the previous condition of health of the patients. Destitute and poorly nourished children are more apt to suffer from complications. Edwards had a mortality of 4 per cent. among a series of 150 cases occurring in a destitute class in a hospital. There were five deaths in 165 cases; 2 died of pneumonia and enteritis, 2 of enterocolitis, and 1 of tuberculous meningitis. Among his private cases he never saw a death. Hatfield records a mortality of 9 per cent. occurring among patients in bad sanitary environment. Hemming, Alexander, Cuomo, Slagle, Roberts, McFarlan, Davis, and Forchheimer have each reported deaths, the last-named writer as a result of nephritis. In about 100 cases observed by us in children convalescing from scarlet fever there were no deaths and no complications worthy of mention; indeed, the illness, almost without exception, was of a most trivial character scarcely necessitating the detention of the children in bed. THE TREATMENT OF RUBELLA. What has been said in connection with varicella is equally true of this disease; it is questionable whether it is necessary to isolate rubella patients in their homes. The disease is so mild, and in individuals in average health so devoid of complications and mortality, that such persons might be allowed to take it when it appears in their home. In hospitals it is proper to isolate patients with rubella, for here it may be inadvisable to superadd to another disease any infectious malady, however mild. The same may be said of institutions in which there are children in depraved health. The only treatment that is necessary in the majority of cases is the guarding of the patient against undue exposure. Where fever is absent and catarrhal symptoms slight, one need not insist on rest in bed, although the child should be kept in a properly heated and ventilated room. The diet should be regulated according to individual requirements. No special medication is required unless the attack be severe or some complication develop. If it be desirable to protect others from infection the patient should be isolated for about a fortnight. CHAPTER XI. TYPHUS FEVER. Definition. Typhus fever is a specific, acute, infectious disease, characterized by a continued fever of about two weeks' duration, pronounced nervous and brain symptoms, and by the appearance on the fourth or fifth day of a macular eruption which tends to become hemorrhagic. Synonyms. Spotted fever, petechial fever, ship fever, jail fever, putrid fever, brain fever, camp fever. Latin, febris typhus; typhus exanthematicus; French, le typhus; German, Exanthematischer typhus, Fleck feber; Italian, il Tifo. History. It is impossible to fix with accuracy the date of origin of typhus fever. The name "typhus" is mentioned in one of the Hippocratic essays, but it was applied at this period to acute fevers in general, accompanied by stupor and disturbance of the mental faculties. Many writers are of the opinion that Hippocrates actually observed cases of typhoid fever. According to Hirsch, the first clear evidence of the occurrence of typhus is given by Fracastorius, a physician of Verona, who carefully chronicled the great pestilence which began in Cyprus and swept Italy on several occasions between the years 1805 and 1830. He distinguished this malady, which he called morbus lenticularis, from the plague. After devastating Italy, the epidemic spread to France, Spain, Germany, and other European countries. Some writers claim that typhus was unmistakably seen and described by Jacobus de Partibus in 1463 and by Agricola. Typhus prevailed in extensive epidemics in different parts of Europe in the seventeenth century. During all this time it was confounded with typhoid fever. Indeed, these two diseases were not generally accepted as separate entities until almost the middle of the nineteenth century. Much credit is due to that splendid clinician, Hildenbrand, of Vienna, for the pioneer work in clarifying the medical comprehension of these fevers. While Hildenbrand alludes in particular to the epidemic typhus of 1806, he states that he had been studying the disease for upward of twenty years. Two fearful agencies of destruction, war and pestilence, have ever travelled in company. Conquest has often been purchased at a frightful sacrifice. Armies have carried home the laurels of victory, but also death-dealing plagues. Almost every great European war from the time of Charles the Fifth, in the middle of the sixteenth century, to the Turko-Russian conflict in 1878, has had its epidemic of typhus fever. The Napoleonic campaigns saw thousands of France's soldiers perish by the hand of this ruthless enemy. According to Michaeli,1 no less than 100,000 Russian soldiers in the Turko-Russian War contracted typhus; of this number, about one-half died. The mortality was particularly high among surgeons, 60 per cent. of the stricken succumbing to the disease. In 1799, Rasori described a disease prevailing in epidemic form about Genoa. Although the designation "petechial fever" was given to this malady, it is evident that it was typhus. The widespread military expeditions of the early years of the nineteenth century served to disseminate typhus throughout Europe. The disease later subsided, only to reappear from time to time in certain localities. Ireland has suffered many decimating outbreaks, and has been for many years the home of typhus fever. Scotland and England have also frequently experienced the blighting influence of this scourge. According to Murchison, one million persons were attacked by typhus in England in the epidemic of 1847. Germany has suffered frequent epidemics, the disease being usually imported from the Russian frontiers. France has had a greater exemption from typhus than most of the other European countries. The disease nevertheless prevailed extensively during the Napoleonic wars, and at infrequent intervals since then. The eastern seaport towns of the United States-New York, Philadelphia, Boston, Baltimore, etc.-have seen occasional epidemics of typhus fever, the disease being brought in by immigrants. According to Licéaga, an epidemic of fever marked by a spotted eruption ravaged Mexico in 1530. As this was coincident with the epidemics of typhus in Spain about this time, the view is reasonable that this disease was probably typhus. In 1545 another severe epidemic, in all probability typhus, swept Mexico, destroying eight hundred thousand lives. Typhus fever is endemic in the large cities of the central plateau of Mexico; it increases in the winter months and not infrequently assumes epidemic proportions. Among the most important contributions to our knowledge of the disease may be mentioned the writings of Sir John Pringle, Hecker, Rasori, Hildenbrand, Hufeland, Larry, Armstrong, Horn, Roupell, and, more recently, Murchison, Virchow, Lindwurm, Wood, and Griesinger.3 In the United States the writings of Gerhard and Pennock' are deserving of special praise. Curschmann says: "To two American physicians, Gerhard and Pennock, belongs the credit of having finally established the differentiation (between typhus and typhoid fever). The 1 Quoted by Curschmann, Nothnagel's Encyclopedia of Practical Medicine, Amer. ed., 1901. 2 Article on Typhus Fever, Twentieth Century Practice of Medicine, 1898. * Curschmann gives full bibliographic references to the modern literature of typhus fever, and Murchison the literature before 1865. On the Typhus Fever which Occurred in Philadelphia in 1836, Showing the Distinction between it and Dothienteritis, The American Journal of the Medical Sciences, 1837, vols. xix. and xx. clearness of their differential diagnostic statements is noteworthy for their time." Geographical Distribution.-Ireland and England (more particularly the former) have always been the home and distributing centre of typhus fever. This pestilence has been almost continuously present in these countries, exhibiting from time to time violent epidemic outbursts. The aggregate loss of life in Ireland from this disease has been appalling. Typhus fever has fortunately declined in recent years. The Russian provinces bordering on the Baltic Sea and Poland have also been for years typhus-stricken territories. In Germany the disease is usually limited to the southeastern provinces and to upper Silesia, although in times of epidemic prevalence Prussia also suffers. Germany receives its infection almost exclusively from the Russian borders. In France typhus fever is seldom widely diffused, although it is said to persist endemically in certain parts of Brittany. The disease is endemic to a certain extent in Northern Italy and also in Sicily and the neighboring islands. During periods of epidemic extension the entire country is overrun, as well as the lower provinces of Switzerland. Austro-Hungary has its endemic centres in Galicia, Silesia, Moravia, and Bohemia. The disease is practically never extinct in Turkey, nor in Persia and China. India is comparatively free from typhus and the northern coast of Africa suffers only at times, with the exception of Algeria, in which country the disease has become endemic. Spain and Portugal appear to be protected by their peninsular isolation and enjoy a relative degree of freedom from typhus. Ireland and Russia represent the two important hotbeds of the disease. From these centres the disease is carried from time to time to the Central and Northern European countries, and to America, Irish emigration has frequently brought the disease to New York, Philadelphia, Baltimore, and other ports of the United States, but typhus has never gained a permanent footing in this country. The disease persists endemically in the large cities of the central plateau of Mexico. In these densely populated districts typhus is never absent and epidemic outbreaks occur not infrequently. THE ETIOLOGY OF TYPHUS FEVER. Typhus fever is an infectious disease due to a specific cause, the nature of which has not been definitely determined. As a necessary corollary to this proposition it must be accepted that the disease spreads from one individual to another through the transmission of the typhus germs; this may take place directly or through the intermediation of infected articles. The doctrine of the spontaneous origin of typhus fever, confidently asserted not many years since, dies with the acknowledgment of the germ genesis of the disease. It is now universally recognized that under feeding and overcrowding do not cause typhus, but merely favor its development and dissemination. Contagiousness of Typhus.-Typhus fever is an extremely contagious disease, resembling in this respect the eruptive affections, such as measles, scarlet fever, and smallpox. Inasmuch as it is accompanied quite constantly by a cutaneous eruption of uniform character, there is good reason to include typhus among the exanthemata. While typhus is an extremely transmissible disease, its infection is not so readily conveyed to others as is that of measles or smallpox. The chances of contracting the disease are directly proportionate to the frequency, duration, and intimacy of the exposure and to the degree of concentration of infection in the atmosphere. Ventilation is a most important matter in lessening the dissemination of the disease. The poison of typhus fever commonly requires a certain degree of concentration to acquire an active infectiousness. The intensity of the infection may be greatly diminished by the free admixture of air. In a well-aired hospital ward containing but a few patients the danger of contracting the disease is by no means as great as when the reverse conditions prevail. When a previously unattacked individual enters a hospital ward in which a large number of typhus patients are being treated, or in a small and poorly ventilated sick-room, the liability is great that he will contract the disease. While the disease may be acquired after a very brief contact,experience teaches that the frequency and duration of the exposure exert a considerable influence upon the chances of infection. Nurses who are continuously and intimately in attendance upon the sick run the greatest risk. During the Crimean War, within a period of fifty-seven days, 603 nurses out of 840 in the service contracted typhus. In the TurkoRussian conflict all of the Sisters of Charity and 80 per cent. of the orderlies were attacked.1 The incidence of typhus in hospitals is greatest among nurses, next among resident physicians and students, then among visiting physicians, and, finally, among officials who make but occasional visits. Anderson states that at the Fever Hospital at Glasgow, and in the English Fever Hospitals generally, the assistants rarely escape the disease. Stokes and Cusak3 are authority for the statement that from 1813 to 1846 in Ireland there were among physicians 568 cases of typhus and 132 deaths, constituting approximately 46 per cent. of all cases and 10.5 per cent. of the deaths. Sixty per cent. of the surgeons in the Russo-Turkish War were stricken by the disease. There is perhaps no disease which attacks physicians and nurses in such large numbers as typhus fever. Yet when but few patients are treated in well-ventilated wards the danger is slight. On several occa 1 Mentioned by Licéaga, loc. cit. * Quoted by Licċaga. $ Ibid. |