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.