of the lungs or disease of the kidneys. The existence of the pin-hole pupil is also a contraindication to its employment. In young and robust patients, if the insomnia is attended by active delirium, chloral in twenty-grain doses, repeated if necessary, may often be given with advantage, but it should never be prescribed in cases in which the action of the heart is feeble. Other remedies which have been recommended in the treatment of this condition are belladonna, hyoscyamus, musk, chloroform, and cannabis indica. Potassium bromide appears to have no power to relieve it. No special modification of the above treatment is needed when delirium occurs independently of sleeplessness and headache. When the stupor is profound, efforts should be made to rouse the patient by the use of counter-irritants to the shaven scalp or to the nape of the neck. Murchison speaks well of the administration of strong coffee under these circumstances. If there is at the same time suppression or diminution of urine, diuretics should be administered in the hope of stimulating the kidneys to increased secretion. Retention of the urine is not an infrequent occurrence in this condition, and the physician ought never, therefore, to accept the assertions of the nurse or friends of the patient that the latter has passed water, but should satisfy himself by an examination in regard to the condition of the bladder at every visit. He will often find that the apparent passage of urine is nothing more than the dribbling due to an over-distension of this organ. Neglect of this precaution has occasionally been the cause of much subsequent distress to the patient, as cystitis is sometimes set up as a consequence of it. In one case which came under my observation, and in which this precaution had been neglected, the patient suffered from incontinence of urine for some time after his recovery from the fever. Thirst is a symptom which is always present and complained of at the beginning of the fever, and usually bears some proportion to the severity of this process. Weak tea, an infusion of cascarilla-bark, and camphor-water have all been recommended by different authors for its relief, but it is probable that no one of them possesses any superiority over water. If the stomach is irritable and water is not retained, small pieces of ice should be allowed to dissolve in the patient's mouth. Later, when the stage of stupor supervenes, it is very important to see that the patient obtains a full supply of water. In this condition he will not call for it, although it is even more urgently required than before.

Vomiting may occur at any time in the course of typhus fever. If it is observed at the very beginning of an attack, an emetic will often arrest it, but when it supervenes at a later period, it is generally of cerebral origin, and will usually subside under the use of the remedies already referred to which are prescribed for the relief of the nervous symptoms. In addition to these, sinapisms may be applied to the epigastrium, and champagne, when the circumstances of the patient will permit it, should be given in the place of whiskey or brandy. When everything is rejected by the stomach, recourse must be had to nutritious enemata. Constipation is to be overcome by gentle purgatives, as the use of powerful cathartics is very apt to be followed by troublesome diarrhoea. If this should come on, it is best treated by small doses of opium in combination with a mineral or vegetable astringent. When these fail, it may sometimes be relieved by a prescription containing sulphuric acid and morphia, and at others by enemata of from twenty to thirty drops of laudanum in warm water. When glandular swelling occurs in the parotid region or in other parts of the body, an effort should be made to promote resolution by painting them with tincture of iodine. Blisters have also been recommended for the same purpose, but they should be used carefully, as in low conditions of the system they are sometimes followed by sloughing of the integuments. If these remedies fail, poultices should be applied. As soon as pus has formed it should be evacuated by one or more free incisions.

Very few attacks of typhus fever run their course without the occurrence of some pulmonary complication. When this is slight it demands no special modification of the previous treatment, and it is sufficient to apply mustard poultices or stimulating liniments to the chest. But in cases of greater gravity, it matters not whether the complication is bronchitis, congestion of the lungs, or pneumonia, a more active treatment is required. Under these circumstances the ammonium carbonate in five-grain doses, given in mucilage of acacia, frequently repeated, or from thirty minims to a teaspoonful of the aromatic spirit of ammonia every two hours, sufficiently diluted, may be prescribed with great advantage. When gangrene supervenes the prognosis is almost hopeless, but an effort should be made to save the patient's life by the administration of potassium chlorate and of an increased amount of stimulus. Murchison also speaks well of the inhalation of tar vapor and of carbolic acid.

As the other complications of typhus are at least of as common occurrence in typhoid fever, it will avoid a good deal of useless repetition to refer the reader to the article on the latter disease for a description of the treatment which they render necessary.

The patient should be kept in bed for some time after the subsidence of fever. Although relapses are rare in this disease, recrudescences of fever not infrequently occur as a consequence of undue exertion in the early part of convalescence. Syncope is also not infrequently produced by the patient's sitting up too soon. The diet should be carefully regulated until the recovery is complete. It should at first consist wholly of liquid or semi-liquid articles of food, but later meat in some digestible form may be allowed. Stimulants are often as urgently demanded at this time as during the fever itself. They should be given as the strength returns in gradually diminishing quantities. The length of time during which it is necessary to continue them will depend in great measure upon the previous habits of the patient. As a general rule, their use should not be abandoned until he is able to leave his bed, and they may often be continued after this with benefit to him. As convalescence progresses it will be well to substitute ale or porter for the brandy or whiskey the patient had previously taken. A return to health will also be promoted by the judicious use of tonics, such as iron, quinia, Huxham's tincture, tincture of nux vomica, the mineral acids, and even cod-liver oil in some cases.