TYPHUS A.ND TYPHOID FEVERS have so much in common, that to avoid repetition, we shall discuss them in one article. Until comparatively few years ago, it was gener ally believed that no definite distinctions could he drawn between the various forms of continued low fever znet with in this country. In 1840, Dr. A. P. Stewart, lately one of the physicians to the Middlesex hospital, pointed out the differences which are now almost universally recognixed between typhus and typhoid fevers; but his views received little attention till 1848-50, when Dr. Jenner,* physician to her majesty, published two papers on The Identity or Hon-identity of Typus and Typhoid Fevers, and on Diseases eommonly confounded under the term Continued Fevers. Iu these memoirs, Dr. Joiner shows, by evidence which mast be satisfactory to every unbiased mind, that typhus and typhoid fevers differ, as Dr. Watson observes, "notably and constantly in their symp toms and course, in their duration, in their comparative fatality, in the superficial mark ings which respectively belong to them, and which warrant our classing them among the exanthemata, in the internal organic changes with which they are severally attended, and (what is the most important and the most conclusive) in their exciting causes."— Lectures on the Principles and Practice of 2Ifedicine, 4th ed., 1857, vol. ii. p. 795. In addition to typhus and typhoid, there is a third well-marked variety of continued fever, known as relapsing fever, which has been considered in a special article.
Typhus fever sometimes commences to show itself by certain premonitory symptoms, due to the depressing action of the poison—which, as will presently be seen, is the cause of the diseaese—upon the nervous system before it begins to affect the circulation. The patient, in these cases, is listless, unwilling to make any bodily or mental exertion, loses appetite, feels wandering pains over the body, is drowsy during the day, and restless at night. More commonly, however, the disease begins suddenly, a shivering fit being the first symptom. Severe headache, especially across the forehead, is another common early symptom. The muscular power rapidly becomes enfeebled, and the patient very soon feels compelled to take to his bed. As in typical cases of the disease, there are three sets of symptoms, each of which occupies about a week, it is convenient to divide the descrip tion of the continued fever into that of three weekly stages. In the first week, in addi tion to the symptoms already noticed, the heat of the skin becomes increased, and the pulse, which at first is hard, becomes soft and weak, and more frequent than in health, often now rising to 120, and in severe cases reaching 130 or 140 beats in a minute. Accord• log to Dr. Jenuer, the pulse in uncomplicated typhus gradually rises to a maximum, preserves that rate for a variable time, and then slowly falls; while in typhoid it rises and falls irregularly. There is considerable thirst; the tongue becomes clammy and dry, and its center is covered with a white fur, which is often mesially divided by a straight brown streak, which is the first step to the blackness of that organ which afterward ensues. The intelligence is blunted; but on being sharply spoken to, the patient still gives rational answers. As the week advances, the strength is so reduced, that he lies on his back, and is unable to turn about iu bed without assistance. In the second week, the pulse becomes more frequent, weaker, and more compressible, and the tongue grows drier and browner. The teeth and lips are invested with dark sordes, consisting of morbid epithelium that had been shed; and the weakness is now so extreme, that the patient sinks down in his bed. His voice becomes very feeble, and in bad cases lie can not swallow, nor can he put out his tongue. The two most remarkable symptoms o; the second week are the delirium which seems to replace the headache, and about the ninth duty ensues, and the appearance of the characteristic eruption. The delirium usually ap pears on the patient's awakening from sleep. He is inattentive to all that goes ou around him, and usually lies still, muttering disjointed sentences, like a man talking in his dreams. Sometimeg, however, he is more actively delirious, talking loudly, and trying to leave his bed. He may sometimes he roused by a strange voice, but soon relapses into his previous state. The senses are in a disturbed condition, the patient being com monly deaf, and, in advanced cases, often suffering from musem volitantes (q.v.), which
gives rise to attempts to grasp these visonary objects, or to pick them from the bedclothes. This symptom, which is known in medical language under the name of jloccitatio, is almost certainly indicative of a fatal result. The characteristic eruption, which Dr. Jenner calls the mulberry rash, may show itself as early as the fifth day, but most com monly appears at the beginning of the second week, and sometimes a little later. The characters of the rash vary with its age. It consists of very slightly elevated spots of a dusky Each spot is flattened on its surface, irregular in outline, with no \ yell-defined margin, but fades insensibly into the hue of the surrounding skin, disap pears completely on pressure, and varies to size from a point to three or four lines 'in diameter. In two or three days these spots undergo a marked change. They no longer remain elevated above the surrounding cuticle; their hue becomes darker and mare dingy than at first, and they now only fade on pressure, instead of completely.disappear ing. From this state they commonly grow paler, pass into faintly marked reddish brown stains, and finally disappear. The spots composing this mulberry rash are gen erally very numerous, close together, and occasionally almost covering the skin. Some times, however, they are very few in number, situated at some distance from one another, and not to be distinguished at first from the rose-spots which, as will be pres ently seen, occur in typhoid fever. The mulberry rash is usually situated on thestrunk and extremities, but is occasionally limited to the trunk, and in rare cases is seen on the face. No fresh spots appear after the third day of the eruption, and the rash subsides between the 14th and 21st days. The mulberry rash, though characteristic of typhus when it occurs, is not an essential symptom of the disease. Dr. Jenner states that in patients less than 15 years old, in whom the mortality is not more than 2 or 3 per cent, it is mostly either absent, or pale in hue and scanty in quantity; while in persons upward of 59 years of age. in whom the mortality is about 56 per cent, the rash is always pres ent, and dark and abundant_ Hence, the case of small-pox, the degrees of development of the eruption may be taken as a direct measure of the intensity of the dis ease. It is in the course of this second week that death is most apt to occur. Among 25 fatal cases noted by Jenner, nine deaths only occurred after the 15th day, and not one after the 20th. If the case is going to terminate fatally, symptoms commonly and expressively termed putrid set in; a peculiar fetor is exhaled from the breath and the surface of the body; the tongue is dry, black, and fissured; the teeth are covered with dark sordes, and sloughing bed-sores occur. The prostration increases to the last degree, and subsultus tendinum, or involuntary twitchings of the muscles of the face and arms, make their appearance. In some cases the ordinary stupor is replaced a day or two before death by the condition known as coma vigil. In this condition the patient never sleeps, but lies on his back, with the eyelids widely separated, the eyes staring and fixed in vacuity, the month partially open, and the face pale and devoid of expression. He is totally incapable of being roused to give a sign of consciousness, the pulse and breathing are hardly perceptible, and the skin is cool. The occurrence of death is only marked by the eve losing its slight luster, and the chest ceasing its slow and feeble movements. Dur ing- the third week the symptoms gradually abate in those cases which are going to end in recovery. The patient often falls into a profound, quiet, and prolonged sleep between the 14th and 17th day, from which he awakes with a decided general improvement. The complexion is clearer, the delirium has disappeared, the pulse has fallen, and the tongue begins to show signs of moisture at the edges. In a few days the tongue gradually becomes clean, the appetite becomes ravenous, and from that time the patient rapidly gains strength. In many cases the amendment is so gradual that it is impossible to say when it begins. and occasionally the favorable crisis is preceded by a temporary aggra vation of the symptoms. A profuse sweat sometimes accompanies the favorable change. In the cases that terminate fatally there is no rallying from the symptoms described as occurring in the second week.