quinine given in large doses hypodermatically has given favorable results
in a few cases. The temperature may be controlled by the hydrotherapeutic
measures indicated in enteric fever; the bowels should be kept open and
the severe pains may be relieved by the administration of Dover's powder
or small doses of morphine.
The diet and general management applicable in enteric fever are indicated.
TYPHUS FEVER.
Synonyms. Jail, Camp, Ship, Hospital, Putrid or Spotted Fever; Black
Death.
Definition. An acute infectious disease characterized by a typical skin
eruption, nervous symptoms and a high temperature terminating usually
by crisis in about two weeks.
.Etiology. Typhus, while comparatively rare during the past few decades,
was formerly one of the world's greatest scourges. Its gradual disappearance
is undoubtedly due to the increased attention paid to sanitation and the
education of the masses along general hygienic lines.
TYPHUS FEVER. 25
The disease is of markedly infectious nature but up to the present its specific
cause has not been determined. It is most common in young adults but no
age is exempt. Its occiurence is favored by crowded and filthy conditions,
unhygienic surroundings and mode of life, poor ventilation and famine.
â– As these factors are becoming year by year less conspicuous features of our
civilization there is every reason to hope that the disease will ultimately dis-
appear from the earth.
Isolated cases at times have occiu"red, but despite this evidence and the
fact that Murchison considered the spontaneous origin as possible, it is not
to be regarded as a probability in the light of present day knowledge.
While the nature of the contagion is unknown it is recognized that it is of
easy acquirement and difi&cult of destruction. It seems to be transmitted
through the atmosphere and to be given off from the patient's body. Con-
sequently it is communicable from one person to another and through furnitiure,
bedding, clothing, etc., to which the poison of the disease clings for long periods.
It is said that the contagium cannot pass through the air from hospitals or
other structures in which patients suffering from the disease are confined, to
dwellings in the vicinity. To acquire the infection intimate and fairly con-
tinuous association with the patient seems to be necessary, consequently nurses
are much more frequently affected than physicians who are with the sufferer
for but a few moments each day, unless indeed these latter are in attendance
upon a typhus hospital or ward.
It has been thought that the contagium is given off from the skin and in
the expired air; it may, however, be in all the body excretions and discharges
for anything that is certainly known to the contrary.
Pathology. There are no characteristic post mortem lesions. The
tissues show the changes which always accompany acute febrile disease of
severe type. The petechial eruption persists after death, in contradistinction
to that of enteric fever, and bed sores may be present ; the blood is dark and
fluid. The spleen and lymph glands are enlarged and soft, the kidneys and
liver may be increased in size. The tissues, including the muscles, and
particularly that of the heart, and organs are in a condition of acute degen-
eration (cloudy swelling). There is no intestinal ulceration; the lungs are
frequently the seat of hypostatic congestion and there may be evidences of
bronchial inflammation.
Symptoms. The incubation is from 10 to 12 days and while the invasion
is usually sudden general malaise may occur before this event takes place.
The invasion is marked by one or more chills followed by fever and headache
and severe bodily pain especially in the back. After the initial chill the tem-
perature rises rapidly and reaches its maximum (104° to 106° F. — 40° to 41.1°
C.) from the fourth to the seventh day. The patient is greatly prostrated, his
tongue is coated and soon becomes dry, nausea and vomiting are commonly
26
THE INFECTIOUS DISEASES.
present, the eyes are suffused and the expression is apathetic. Bronchitis is
frequent. The bowels are usually constipated.
After reaching its maximum at the end of the first week the fever continues
with sUght morning remissions for from 12 to 14 days. At the end of this
period it usually begins to fall by crisis and may drop to a subnormal level
within 24 hours. Death in severe infections may be preceded by a tempera-
ture of 108° to 109° F. (42.2° to 42.7° C).
The pulse is at first rapid and full but soon becomes weak and perhaps
dicrotic as the disease progresses; the first sound of the heart may be indis-
tinct and a systohc apical murmur may be present.
The respirations are rapid, their rate often being further increased by
DISEASE
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Fig. 2. — Clinical chart of typhus fever ending in recovery.
pulmonary congestion, bronchitis or a co-existent broncho-pnemnonia which
may be foUowed by pulmonar}^ gangrene.
The urine is scanty and high colored and frequently contains albumin
and casts.
There may be a slight increase in the number of the leucocytes, the opposite
of this condition obtaining in enteric fever.
The eruption is constant and appears on the third to the fifth day; its evolu-
tion is rapid. It presents itself first upon the chest and abdomen and, quickly
spreading to the limbs and face, involves the whole body within two or three
days. The rash consists of two elements: a dark mottling of the skin char-
acterized by blotches of light or dark purple; these may be rendered lighter
TYPHUS FEVER. 27
in color by pressure and at times become the seat of subcutaneous haemor-
rhage; and a slightly raised petechial eruption. This is pinkish in color and
resembles the rash of enteric fever, disappearing at first on pressure but
later persisting; these spots also are hasmorrhagic and like the mottling
persist post mortem. After the eruption, which lasts from 7 to 10 days, has
disappeared desquamation usually takes place. Children, in whom the
disease is seldom fatal, may show no rash whatever, or the skin may be covered
by an eruption not unlike that of measles.
Diuring the second week all the symptoms become more marked. The
prostration is severe, and delirium changing into stupor with subsultus tendi-
num, nystagmus and even coma vigil, develops. The tongue is cracked and
dry, the teeth are covered with sordes, the temperatiure is persistently high,
the pulse rapid, weak and perhaps dicrotic, the respiration is accelerated
and the patient may die exhausted by the infection. In the event of his recovery
the temperatiire rapidly falls by crisis and a deep sleep occiurs from which
the patient awakes greatly improved, the mental and all other symptoms
being in a much ameliorated condition. The convalescence now progresses
unless a relapse, which rarely takes place, occiurs.
Variations in the coiuse of the disease may be observed. Both malignant
forms, in which death supervenes within a few days, and mild types with
only slight rise in temperature and the other insignificant symptoms, are
described.
Complications. Of these broncho-pneumonia is the most frequent. Gan-
grene of the extremities, paralysis and septic infections such as subcutaneous
abscesses, parotitis and arthritis may occur. Noma has been observed in
children.
The diagnosis in epidemics is easily made but isolated cases may be mis-
taken for enteric fever, from which typhus fever may be differentiated by its
more rapid initial rise in temperature and otherwise more sudden invasion,
by its eruption and the absence of Widal reaction. In malignant smallpox
the more common occurrence of haemorrhages is an aid in differentiation.
Epidemic cerebrospinal meningitis at the onset may closely resemble typhus
fever but after a few days the diagnosis is usually clear, and malignant measles
may be differentiated by the accompanying conjunctivitis and coryza and
the fact that other cases of measles are in the vicinity. The eruption of
measles is of brighter red, presents itself first on the face and is Kkely to be
crescentic in form.
The prognosis varies in different epidemics ranging at times as high
as 50 percent., the usual figures are, however, from 12 to 20 percent. In
children the disease is seldom fatal.
Treatment. Patients suffering from typhus fever should be strictly
isolated, preferably in tents where the free ventilation not only exerts a favor-
28 THE INFECTIOUS DISEASES.
able effect upon the patient but renders the physicians and attendants less
likely to contract the disease. The fever should be controlled by the hydro-
therapeutic measures employed in typhoid fever. By these means not only
is the temperatm^e lowered but a favorable influence is exerted upon the
nervous system. Coal tar antipyretics should not be relied upon although
they may be occasionally prescribed in connection with other antipyretic treat-
ment. Their weakening effect upon the heart should never be lost sight of,
and if given, these drugs should be administered in connection with stimu-
lants which shall counteract this action. Heart stimulants are indicated early
in the disease and of these alcohol in the form of whiskey or brandy is to be
preferred ; digitaUs and strychnine are also useful in this connection. Quinine
is strongly recommended. Attacks of cardiac failure should be combated by
the hypodermatic administration of gether and camphor and the general
treatment of symptoms is practically identical with that indicated in enteric
fever. The bowels should be kept freely open from the onset of the disease,
it being usual when seeing the patient for the first time to prescribe a course
of calomel in fractional doses to be followed by a saline laxative. The specific
treatment by means of the sulphocarbolates, phenol and other antiseptics is
probably useless.
In the treatment of this disease the one fact to be kept in mind is that
sufl&cient stimulation is necessary to counteract the continued tendency to
heart weakness. In order to control this symptom the dosage should be
regulated in accordance with the patient's condition. In markedly asthenic
states the administration of as much as an ounce (30.0) or more of whiskey
hourly may be necessary.
The diet should be entirely of fluids during the febrile stage, milk either
plain or in the form of punch with egg and brandy, nourishing soups and
the like should be frequently given. As convalescence becomes established
soft solids and a gradual return to ordinary diet may be allowed. (See diet
of enteric fever, pp. 10 and 11.)
When the disease is treated in hospital wards or private dwellings the
most thorough ventilation must be insisted upon.
During the coiu-se of the disease the excreta and aU articles which come
into contact with the patient should be disinfected and if possible destroyed.
After recovery the patient's room and its contents must be thoroughly fumi-
gated.
MALTA FEVER.
Synonyms. Mediterranean Fever; Neapolitan Fever; Rock Fever; Undu-
lant Fever.
Definition. An acute infectious disease typified by an irregular tem-
perature, profuse sweats, diffuse pains and a tendency to relapse.
MALTA FEVER. 29
etiology. This disease prevails at Malta and in other countries whose
shores skirt the Mediterranean Sea. While infrequent in other regions it
has been observed in the West and East Indies, in China and the Philippines.
While one or two cases have made their appearance in England none has
ever originated in the United States. Malta fever attacks young adults most
frequently and prevails chiefly in the summer; its occurrence is favored by
unsanitary conditions.
The specific cause of this affection is the micrococcus melitensis. This
organism is found in the spleen in all cases which have come to autopsy but
as yet has not been isolated from the blood. When inoculated into monkeys
a similar disease to that occurring in human beings is produced and the
micrococcus may be isolated from the tissues of the infected animals. The
organism probably enters the body either upon the inspired air or in drinking
water; in one instance the infection has taken place through the conjunctiva.
It has been shown that the blood of patients siiffering from Malta fever causes
agglutination of pure cultures of the bacillus.
Pathology. No definitely characteristic lesions are found in patients
dying of this disease. It has been stated that the spleen is enlarged and that
other typical lesions of enteric fever are present.
Symptoms. The incubation period is from a few days to three or four
weeks. The invasion of the disease is gradual without chill or marked rise
in temperature, but is accompanied by malaise, headache, restlessness and
anorexia. These symptoms persist from one to three weeks when the tem-
perature falls and remains normal for two or three days, when it rises once
more, is accompanied by chills, associated with which is the return of the
other symptoms previously mentioned. This relapse lasts a month or six
weeks when a second remission takes place. This may last from one to two
weeks and is succeeded by a second relapse which is accompanied by more
marked symptoms than the first, and in addition others such as sweats, joint
pains, effusions, constipation, inflammations of the fibrous tissues, and orchitis;
following this is a third remission, after which in turn another relapse appears,
characterized by the symptoms of those preceding, with high fever, night
sweats and severe pains. The spleen is as a rule enlarged and may be tender.
The characteristic features of this disease consist in the recurrence of
rises of temperature lasting from one to three weeks and separated by afebrile
intervals lasting a few or more days. The relapses may recur for two or three
years but the usual length of the disease is three or four months. The fever,
pain and other symptoms, if long continued, must necessarily exert an exhaust-
ing effect on the patient which may prove fatal. Cardiac and pulmonary
complications may augment the severity of the disease and become factors
in its fatal outcome.
Variations in the type of Malta fever occur, a malignant variety, which
30 THE INFECTIOUS DISEASES. .
may result fatally within one or two weeks and a mild form with few symp-
toms save an evening rise of temperature having been described. One attack
of the disease is likely to confer immunity, for several years at least.
The differential diagnosis from enteric fever may be made by means of
agglutination tests.
The prognosis is usually favorable, the mortality being put at about 2 percent,
by most observers.
Treatment. No drug has a specific effect upon this disease. Attempts
have been made to elaborate an antitoxin and at least one patient seems
to have been successfully treated by this means.
The bowels should be kept open and the kidneys active. Hydrotherapeutic
measures, particularly sponging with cool water, should be employed to
control the temperature and the symptoms should be relieved by the methods
applicable in like conditions, such as those which occur in enteric fever.
Recently it has been suggested that an exclusively milk diet is unnecessary
unless the temperature runs above 103° F. (39.5° C). To patients whose
evening temperature does not rise above this point easily digestible solids
such as the cereals, eggs and bread are allowed in addition to milk and broths.
Even fish and meat are permitted if no iU-effects result from the lighter solids.
During convalescence the patient's exhaustion and ansemia should receive
tonic treatment, he should keep in the fresh air as much as possible and his
emaciation may derive benefit from inunctions of codliver oil and lanoline.
A change of climate, when the patient is able to travel, is distinctly indicated.
RELAPSING FEVER.
Synonyms. Famine Fever; Recurrent Typhus; Spirillum Fever; Seven
Day Fever.
Definition. A specific acute infectious disease characterized by a febrile
movement lasting six or seven days, followed by an afebrile interval of about
a week, after which the febrile paroxysm recurs and may be repeated three or
four times.
Etiology. The most favorable conditions for the development of this
disease are those of over-crowding, famine and filth, just as is the case with
typhus fever. It is common in East India and has prevailed at times in
Europe and the United States. It has not been observed, except in isolated
instances, in this country, however, since 1869. Age and sex seem to have no
influence upon its incidence.
The specific cause of the infection is the spirochaete of Obermeier which
was discovered in 1873. This organism is a spiral shaped bacterium in
length from three to six times the diameter of a red blood cell. It is found
in the blood, but only during the febrile stage; it has never been demonstrated
RELAPSING FEVER.
31
in the secretions or excretions. The disease has been produced in human
beings and monkeys by the injection of blood from a patient during the
febrile stage. Formerly it was believed that recurrent fever was transmitted
by means of fomites but the more recent studies of Tictin tend to confirm
the idea that it may be carried by means of suctorial insects such as bed
bugs, since blood taken from one of these insects which had bitten an infected
individual has produced the disease when injected into apes.
One attack of the disease does not confer immunity.
Pathology. No typical morbid changes are observed after death from
this disease. During the febrile movement, however, the spleen is enlarged,
and the viscera are swollen and are the seat of an acute degeneration.
DAY OF
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The skin may be jaundiced and ecchymotic and the bone marrow is in a
state of hyperplasia.
Symptoms. The incubation period is usually about one week although
the symptoms in certain instances may appear within a day or two after
infection. The onset is sudden with a chill followed by fever, malaise and