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

by Unknown

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.