Page:The American Cyclopædia (1879) Volume VII.djvu/175

 FEVERS 16T not known. The extent of its diffusion, or what is termed the infecting distance, is not great, and it is rarely that the contagion is transported by means of clothing or other sub- stances to which it adheres ; that is, by fo- mites. In general, it is necessary that the miasm be concentrated, as when the emana- tions from a number of patients accumulate in hospital wards, or when the room in which a single patient is treated is small and ill ventilated, for the disease to be communi- cated, excepting to those who may be brought into close and continued contact with cases. Among nurses and physicians in the fever wards of a hospital, a considerable proportion contract the disease. A single case in a hos- pital ward may communicate the disease to patients lying in close proximity. It is prob- able that the special cause is sometimes gene- rated in the concentrated emanations from the bodies of healthy persons congregated in over- crowded and imperfectly ventilated apart- ments, as in jails, camps, almshouses, and crowded ships. In typhus, as in other fevers, the intensity of the febrile condition is denoted especially by the temperature of the body, the range in different cases varying from 102 to 107 F. The temperature in the evening, as a rule, is some what higher than that of the morn- ing ; and approaching convalescence is often first denoted by a fall of temperature. The frequency of the pulse is also a good criterion of the severity of the disease. In most cases there is marked stupor throughout its course. The patient often lies in apparent somnolen- cy, and when aroused the countenance has a stupid, besotted expression. The face has a dusky hue, from the retardation of the circu- lation through the capillary vessels. A low muttering delirium is frequent, patients often attempting to get out of bed from some tran- sient delusion, but being easily induced for the moment to refrain from the attempt. Active delirium requiring forcible restraint is rare. The tongue is often covered with a thick brown or black coating, and, if not prevented by the removal of the accumulations on the teeth and lips, these become covered with a dark or black material called sordes. Tremor of the muscles of the extremities, called sulsultus tendinum, occurs in severe cases. The bowels are usually constipated. Swelling and suppu- ration of the parotid glands occasionally occur. In the great majority of cases there is an eruption on the skin, the character of which serves to distinguish this fever. It appears generally on the third day after the patient takes to the bed. The distinctive characters are as follows : It is maculated, that is, consists of spots, not elevated above the surface of the skin, of a dark or dusky color, and not readily obliterated by pressure with the finger. They continue throughout the disease, and are per- ceptible after death. Frequently the body and limbs are thickly studded with them, but in some cases they are few in number and limited to the trunk. This fever differs from the ma- larial fevers (intermittent and remittent) in being a self-limited disease. The length of its course varies between 8 and 20 days, the mean duration being about 14 days. The mortality varies considerably at different times and places, the range of variation being from 9 to 25 per cent. ; the average mortality is as 1 to 5 or 6. The death rate differs according to the age of patients; it is least between 10 and 20 years, increases progressively after the age of 30, and the proportion of fatal cases is about one half after 50 years of age. A fatal termi- nation is sometimes attributable to an impor- tant complication, as for example pneumonia ; and it may be due to an antecedent disease, such as some affection of the kidneys. In gen- eral, the mode of dying is by exhaustion or as- thenia. 4. Typhoid Fever. Although this has many symptoms in common with typhus, it differs in essential points. The name signifies resemblance to typhus. Owing to the existence of a characteristic affection of the intestines, it is called by German writers abdominal typhus, and by English and American writers, for the same reason, enteric fever. This characteristic intestinal affection is one of the essential points of distinction between typhoid and typhus fe- ver. The affection is seated in the Peyerian and solitary glands of the small intestine. These glandular sacs become enlarged by mor- bid growth, softening ensues, and at length they exfoliate or slough away, leaving ulcera- tions in the spaces they occupied. Perfora- tion of the intestines is an accident which some- times occurs, the contents of the intestinal ca- nal escaping into the peritoneal cavity ; perito- nitis follows as a result, terminating almost always in death. Another occasional event is hemorrhage from the ulcers. This is sometimes profuse, and may be the cause of a fatal termi- nation; but in the majority of the cases in which this accident occurs recovery takes place. The mesenteric glands which are in im- mediate relation to the Peyerian and solitary glands become considerably enlarged. If re- covery from this fever takes place, the enlarge- ment of these glands gradually disappears, and the intestinal ulcerations become cicatrized. The spleen is also constantly more or less en- larged and softened in typhoid fever. These morbid changes constitute what are called the anatomical characteristics of this disease ; they are wanting in typhus fever. Typhoid fever is undoubtedly communicable ; yet it is rarely communicated to those who are brought into contact with cases of it, namely, physicians, nurses, and fellow patients in hospital wards ; and it occurs when it is quite impossible to at- tribute it to a contagium. Hence, this is a dis- ease which, although produced in a certain proportion of cases irrespective of either a virus or an infectious miasm, may yet generate either one or both of these forms of conta- gious material. Facts go to show strongly that the contagium is contained in the intestinal