(299) Symptoms.

The advent of typhus is nearly always sudden. It may be preceded by the usual indefinite slight headache and malaise for one or two days, but oftener the date is sharply defined by rigors, frontal headache, lassitude, pain in the back and limbs (especially in the thighs), and a high temperature. The temperature on the second day is mostly above 102°, by the fifth day above 103°, and may reach 105°. A fever in which by the fifth day the temperature is not higher than 102° is probably not even a mild attack of typhus. In severe cases the temperature is very high-104° to 104.9° on the second or third day. Between the fourth and seventh days, but usually on the fourth or fifth, there is an eruption. The eruption, when it first appears, is specially likely to be confused with the eruption of measles. The spots are small, varying in diameter from a few lines to mere specks, and grouped together in patches with an irregular outline. At first of a dirty pink, and slightly elevated above the surface of the skin, they disappear on pressure, but after the first or second day they become of a darker colour, and on pressure only get paler.

The best place to look for the eruption is on the back. The eruption is often scanty, and in dark-skinned races difficult to see. There may also be difficulty in detecting the eruption in the lower orders from the presence of dirt, as well as in kitchens and dark rooms from the absence of a good light. The eruption is present in 97.7 per cent. of the cases, when looked for by skilled and experienced observers. As it does not appear until the fourth day, and it may be later, in the first cases of a typhus epidemic, the patients will probably be not moved to hospital before the fifth or sixth day. The eruption does not appear in successive crops; they all appear as a rule within 24 hours of the commencement of the eruption. About the second week of the disease minute hæmorrhages take place subcutaneously, giving rise to purplish spots or petechiæ. These, of course, do not disappear on pressure. The frequency of petechia has given rise to one of the synonyms of typhus fever, viz., "petechial fever," but petechiæ in the milder cases may be absent. On the other hand, they are sometimes to be seen at the commencement of the malady. A very good representation of the eruption on the skin in its different

stages is given in Murchison's classical work on The Continued Fevers.

The petechiae have been confounded with flea-bites and vice-versa. In the author's experience a child, three years old, during an epidemic of typhus, was sent upon the certificate of a physician to the hospital, but the authorities returned the child two days afterwards, stating the spots were those produced by fleas-a curious error, the more so because the petechiae of typhus are not very similar. A close examination with a lens will reveal the fine puncture in the centre of the spot made by the piercing apparatus of the little vampire.

About the end of the first week delirium sets in. The delirium may be acute, although this is rare. It is, however, important to remember that cases have been known in which the patient has escaped from his attendants and appeared in the street. Fortunately, owing to the rapid manner with which abundance of fresh air dilutes and renders innocuous the typhus poison, this circumstance is not very dangerous to the public, a chance meeting of a delirious patient in the open street being probably more alarming than infective. Nevertheless, the possibility of such an occurrence shows the necessity of isolation in a suitable place, and nursing by trained nurses.

After three or four days of delirium succeed nervous depression and stupor. The muscular prostration is extreme, the patient lies in bed with vacant stupid countenance, the conjunctivæ injected, the eyelids closed, and the pupils contracted, the tongue dark brown and coated with sordes. There may be tremors, subsultus, and picking of the bed-clothes. The pulse is frequent, small, and undulating. The bowels nearly always confined. The urine generally copious and either evacuated involuntarily, or having to be drawn away by a catheter. In this state the patient passes many hours or several days with life trembling in the balance; if the case is to terminate fatally the stupor passes into profound coma, or sudden engorgement of the lungs suffocates the patient, or a combination of syncope and coma supervene. If the case is to terminate in recovery, then on or about the fourteenth day there is a more or less sudden amendment, the patient falls into a quiet sleep from which he wakes another man. Recovery is now rapid. In a week there will be only left great muscular weakness, and often also some cerebral debility, both to be completely recovered from.

(300) Etiology of Typhus.

It is only by analogy that typhus is classed with diseases supposed to be of micro-parasitic origin. The truth must be told that con. cerning its real nature we know extremely little. There are some grounds for believing typhus to be the emasculated plague, in a few cases of typhus there are purulent swellings very similar to the buboes and abscesses of the plague, and it is a circumstance of some significance that Clot Bey, the eminent Egyptian physician, on visiting the London Fever Hospital some years since, saw cases of typhus complicated with swellings in the parotid region, and declared that such cases in Egypt would be called cases of the "Plague." There have only been isolated bacteriological observations on cases of typhus; for instance, Mott 1 has described active motile dumb-bell cocci in the blood, and plugs of cocci in the lymphatics of the heart, but no elaborate sustained inquiry into the nature of typhus has been made by modern methods. Typhus has in all historic times marked out for its peculiar habitat spots where human beings heaped themselves together in poverty and mental misery. Of all predisposing causes the most fertile have been overcrowding, mental and bodily depression. It has followed the wake of armies, it has penetrated with the felon into the jail, it has sailed in the slave ship, and become endemic in the lowest and most densely populated parts of large cities.

'A careful study," says Murchison, "of the history of typhus epidemics demonstrates, in my opinion, the intimate connection between these epidemics and famine or distress. They have appeared during every variety of climate, season, and weather; famine and overcrowding have been the sole conditions common to them all." Murchison even went so far as to believe that under these circumstances typhus might be produced de novo, but this doctrine will not be accepted at the present day. Presuming it to be caused by a micro-parasite, it is known that many of these live under ordinary circumstances as saprophytes on vegetable and other organic matter; it is therefore more reasonable to suppose that, instead of a creation of the typhus poison, it ever exists, and under certain circumstances attacks human beings.

Whatever may be the nature of typhus poison there is good

1 British Medical Journal, 1883.

evidence to believe that it is lighter than atmospheric air. Haller found that ozone introduced into a typhus ward was most rapidly consumed in the upper part of the room. It has also been observed that if typhus be treated on the second floor of a hospital, patients, on the third or upper floors are likely to catch it, while on the contrary, if the typhus patients are placed at the top, the infection does not descend. The bodies of typhus patients emit a peculiar odour, and the odour is supposed to be connected with the infection; those patients who have the strongest odour are most apt to communicate the disease. The typhus poison is most probably thrown off by the skin and lungs, and taken in by breathing. The striking distance of typhus is important; the oldest observations are those of Haygarth, on the subject. In 1777 he devoted much attention to this matter, and concluded that the infectious matter of small pox does not exceed half a yard, and that the contagion of typhus is confined to a much narower sphere. We, however, now know that this opinion with regard to small pox is entirely misleading. Lind, Tweedie, and Murchison all, however, agree that the typhus poison only strikes within a very small distance, probably a fever hospital taking typhus patients may be situated in the centre of a large population without public danger; at all events no indictment has been laid against the London Fever Hospital, and at no time has typhus fever prevailed in its neighbourhood in such a manner as to suspect the hospital as the cause. Murchison says, "From all experience it follows that if a typhus patient be placed in a large, well ventilated apartment the attendants incur little risk, and the other residents in the same house none whatever. There are likewise no grounds for the popular belief that typhus may be propagated through the atmosphere from a fever hospital to the houses in its neighbourhood. On the other hand, medical men who auscultate typhus patients, or who inhale their concentrated exhalations from under the bedclothes, run no small danger, and the danger is always increased or diminished in proportion to the supply of fresh air.”

The typhus poison adheres to clothes and woollen or organic substances generally, but if these are exposed to the air it becomes innocuous; no instance is on record of a medical man carrying typhus home to his family, although some have been in constant attendance. on typhus patients. On the other hand, if clothes infected with typhus have been tied up in bundles or put away in boxes or

drawers, or have been kept under other conditions which have prevented full areation, under these circumstances the infection may be long retained, and in medical literature may be found several instances in which fomites have conveyed the infection after a considerable time has elapsed.

From available evidence it appears that the first few days of illness are not so infectious as when the fever is at its height and during the period of convalesence. Murchison says, "My opinion is that the disease is really most contagious from the end of the first week up to convalescence, when the peculiar odour from the skin. is strongest, and that the body ceases to give off the poison as soon as the fever subsides and the appetite and digestion are restored. During the first week of typhus there is little danger, when the patient is removed within this time the disease rarely spreads." If this doctrine be accepted patients should be safe to discharge from hospital a week after the complete cessation of the fever. The evidence as to whether a dead body of a person dying from typhus is contagious or not is far from clear, but it is safest to consider such a corpse contagious, and to take measures accordingly.

(301) Mortality.

The mortality calculated from 18,268 cases admitted into the London fever hospital during the years 1848-59 was 18.9 per cent. of the cases, but the mortality from more recent statistics is less; for instance, in 54 cases of typhus in an outbreak in St. Marylebone in 1881 the mortality was 156 per cent, and in 1887 the case mortality of typhus treated at the hospitals of the Asylum Board was only 11.6 per cent. Typhus is not alone less prevalent but less mortal than formerly.

The mortality is greatly influenced by age, the mortality being lowest among children from 10-14 years of age, highest in adult life; for example, in cases admitted to the London Fever Hospital between the years 1862-70 the following was the age-distribution mortality :