1902 Encyclopedia > Typhus

Typhus




TYPHUS, TYPHOID, AND RELAPSING FEVERS. These are conveniently considered together, as they con-stitute the important class of continued fevers, having certain characters in common, although each is clearly dis-tinguishable from the others. The following is a general account of the more salient features of each.

TYPHUS FEVER.

in the case of typhus fever. This disease is now much less frequently encountered in medical practice than formerly, —a fact which must mainly be ascribed to the great attention which in recent times has been directed to improvement in the sanitation of towns, especially to the opening up of crowded localities so as to allow the free circulation through them of fresh air. In most large cities, however, limited epidemic outbursts of the disease occur from time to time, under the conditions of over-crowding and poverty, although the increased facilities possessed by local authorities for recognizing such outbreaks, and for the prompt isolation or removal of infected persons to hospitals, operate in general effectually to prevent any extensive spread of the fever. All ages are liable to typhus, but the young suffer less severely than the old. The disease appears to be communicated by the ex-halations given off from the bodies of those suffering from the fever, and those most closely in contact with the sick are most apt to suffer. This is shown by the frequency with which nurses and physicians take typhus from cases under their care. As in all infectious maladies, there is often observed in typhus a marked proclivity to suffer in the case of individuals, and in such instances very slight exposure to the contagion may convey the disease. Typhus is highly contagious throughout its whole course and even in the early period of convalescence. The contagion, how-ever, is rendered less active by the access of fresh air; hence this fever rarely spreads in well-aired rooms or houses where cases of the disease are under treatment. As a rule one attack of typhus confers immunity from risk of others, but numerous exceptions have been recorded.

The course of typhus fever is characterized by certain Course well-marked stages. (1) The stage of incubation, or theoftne period elapsing between the reception of the fever poison fever" into the system and the manifestation of the special evidence of the disease, is believed to vary from a week to ten days. During this time, beyond feelings of languor, no particular symptoms are exhibited. (2) The invasion of the fever is in general well marked and severe, in the form of a distinct rigor, or of feelings of chilliness lasting for hours, and a sense of illness and prostration, together with headache of a distressing character and sleeplessness. Feverish symptoms soon appear and the temperature of the body rises to a considerable height (103°-105° Fahr.), o at which it continues with but little daily variation until about the period of the crisis. It is, however, of import-ance to observe certain points connected with the tem-perature during the progress of this fever. Thus about the seventh day the acme of the fever heat has been reached, and a slight subsidence (1° or less) of the tem-

== TABLE ==

Temperature chart of typhus fever.

perature takes place in favourable cases, and no further subsequent rise beyond this lowered level occurs. When it is otherwise, the case often proves a severe one. Again, when the fever has advanced towards the end of the second week, slight falls of temperature are often observed, prior to the extensive descent which marks the attainment of the crisis. The pulse in typhus fever is rapid (100-120

or more) and at first full, but later on feeble. Its condi-tion as indicating the strength of the heart's action is watched with anxiety. The tongue, at first coated with a white fur, soon becomes brown and dry, while sordes (dried mucus, &c.) accumulate upon the teeth; the appetite is gone and intense thirst prevails. The bowels are as a rule constipated, and the urine is diminished in amount and high-coloured. The physician on examination may make out distinct enlargement of the spleen. (3) The third stage is characterized by the appearance of the eruption which generally shows itself about the fourth or fifth day or later, and consists of dark red (mulberry coloured) spots or blotches varying in size from mere points to three or four lines in diameter, very slightly elevated above the skin, at first disappearing on pressure, but tending to become both darker in hue and more permanent. They appear chiefly on the abdomen, sides, back, and limbs, and occasionally on the face. Besides this, the character-istic typhus rash, there is usually observed a general faint mottling all over the surface. The typhus rash is rarely absent and is a very important diagnostic of the disease. In the more severe and fatal forms of the fever, the rash has all through a very dark colour, and slight subcutaneous haemorrhages (petechias) are to be seen in abundance. After the appearance of the eruption the patient's condition seems to be easier, so far as regards the headache and discomfort which marked the outset of the symptoms; but this is also to be ascribed to the tendency to pass into the typhous stupor which supervenes about this time, and becomes more marked throughout the course of the second week. The patient now lies on his back, with a dull dusky countenance, an apathetic or stupid expression, and con-tracted pupils. All the febrile symptoms already mentioned are fully developed, and delirium, usually of a low muttering kind, but sometimes wild and maniacal (delirium ferox) is present both by night and day. The peculiar condition to which the term " coma vigil" is applied, in which the patient, though quite unconscious, lies with eyes widely open, is regarded, especially if persisting for any length of time, as an unfavourable omen. Throughout the second week of the attack the symptoms continue unabated; but there is in addition great prostration of strength, the pulse becoming very feeble, the breathing shallow and rapid, and often accompanied with bronchial sounds. (4) A crisis or favourable change takes place about the end of the second or beginning of the third week (on an average the 14th day), and is marked by a more or less abrupt fall of the temperature (vide chart) and of the pulse, together with slight perspiration, a discharge of loaded urine, the return of moisture to the tongue, and by a change in the patient's look, which clears up and shows signs of returning intelligence. Although the sense of weakness is extreme, convalescence is in general steady and comparatively rapid.

Typhus fever may, however, prove fatal during any stage of its progress and in the early convalescence, either from sudden failure of the heart's action—a condition which is specially apt to arise— from the supervention of some nervous symptoms, such as meningitis or of deepening coma, or from some other complication, such as bronchitis. Further, a fatal result sometimes takes place before the crisis from sheer exhaustion, particularly in the case of those whose physical or nervous energies have been lowered by hard work, inadequate nourishment and sleep, or intemperance, in all which conditions typhus fever is apt to assume an unusually serious form.

Occasionally troublesome sequelae remain behind for a greater or less length of time as the effects of the fever. Among these may be mentioned mental weakness or irritability, occasionally some form of paralysis, an inflamed condition of the lymphatic vessels of one leg (the swelled leg of fever), prolonged weakness and ill health, &c. Gradual improvement, however, may be confidently anticipated and even ultimate recovery.

The mortality from typhus fever is estimated by Murchison and others as averaging about 18 per cent, of the cases, but it varies much according to the severity of type (particularly in epidemics), the previous health and habits of the individual, and very specially the age,— the proportion of deaths being in striking relation to the advance of life. Thus, while in children under fifteen the death-rate is only 5 per cent., in persons over fifty it is about 46 per cent.

The treatment of typhus fever includes the prophylactic measures Treat-of attention to the sanitation of the more densely populated por- ment. tions of towns. The opening up of cross streets intersecting those which are close-built and narrow, whereby fresh air is freely admitted, has done much to banish typhus fever from districts where previously it was endemic. Further, the enforcement of the law regulating the number of persons accommodated in common lodging-houses, and the application of the powers now vested in local authorities for dealing with cases of overcrowding everywhere, and for isolation and treatment of the infected, have had a like salutary effect. "Where typhus has broken out in a crowded dis-trict the prompt removal of the patients to a fever hospital and the thorough disinfection and cleansing of the infected houses are to be recommended. AVhere, on the other hand, a single case of acci-dentally caught typhus occurs in a member of a family inhabiting a well-aired house, the chance of it being communicated to others in the dwelling is but small; nevertheless every precaution in the way of isolation and disinfection should be taken.

The treatment of a typhus patient is conducted upon the same general principles as have been illustrated in other fevers (see SCARLET FEVER, SMALLPOX). Complete isolation should be main-tained throughout the illness, and the services of a day and a night nurse procured, who should keep a strict watch and preserve a record of the temperature and other observations, the times of feeding and the form of nourishment administered, as well as every other fact noticed, for the physician's information. Due attention should be given to the ventilation and cleansing of the sick chamber. The main element in the treatment of this fever is good nursing, and especially the regular administration of nutriment, of which the best form is milk, although light plain soup may also be given. The food should be administered at stated intervals, not, as a rule, oftener than once in one and a half or two hours, and it will fre-quently be necessary to rouse the patient from his stupor for this purpose. Sometimes it is impossible to administer food by the mouth, in which case recourse must bo had to nutrient enemata. Alcoholic stimulants are not often required, except in the case of elderly and weakly persons who have become greatly exhausted by the attack and are threatening to collapse. The best indication for their use is that furnished by the condition of the circulation : when the pulse shows unsteadiness and undue rapidity, and the first sound of the heart is but indistinctly heard by the stethoscope, the prompt administration of stimulants (of which the best form is pure spirit) will often succeed in averting danger. Should their use appear to increase the restlessness or delirium they should be discontinued and the diffusible (ammoniacal or ethereal) forms tried instead.

Many other symptoms demand special treatment. The headache, which persists for days at the commencement and is with many a very distressing symptom, may be mitigated by removing the hair and applying cold to the head. The sleeplessness, with or without delirium, may be combated by quietness, by a moderately darkened room (although a distinction between day and night should be made as regards the amount of admitted light), and by soothing and gentle dealing on the part of the nurse. Opiate and sedative medicines in any form, although recommended by many high authorities, must be given with great caution, as their use is often attended with danger in this fever, where coma is apt to supervene. When resorted to, probably the safest form is a combination of the bromide of potassium or ammonium with a guarded amount of chloral. The writer has seen alarming effects follow the administra-tion of opium. Occasionally the deep stupor calls for remedies to rouse the patient, and these may be employed in the form of mustard or cantharides to the surface (calves of legs, nape of neck, over region of heart, &c.), of the cold affusion, or of enemata containing turpentine. The height of the temperature may be a serious symptom, and antipyretic remedies appear to have but a slight influ-ence over it as compared to that which they possess in typhoid fever, acute rheumatism, &c. The cold bath treatment, which has been recommended, cannot be carried out without serious risk to life in the necessary movement of the patient. It is a well-recognized rule that persons suffering from typhus fever ought not to be moved up in bed for any purpose after the first few days. Cold sponging of the hands and feet and exposed parts, or cold to the head, may often considerably lower the temperature. Throughout the whole progress of a case the condition of the bladder requires special attention, owing to the patient's drowsiness, and the regular use of the catheter becomes, as a rule, necessary with the advance of the symptoms.

The complications and results of this fever fall to be dealt with according to the methods of treatment applicable to their character and extent.

TYPHOID OR ENTERIC FEVER.

Typhoid or enteric fever (evrepov, the intestine) is a con-tinued fever characterized mainly by its insidious onset, by a" peculiar course of the temperature, by marked abdominal symptoms occurring in connexion with a specific lesion of the bowels, by an eruption upon the skin, by its uncertain duration, and by a liability to relapses.

This fever has received various names, such as gastric fever, abdominal typhus, infantile remittent fever, slow fever, nervous fever, &c. Dr Murchison, in reference to its supposed origin in putridity, uses the term "pythogenic fever," but this designation has not been generally adopted. Up till a comparatively recent period typhoid was not dis-tinguished from typhus fever. For, although it had been noticed that the course of the disease and its morbid ana-tomy were different from those of ordinary cases of typhus, it was believed that they merely represented a variety of that malady. The distinction between the two diseases appears to have been first accurately made in 1836 by Messrs Gerhard and Pennock of Philadelphia, and still more fully demonstrated by Dr A. P. Stewart of Glasgow (afterwards of London). Subsequently all doubt upon the subject was removed by the careful clinical and pathological observations made by Sir William Jenner at the London Nature fever hospital (1849-51). A clear distinction has been of established between the two fevers, not only as regards their typhoid. p]jenomena or morbid features, but equally as regards their origin. While typhus fever is a disease of overcrowding and poverty, typhoid may occur where such conditions are entirely excluded; and the connexion of this malady with specific emanations given off from decomposing organic or fasculent matters, or with contamination of food or water by the products of the disease, is now almost universally admitted. Alike in sporadic cases and in extensive epidemic outbreaks the existence of insanitary conditions in house drainage, water supply, dec., can in the majority of instances be made out. The question whether such conditions alone will suffice to beget this fever—or, in other words, its de novo origin—has, as in the case of typhus, been much dis-cussed, and an affirmative opinion expressed by some high authorities. But the same remark must again be made as to the difficulties in the way of maintaining such a position in view of the evidence of the part played by microbes in infective processes. Causes of That all insanitary conditions in respect of drainage of its out- houses and localities furnish the most ready means for the break, introduction of the contagion of typhoid there is a general agreement, as there is equally that the most certain means of preventing its appearance or spread are those which provide a thoroughly trustworthy and secure drainage, a safe method of disposal of sewage, and a pure and abundant water supply. Typhoid fever is much less directly com-municable from the sick to the healthy than typhus. The infective agent appears to reside in the discharges from the bowels, in which, particularly when exposed and under-going decomposition, the contagium seems to multiply and to acquire increased potency. Thus in sewers, drains, &c, in association with putrefying matter, it may increase indefinitely, and by the emanations given off from such de-composing material accidentally escaping into houses, or by the contamination of drinking water in places where wells or cisterns are exposed to fascal or sewage pollution, the contagion is conveyed. Of the precise nature of the contagious principle we have as yet no full information, but there appears to be strong reason for believing that a specific microbe or organism plays a part in the propagation of the disease. Still it is obvious that for its successful implantation in and effect upon the system a peculiar con-dition of preparedness or receptivity to the morbific agent must be presupposed to exist in the individual, regarding which also our knowledge is of the vaguest. There is abundant evidence that one of the vehicles for the con-veyance of the contagion is food, especially milk, which may readily become contaminated with the products of the disease where an outbreak of the fever has occurred in a dairy.

Typhoid fever is most common among the young, the majority of the cases occurring between the ages of fifteen and twenty-five (Murchison). But children of any age may suffer, as may also, though more rarely, persons at or beyond middle life. It is of as frequent occurrence among the well-to-do as among the poor. The greater number of cases appear to occur in autumn. In all countries this fever seems liable to prevail; and, while some of its features may be modified by climate and locality, its main characters and its results are essentially the same everywhere.

The more important phenomena of typhoid fever will be better understood by a brief reference to the principal pathological changes which take place during the disease. These relate for the most part to the intestines, in which the morbid processes are highly character- of istic, both as to their nature and their locality. The changes (to typhoid, be presently specified) are evidently the result of the action of the contagium on the system, and they begin to show themselves from the very commencement of the fever, passing through various stages during its continuance. The portion of the bowels in which they occur most abundantly is the lower part of the small intestine (ileum), where the "solitary glands " and " Peyer's patches " on the mucous surface of the canal become affected by diseased actiftn of a definite and progressive character, which stands in distinct relation to the symptoms exhibited by the patient in the course of the fever. (1) These glands, which in health are comparatively indistinct, become in the commencement of the fever enlarged and prominent by infiltration due to inflammatory action in their substance, and consequent cell proliferation. This change usually affects a large extent of the ileum, but is more marked in the lower portion near the ileo-CEecal valve (see ANATOMY). It is generally held that this is the condition of the parts during the first eight or ten days of the fever. (2) These enlarged glands next undergo a process of slough-ing, the inflammatory products being cast off either in fragments or en masse. This usually takes place in the second week of the fever. (3) Ulcers are thus formed varying in size according to the gland masses which have sloughed away. They may be few or many in number, and they exhibit certain characteristic appearances. Thus they are frequently, but not always, oblong in shape, with their long axis in that of the bowel, and they have somewhat thin and ragged edges. They may extend through the thickness of the intestine to the peritoneal coat and in their progress erode blood-vessels or per-forate the bowel. This stage of ulceration exists from the second week onwards during the remaining period of the fever, and even into the stage of convalescence, (i) In most instances these ulcers heal by cicatrization, leaving, however, no contraction of the calibre of the bowel. This stage of healing evidently occupies a consider-able time, since the process does not advance at an equal rate in the case of all the ulcers, some of which have been later in forming than others. Even when convalescence has been apparently com-pleted, some unhealed ulcers may yet remain and prove, particularly in connexion with errors in diet, a cause of relapse of some of the symptoms, and even of still more serious or fatal consequences. The mesenteric glands external to, but in functional relation with, the intestine, become enlarged during the progress of the fever, but usually subside after recovery.

Besides these changes, which are well recognized, others more or less important are often present. Among these may be mentioned one which the present writer has repeatedly observed in the severe and protracted forms of this fever, namely, marked atrophy, thin-ning, and softness of the coats of the intestines, even after the ulcers have healed,—a condition which may not improbably be the cause of that long-continued impairment of the function of the bowels so often complained of by persons who have passed through an attack of typhoid fever. Other changes common to most fevers are also to be observed, such as softening of the muscular tissues generally, and particularly of the heart, and evidences of complica-tions affecting chest or other organs, which not unfrequently arise. The swelled leg of fever sometimes follows typhoid, as does also periosteal inflammation.
The symptoms characterizing the onset of typhoid fever are very Progress much less marked than those of most other fevers, and the disease of the in the majority of instances sets in somewhat insidiously. Indeed, disease, it is no uncommon thing for patients with this fever to go about for a considerable time after its action has begun. The most marked of the early symptoms are headache, lassitude, and discomfort, together with sleeplessness and feverishness, particularly at night; this last symptom is that by which the disease is most readily de-tected in its early stages. The peculiar course of the temperature

is also one of the most important diagnostic evidences of this fever. During the first week it has a morning range of moderate febrile rise, but in the evening there is a marked ascent, with a fall again towards morning, each morning and evening, however, showing respectively a higher point than that of the previous day, until about the eighth day, when in an average case the highest point is

== IMAGES ==

Temperature chart of typhoid fever

but it is no unusual thing to register 104° or 105° Fahr. in the even-ing and 103° or 104° in the morning. During the second week the daily range of temperature is comparatively small, a slight morning remission being all that is observed. In the third week the same condition continues more or less ; but frequently a slight tendency to lowering may be discerned, particularly in the morning tempera-ture, and the febrile action gradually dies down as a rule between the twenty-first and twenty-eighth days, although it is liable to recur in the form of a relapse. Although the patient may, during the earlier days of the fever, be able to move about, he feels languid and uneasy ; and usually before the first week is over he has to take to bed, and soon the effects of the attack become more apparent. He is restless, hot, and uncomfortable, particularly as the day ad-vances, and his cheeks show a red flush, especially in the evening or after taking food. The aspect, however, is different from the oppressed stupid look which is present in typhus, and more resem-bles the appearance of hectic. The pulse in an ordinary case, al-though more rapid than normal, is not accelerated to an extent corresponding to the height of the temperature, and is, at least in the earlier stages of the fever, rarely above 100°. In severe and protracted cases, where there is evidence of extensive intestinal ulceration, the pulse becomes rapid and weak, with a dicrotic character indicative of cardiac feebleness. The tongue has at first a thin whitish fur and is red at the tip and edges. It tends, however, to become dry, brown or glazed looking, and fissured transversely, while sordes may be present about the lips and teeth. There is much thirst and in some cases vomiting. Splenic and hepatic enlarge-ment may be made out. From an early period in the disease abdo-minal symptoms show themselves with greater or less distinctness and are frequently of highly diagnostic significance. The abdomen is somewhat distended or tumid, and pain accompanying some gurgling sounds may be elicited on light pressure about the lower part of the right side close to the groin,—the region corresponding to that portion of the intestine in which the morbid changes already referred to are progressing. Diarrhoea is a frequent but by no means constant symptom. "When present it may be slight in amount, or, on the other hand, extremely profuse, and it corresponds as a rule to the severity of the intestinal ulceration. The discharges are highly characteristic, being of light yellow colour resembling pea soup in appearance. Should intestinal haemorrhage occur, as is not unfrequently the case during some stage of the fever, they may be dark brown, or composed entirely of blood. The urine is scanty and high-coloured. About the beginning, or during the course of the second week of the fever, an eruption frequently makes its appearance on the skin. It consists of isolated spots, oval or round in shape, of a pale pink or rose colour, and of about one to one and a half lines in diameter. They are seen chiefly upon the abdomen, chest, and back, and they come out in crops, which continue for four or five days and then fade away. At first they are slightly elevated, and disappear on pressure. In some cases they are very few in number, and their presence is made out with difficulty ; but in others they are numerous and sometimes show themselves upon the limbs as well as upon the body. They do not appear to have any relation to the severity of the attack, and in a very consider-able proportion of cases (particularly in children) they are entirely absent. Besides this eruption there are not unfrequently numer-ous very faint bluish patches or blotches about half an inch in diameter, chiefly upon the body and thighs. When present the rose-coloured spots continue to come out in crops till nearly the end of the fever, and they may reappear should a relapse subse-quently occur. These various symptoms persist throughout the third week, usually, however, increasing in intensity. The patient becomes prostrate and emaciated ; the tongue is dry aud brown, the pulse quickened and feeble, and the abdominal symptoms more marked; while nervous disturbance is exhibited in delirium, in

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attained. This varies according to the severity of the attack;
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tremors and jerkings of the muscles (sulsultus teiidinum), in drowsi-ness, and occasionally in "coma vigil." In severe cases the ex-haustion reaches an extreme degree, although even in such instances the condition is not to be regarded as hopeless. In favourable cases a change for the better may be anticipated between the twenty-first and twenty-eighth days, more usually the latter. It does not, how-ever, take place as in typhus by a well - marked crisis, but rather by what is termed a "lysis" or gradual subsidence of the febrile symptoms, especially noticeable in the daily decline of both morning and evening temperature, the lessening of diarrhoea, and im-provement in pulse, tongue, &c. Convalescence proceeds slowly and is apt to be interrupted by relapses (due not unfrequently to errors in diet), which are sometimes as severe and prolonged as the original attack, and are attended with equal or even greater risks. Should such relapses repeat themselves, the case may be protracted for two or three months, but this is comparatively rare.

Death in typhoid fever usually takes place from one or other of Causes of the following causes. (1) Exhaustion, in the second or third weeks, death in or later. The attending symptoms are increasing emaciation, weak- typhoid, ness of the pulse, and cadaveric aspect. Sometimes sinking is sudden, partaking of some of the characters of a collapse. (2) Haemorrhage from the intestines. The evidence of this is exhibited, not only in the evacuations, but in the sudden fall of temperature and rise in pulse-rate, together with great pallor, faintness, and rapid sinking. Sometimes haemorrhage, to a dangerous and even fatal extent, takes place from the nose. (3) Perforation of an intestinal ulcer. This gives rise, as a rule, to sudden and intense abdominal pain, together with vomiting and signs of collapse, viz., a rapid flickering pulse, cold clammy skin, and the marked fall of tempera-ture. Symptoms of peritonitis (see PERITONITIS) quickly supervene and add to the patient's distress. Death usually takes place within 24 hours. Occasionally peritonitis, apart from perforation, is the cause of death. (4) Occasionally, but rarely, hyperpyrexia (excessive fever). (5) Complications, such as pulmonary or cerebral inflamma-tion, bedsores, &c.

Certain sequelae are sometimes observed, the most important being the swelled leg, periostitis affecting long bones, general ill-health, and anaemia, with digestive difficulties, often lasting for a long time, and sometimes issuing in phthisis. Occasionally, after severe cases, mental weakness is noticed, but it is usually of com-paratively short duration.
The mortality in typhoid fever varies with the character of the Mor-outbreak, the general health and surroundings of the individuals tality. attacked, and other conditions. At one time it was regarded as, on an average, about the same as that of typhus; but under modern methods of treatment the -chances of recovery are much greater, and the death-rate maybe stated as about 12 per cent, or perhaps some-what less.

The treatment embraces those prophylactic measures which aim Treat-at preventing the escape of sewer gases into dwelling-houses by ment. careful attention to the drainage and plumber-work, and also secure an abundant supply of pure water for domestic use (see HYGIENE, SEWERAGE, and VENTILATION). When an outbreak of the fever occurs in a family, all such matters should be specially inquired into, and the sources of milk supply carefully scrutinized. The discharges from the bowels of the typhoid patient should be at once disinfected with carbolic acid or other similar agent, and the greatest care taken as to their disposal, with the view of obviating any risk of contamination of drinking-water, &c. The general management is conducted upon the same principles as are observed in the case of typhus, except that in typhoid fever very special care is neces-sary in regard to diet. Milk, the great value of which as a fever-food was first clearly set forth by Prof. Gairdner, is of eminent service in typhoid, but it must be administered with due regard to time and to the digestive powers of the patient. When given too frequently or in too great quantity it may, by its imperfect digestion, prove a source of irritation to the bowels. Even when given with every care it may fail to agree, as is proved by the presence of un-digested curd in the evacuations. In such a case its admixture with lime water or with peptonizing agents may render its digestion less difficult, but sometimes its use must for a time be suspended. It is, however, rare that milk cannot be borne when carefully ad-ministered. Barley water or simple soups, such as chicken broth, beef-tea, &c., are occasionally useful either as substitutes for or adjuvants to milk. All through the fever the patient should be feci at regular periods—not, as a rule, oftener than once in one and a half or two hours—although in the intervals water or other fever-drink may be given from time to time. In convalescence the diet should still be largely milk and soft matters, such as custards, light puddings, meat jellies, boiled bread and milk, &c, but other solid foods, with the exception of fish, should be for a long time avoided. In changing the diet it is of importance to note its effect upon the temperature, which may sometimes be considerably disturbed from this cause, even after the apparent subsidence of all febrile action. Stimulants, although unnecessary in a large proportion of cases, arc occasionally called for when there is great exhaustion, and in prolonged attacks. Their effect, however, should be carefully watched. They are usually best administered in the form of pure spirit.

The more prominent symptoms which mark the course of typhoid fever frequently call for special treatment. Thus, when the fever continues long, with little break in its course, the employment of remedies to control its action (antipyretics) may often be resorted to with benefit. Such drugs as quinine, salicin, salicylic acid, and salicylate of soda, kairin, antipyrin, antifebrin, &c. (in ten to thirty grain doses of one or other), may frequently break in upon the con-tinuity of the fever, and by markedly lowering the temperature relieve for a time the body from a source of waste, and aid in tranquillizing the excited nervous system. The times for their administration are either one or two hours before the usual maximum temperature or during the period of remission. These remedies may, however, fail, or by inducing sickness or great prostration and depression of the circulation require to be discontinued. For a similar purpose the cold bath is recommended by many high authorities and is regularly employed in Germany. The method recommended by Liebermeister is this : '' When the temperature rises above 104° Fahr., the patient should be placed in a bath of about 94°, which is gradually cooled down by the addition of cold water to 68° Fahr., and remain immersed for twenty or thirty minutes, the limbs being all the while gently rubbed. He should then be put back into bed." Another method is that of Dr Brand of Stettin: "When the patient's temperature attains 102° Fahr., he should be placed in a tepid bath of 70° and allowed to remain till a sense of coldness or shivering is produced, which usually occurs in from five to twenty minutes." By such means no doubt the temperature can often be reduced 2° or 3° Fahr., but it is very apt to rise again and the bath must then be repeated. It is claimed by the advocates of this method of treatment that it has been successful in diminishing greatly the mortality of typhoid fever, but they hold at the same time that its success in large measure depends upon its employment from an early stage in the disease. British physicians are much divided upon the point, many high authorities agreeing in its marked utility, while others no less eminent regard it as fraught with danger from the frequent movement of the patient from bed, the shock to the system, and the risk of hemor-rhage, pneumonia, or other complications, and as a plan of treat-ment difficult of being carried out in ordinary practice. Although employed in some fever hospitals and with apparent success, it has not yet commended itself for general adoption. Other methods of applying cold, while probably less effectual than the bath, are much more available, as, for example, the tepid or cold pack, the frequent sponging of portions of the body with cold water, or the applica-tion of icebags to the head. The present writer has resorted to these methods in many cases of typhoid fever, with the effect of markedly lowering a high temperature. When diarrhoea is ex-cessive it may be restrained by such remedies as chalk, bismuth, Dover's powder, &c. Hemorrhage is dealt with by preparations of ergot, or by acetate of lead, gallic acid, or other styptics. In the event of perforation of the bowel opium is the only means avail-able to lessen the distress attending that fatal occurrence.

In the convalescent stage, and even after apparently complete recovery, the utmost care should be observed by the patient as to diet, all hard and indigestible substances being dangerous from their tendency to irritate or reopen unhealed ulcers, and bring on a relapse of the fever or cause a sudden perforation. Lastly, the general health demands careful attention for a length of time, in view of the remoter risks of chest and other diseases already alluded to.

RELAPSING FEVER.

This is a continued fever occasionally appearing as an epidemic in communities suffering from scarcity or famine. It is characterized mainly by its sudden invasion, with violent febrile symptoms, which continue for about a week and end in a crisis, but are followed, after another week, by a return of the fever.

This disease has received many other names, the best known of which are famine fever, short fever, synocha, bilious relapsing fever, recurrent typhus, and spirillum fever. As in the case of typhoid, relapsing fever was long believed to be simply a form of typhus. The distinction between them appears to have been first clearly established in 1826, in connexion with an epidemic in Ireland. Out-breaks of relapsing fever have occurred in all parts of the world at times and in places where famine has arisen ; but the disease has been most closely observed and studied in epidemics in Great Britain and Ireland, Germany, Poland, Russia, America, and India. It has frequently been found to prevail along with an epidemic of typhus fever.

Relapsing fever is highly contagious, and appears, like typhus, Causes of to be readily communicated by the exhalations from the body. With origina-respect to the nature of the contagion, certain important and inter- tion. esting observations have been made. In 1873 Obermeier discovered in the blood of persons suffering from relapsing fever minute organisms in the form of spiral filaments of the genus Spirochete (see vol. xxi. p. 399, fig. 1, n), measuring in length -5-^5- to XSVIF inch and in breadth 40007 to Tsiss inch, and possessed of rotatory or twisting movements. This organism has received the name of Spirillum obermcieri. It appears to be present in abundance dur-ing the height of the febrile symptoms, and is not seen during the interval until the relapse is impending, when it is again present as before. This observation has been confirmed by numerous investi-gators, and it has been found that inoculation with the blood containing these Spirilla produced the symptoms of relapsing fever in both men and animals. Comparatively little is as yet known of the life-history of these organisms, and the question whether they are to be regarded as the prime source of the disease or as mere , accompaniments affords ground for difference of opinion (see PATH-OLOGY, vol. xviii. p. 403); nevertheless their discovery and the con-ditions of their presence already mentioned are noteworthy facts in reference not only to the pathology of this fever but also to the general doctrine of infectiveness in disease-processes. The most con-stantly recognized factor in the origin and spread of relapsing fever is destitution ; but this cannot be regarded as more than a predis-posing cause favouring the reception and propagation of the morbific agent, since in many lands widespread and destructive famines have prevailed without any outbreak of this fever. Instances, too, have been recorded where epidemics were distinctly associated with over-crowding rather than with privation. Relapsing fever is most commonly met with in the young. One attack does not appear to protect from others, but rather, according to some authorities, en* genders liability.

Temperature chart of relapsing fever.

(105°-107° Fahr.), at which it continues with little variation, while the pulse is rapid (100-140), full, and strong. There is intense thirst, a dry brown tongue, bilious vomiting, tenderness over the liver and spleen, and occasionally jaundice. Sometimes a peculiar bronzy appearance of the skin is noticed, but there is no character-istic rash as in typhus. There is much prostration of strength. After the continuance of these symptoms for a period of from five to seven days, the temperature suddenly falls to the normal point or below it, the pulse becomes correspondingly slow, and a profuse perspiration occurs, while the severe headache disappears and the appetite returns. Except for a sense of weakness, the patient feels well and may even return to work, but in some cases there remains a condition of great debility, accompanied with rheumatic pains in the limbs. This state of freedom from fever continues for about a week, when there occurs a well-marked relapse with scarcely less abruptness and severity than in the first attack, and the whole symptoms are of the same character, but they do not, as a rule, continue so long, and they terminate in a crisis in three or four days, after which convalescence proceeds satisfactorily. Second, third, and even fourth relapses, however, may occur in exceptional cases.

The mortality in relapsing fever is comparatively small, about 5 per cent, being the average death-rate in epidemics (Murchison).

The fatal cases occur mostly from the complications common to &c. continued fevers. The treatment is essentially the same as that for typhus fever (see above). (J. O. A.)

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The extreme contagiousness of relapsing fever has occasionally Its con-been shown by its spreading widely when introduced into a district, tagious-even among those who had not become predisposed by destitution ness. or other depressing conditions. The contagion, like that of typhus, appears to be most active in the immediate vicinity of the patient and to be greatly lessened by the access of fresh air. It is capable of being conveyed by clothing. The incubation of the disease is about one week. The symptoms of the fever then show themselves with great abruptness and violence by a rigor, accompanied with pains in the limbs and severe headache. The febrile phenomena are very marked, and the temperature quickly rises to a high point

== TABLE ==



Footnotes

A bacillus frequently noticed in certain tissues in cases of typhoid fever has not yet been satisfactorily proved to be an organism character-istic of that disease, nor even to be constantly present.








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