Part 53

My own experience does not enable me to speak with positiveness of the value of this plan of treatment. Indeed, it has been used in so few cases, to the exclusion of all other remedies, that it is difficult to decide how far the result attained in cases treated by them is due to them, and how far to the other therapeutic means employed. With the testimony of such competent observers as those above named it is only proper that the treatment by iodine and carbolic acid should have a further trial. More caution, it seems to me, is required in the use of calomel. While it is probable that in a few cases the intestinal lesions may be favorably modified by the purgation which it induces, the indiscriminate use of the drug is, I am sure, calculated to do more harm than good.

{338}

TYPHUS FEVER.

BY JAMES H. HUTCHINSON, M.D.

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, 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.

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 {339} 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 Corradi it may be said to have been practically undescribed before the year 1546, when Fracastorius 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.

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 Langrish 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, J. Carmichael Smyth, and others.

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 {340} 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, 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. 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, 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 Clymer and Woodward, 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, 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.

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, {341} Ambrose Paré, 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, 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.

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 Gerhard has described, negroes and mulattoes suffered from it more severely than the whites.

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 {342} 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 Tweedie and Sir William Jenner 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. Bateman 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.

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. Buchanan 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. Gerhard says that no children in the asylum attached to the Philadelphia Hospital were {343} 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.

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 {344} 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 {345} 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 {346} 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.