Typhus Fever.
Synonyms:—Ship fever, putrid fever, camp fever, jail fever, exanthematic typhus, hunger typhus.
Definition:—An acute highly infectious self-limiting fever. It is characterized by the suddenness of its onset and by the development of a petechial eruption, general in occurrence and not recurring in crops, like the rose rash of typhoid. The temperature is high from the first, with marked nervous phenomena.
Etiology:—A specific cause for this disease has not been determined. The methods of its conveyance are not known. It is seldom found except among emigrants and sailors in seaport towns. There has usually been immediate, intimate contact with the sick, under circumstances of filth, bad hygiene, poor ventilation, impure drinking water and poor food, restricted in quantity—conditions of poverty and overcrowding. It is not strictly a water borne disease, as typhoid fever appears to be.
It occurs most frequently among young adults and in early middle life, because these are more apt to expose themselves to the essential conditions.
Symptomatology:—The disease requires ten days for its incubation, during the last two of which there is usually general malaise, indisposition and loss of appetite. The occurrence of a severe chill, or a series of light chills, is suddenly followed by immediate prostration, severe muscular pains, headache, tinnitus and vertigo and an almost immediate high temperature, which reaches 104° F. on the first day, and 105° F. on the second day, and persists with no regular remission. There is nausea and vomiting, sometimes most persistent. The tongue is coated with a thick, dirty, yellowish white coat, there is great thirst, but scanty urine of a high specific gravity.
The Nervous Symptoms are often pronounced from the first. With the appearance of the fever there is delirium, which may quickly become active, and as quickly, later on, assume a violent maniacal form, or assume the form of a typhomania. Coma and comavigil quickly follow, the patient profoundly unconscious, yet staring into space with widely opened eyes. There are tremors, carphologia and subsultus tendinum. The face then assumes a dull, expressionless, even stupid appearance, the bright flush assumes a dull, dusky purplish hue, and evidences of the most extreme prostration, tending to complete exhaustion, are plainly apparent, the patient sinking down in the bed in the dorsal position.
About the third day of this serious disease, but often delayed twenty-four or thirty-six hours, a rash, which is characteristic of the disease, appears upon the abdomen first, and then extends to the chest and extremities, seldom appearing upon the face. This quickly assumes the form of a rose-colored eruption. There is no abatement of the temperature, but frequently an increase of the febrile phenomena. The pulse becomes rapid, feeble and irregular. The red spots become darker in hue, are hemorrhagic or petechial, and they coalesce, causing the skin to assume a spotted or mottled appearance. The tongue becomes brown and is dry, fissured and tremulous, and the teeth are covered with sordes.
On the fourteenth day there is usually a sudden rise of the temperature, and the crisis occurs. The decline of the fever is quite rapid, although marked with some exacerbations and irregularities.
Complications and sequelae are not as common as with typhoid fever. The vomitus in some extreme cases may consist principally of blood. The heart shows progressive weakness. The lungs and bronchi are the most commonly affected, as broncho-pneumonia, bronchitis or hypostatic congestion may be induced. Hematuria has been found to occur in extreme cases and meningitis and some mild forms of local paralysis are not uncommon.
Diagnosis:—The presence of an epidemic of this disease suggests its probable character. The character of the eruption is pathognomonic. It is distinguished from typhoid fever by the sudden rise of extreme temperature and absence of regular remissions, also by the absence of enteric symptoms. It is distinguished from cerebral inflammation or from cerebro-spinal meningitis, by the character of the headaches, and by the convulsions, and absence of a similar eruption, in the latter.
Prognosis:—The prognosis of this disease is not necessarily unfavorable, but depends upon the severity of the epidemic, and the previous condition and age of the patient. The mortality rate is perhaps fifteen per cent.
Treatment:—The patient must be placed at once in a condition which is in every way hygienic. Nutritious feeding can be persisted in without the danger present in typhoid, and this should receive much attention because of the immediate and severe prostration. As there is no danger of intestinal irritation and possible inflammation, a thorough, effectual laxative will be of much service, and if the prostration is marked, an enema, or a pint of physiological salt solution should be then given and retained, every three or four hours.
In unquestionably sthenic cases a hypodermic of pilocarpine, one eighth of a grain, may be given early. If marked delirium occurs quickly with the sudden rise of temperature, a sitz bath in hot mustard water, until the skin is markedly reddened, with a sharp mustard paste to the entire spinal column, should precede other treatment. These positive measures often abort the disease or abridge its severity. If the temperature has reached an extreme point, when first seen by the physician, the patient may be wrapped in a sheet wrung out of water of about eighty degrees temperature; with cold cloths to the head. If the patient complains of the increased heat, the sheet may be removed after a time and reapplied at the original temperature. It may be kept on for two or three hours or until there is a reaction and some perspiration.
The further treatment of the disease should be guided by the indications, all of which will be met by remedies advised for typhoid and the same general and specific rules for their application may be followed here. A radical course, calculated to jugulate or abort the disease, should not be adopted after the third or fourth day. A steady impression should be made then upon the dominant conditions by the specifically indicated remedy. The indications for aconite, belladonna, rhus toxicodendron, baptisia, echinacea, hyoscyamus, the acids or alkaline remedies, when they appear, will all be pronounced for one or more of these remedies. Hydrobromic acid will be found serviceable for the delirium, but ergot must be given with caution, because of the deficient power in the capillaries of the skin. Belladonna will serve the purpose of ergot to a much better advantage.
The upbuilding of the patient will need more stimulants at first, than typhoid, but nutrition can be forced, with good judgment, almost through the entire course of the disease. The physician must watch for the crisis; must attend in person, and guide the patient safely through this most critical period of the entire course. Inattention or negligence at this time may render all previous good care unavailing.
