James Ormiston Affleck

“ Although the patient may, during the earlier days of the fever, be able to move about, he feels languid and uneasy; and usually before the first week is over he has to take to bed, and soon the effects of the attack become more apparent. He is restless, hot, and uncomfortable, particularly as the day ad vances, and his cheeks show a red flush, especially in the evening or after taking food. ”

“ The opening up of cross streets intersecting those which are close-built and narrow, whereby fresh air is freely admitted, has done much to banish typhus fever from districts where previously it was endemic. Further, the enforcement of the law regulating the number of persons accommodated in common lodging-houses, and the application of the powers now vested in local authorities for dealing with cases of overcrowding everywhere, and for isolation and treatment of the infected, have had a like salutary effect. ”

“ The views of the disease which now prevail, recognizing the delirium as the effect at once of the poisonous action of alcohol upon the brain and of the want of food, encourage reliance to be placed for its cure upon the entire withdrawal, in most instances, of stimulants, and the liberal administration of light nutriment, in addition to quietness and gentle but firm control, without mechanical restraint. ”

“ The contagion, -like that of typhus, appears to be most active in the immediate vicinity of the patient and to be greatly lessened by the access of fresh air. It is capable of being conveyed by clothing. The incubation of the disease is about one week. The symptoms of the fever then show themselves with great abruptness and violence by a rigor, accompanied with pains in the limbs and severe headache. ”

“ Except for a sense of weakness, the patient feels well and may even return to work, but in some cases there remains a condition of great debility, accompanied with rheumatic pains in the limbs. This state of freedom from fever continues for about a week, when there occurs a well-marked relapse with scarcely less abruptness and severity than in the first attack, and the whole symptoms are of the same character, but they do not, as a rale, continue so long, and they terminate in a crisis in three or four days, after which convalescence proceeds satisfactorily. ”

“ Of the former the most powerful of all are those influences which lower the health of a community, especially overcrowding and poverty. Hence this fever is most frequently found to affect the poor of large cities and towns, or to appear where large numbers of persons are living crowded together in unfavourable hygienic conditions, as has often been seen in prisons, workhouses, &c. Armies in the field are also liable to suffer from this disease; for instance, during the Crimean War it caused an enormous mortality among the French troops. ”

“ In reality, however, it has passed into the dilated or pouched portion of the canal, which is almost always present immediately above the seat of stricture, where it remains until, from its amount, it regurgitates back into the mouth, when it can be seen, by the absence of any evidence of digestion, that it has never been within the cavity of the stomach. While in this way a large quantity of the food returns, it often happens that a small amount of the liquid portion does trickle through the narrowed canal into the stomach, and thus life may be prolonged for a considerable time. ”

“ Cold water may be drunk in small quantities at frequent intervals. Sleeping in the open air in very hot seasons is recommended. The treatment of a patient suffering from an attack necessarily depends upon the form it has assumed. In all cases he should if possible be at once removed into a shaded or cool place. Where the symptoms are mostly those of syncope and there is a tendency to death from heart failure, rest in the recumbent position, the use of diffusible stimulants, such as ammonia or ether, &c., together with friction or warmth applied to the extremities, are the means to be adopted. ”

“ Causes calculated to depress the health, such as previous disease, particularly affections of the nervous system, anxiety, worry, or overwork, irregularities in food, and in a marked degree intemperance have a powerful predisposing influence, while personal uncleanliness, which prevents among other things the healthy action of the skin, the wearing of tight garments, which impede the functions alike of heart and lungs, and living in overcrowded and insanitary dwellings have an equally hurtful tendency. ”

“ Typhus fever may, however, prove fatal during any stage of its progress and in the early convalescence, either from sudden failure of the heart's action—a condition which is specially apt to arise—from the supervention of some nervous symptoms, such as meningitis or of deepening coma, or from some other complication, such as bronchitis. ”

“ The attention of the sufferer is first attracted by the power of the hand becoming weakened, and then there is found to be a wasting of certain of its muscles, particularly those of the ball of the thumb. Gradually other muscles in the arms and legs become affected in a similar manner, their atrophy being attended with a corresponding diminution in power. Although sometimes arrested, this disease tends to progress, involving additional muscles, until in course of time the greater part of the muscular system is impli cated, and a fatal result ensues. ”

“ All through the fever the patient should be fed at regular periods not, as a rule, oftener than once in one and a half or two hours although in the intervals water or other feverdrink may be given from time to time. In convalescence the diet should still be largely milk and soft matters, such as custards, light puddings, meat jellies, boiled bread and milk, &c., but other solid foods, with the exception of fish, should be for a long time avoided. ”

“ The height of the temperature may be a serious symptom, and antipyretic remedies appear to have but a slight influence over it as compared to that which they possess in typhoid fever, acute rheumatism, &c. The cold bath treatment, which has been recommended, cannot be carried out without serious risk to life in the necessary movement of the patient. It is a well-recognized rule that persons suffering from typhus fever ought not to be moved up in bed for any purpose after the first few days. ”

“ The onset is sudden, resembling a convulsive seizure, and symptoms of suffocation are at once developed. The child makes strong efforts to inspire, which are accompanied with stridulous or crowing sounds, but, notwithstanding, very little air can enter the chest owing to the spasm of the glottis, and unless relief speedily comes death may be very rapid. In most cases, however, the attack quickly passes off, and the child seems little the worse. ”

“ Causes of its outbreak.That all insanitary conditions in respect of drainage of houses and localities furnish the most ready means for the introduction of the contagion of typhoid there is a general agreement, as there is equally that the most certain means of preventing its appearance or spread are those which provide a thoroughly trustworthy and secure drainage, a safe method of disposal of sewage, and a pure and abundant water supply. Typhoid fever is much less directly communicable from the sick to the healthy than typhus. ”

“ Again, long standing disease, by affecting the nutrition of an organ and by inducing the deposit of morbid products, may result in atrophy, as frequently happens in affections of the liver and kidneys. Parts that are subjected to continuous pres sure are liable to become atrophied, as is sometimes seen in internal organs which have been pressed upon by tumours or other morbid growths, and is well illustrated in the case of the feet of Chinese ladies, which are prevented from growing by persistent compression exercised from birth. Atrophy may manifest itself simply by loss of sub stance ”

“ A liability to severe headache, which in many cases would seem to depend upon a condition of chronic meningitis, epileptic fits, mental irritability, and alterations in the disposition are among the more important. It is often observed that heat in any form is ever afterwards ill borne, while there also appears to be an abnormal susceptibility to the action of stimulants. The mortality from sunstroke is estimated at from 40 to 50 per cent.
Treatment.— In respect of this disease means should be adopted to prevent attacks in the case of those who must necessarily be exposed to the sun. ”

“ In the condition known as nervous aphonia, which occurs mostly in women of hysterical habit or in circumstances of enfeebled health, the voice becomes reduced to a whisper, but there is seldom any affection of the breathing, or cough, and the laryngoscope reveals a perfectly healthy state of the parts. ”

“ The act of swallowing becomes increasingly difficult, and fluids are apt to regurgitate through the nose. Pain is felt along the Eustachian tube towards the ear, and there are tenderness and swelling in the neck about the angle of the jaw on the affected side. The voice acquires a peculiar and very characteristic snuffling tone, and there may be some embarrassment to the breathing. In a few days the inflamed tonsil shows signs of suppurating, and an abscess is seen to be bulging forward into the mouth. ”

“ Mortality.The mortality from typhus fever is estimated by Murchison and others as averaging about 18 per cent, of the cases, but it varies much according to the severity of type (particularly in epidemics) , the previous health and habits of the individual, and very specially the age,—the proportion of deaths being in striking relation to the advance of life. Thus, while in children under fifteen the death-rate is only 5 per cent, in persons over fifty it is about 46 per cent. ”

“ In favourable cases, which form the majority, the attack tends to abate in a few days, but on the other hand death may occur suddenly in a suffocative paroxysm, particularly in the case of children. Many cases of acute laryngitis are so comparatively slight as to make themselves known only by hoarseness and the character of the cough; nevertheless in every instance the attack demands serious attention. The treatment consists in keeping the patient in bed in an atmosphere of 60 to 70 F., made moist by steam. ”

“ The Tonsils are frequently the seat of inflammation, and acute tonsillitis or quinsy is one of the most common forms of sore throat. This affection is usually induced by cold, but it would appear to arise under other conditions also, such as digestive disturbances, &c. It is said to be more common in persons of rheumatic constitution, and one attack predisposes to others. The symptoms come on somewhat suddenly .and sharply, with chill followed by fever, the temperature frequently attaining a high point of elevation. Pain is experienced in the act of swallowing from the outset. ”

“ Such remedies usually suffice to relieve the attack, but in very severe cases more active interference may be necessary. When there is much swelling of the mucous membrane in the upper portion of the larynx, scarification of the parts with the aid of the laryngoscope may afford relief, but tracheotomy should not be neglected where death appears to be imminent from suffocation. Attacks of laryngitis may be largely prevented in those liable to them by a regimen calculated to invigorate the system, such as the cold bath, regular open-air exercise, &c. ”

“ It does not, how ever, take place as in typhus by a well - marked crisis, but rather by what is termed a "lysis" or gradual subsidence of the febrile symptoms, especially noticeable in the daily decline of both morning and evening temperature, the lessening of diarrhoea, and im provement in pulse, tongue, &c. Convalescence proceeds slowly and is apt to be interrupted by relapses (due not unfrequently to errors in diet) , which are sometimes as severe and prolonged as the original attack, and are attended with equal or even greater risks. ”

“ Thus, in the case of the heart, when affected with fatty degeneration, there is atrophy of the proper muscular texture, which, however, being largely replaced by fatty matter, the organ may undergo no diminution in volume, but may, on the contrary, be increased in size. Atrophy is usually a gradual and slow process, but some times it proceeds rapidly. ”

“ Occasionally, however, the inflammation passes from the one tonsil to the other, and a similar experience has to be gone through again. An attack of quinsy rarely lasts beyond a week or ten days, and is not as a rule attended with danger to life, although it is said that suffocation has occasionally occurred owing to the bursting of a large tonsillar abscess during sleep, and the passage of its contents into the trachea. ”

“ Besides this, the characteristic typhus rash, there is usually observed a general faint mottling all over the surface. The typhus rash is rarely absent and is a very important diagnostic of the disease. In the more severe and fatal forms of the fever, the rash has all through a very dark colour, and slight subcutaneous haemorrhages (petechiæ) are to be seen in abundance. After the appearance of the eruption the patient's condition seems to be easier, so far as regards the headache and discomfort which marked the outset of the symptoms ”

“ The character of the delirium is seldom wild or noisy, but is much more commonly a combination of busy restlessness and indefinite fear. When spoken to the patient can answer correctly enough, but immediately thereafter relapses into his former condition of incoherence. Occasionally maniacal symp toms develop themselves, the patient becoming dangerously violent, and the case thus assuming a much graver aspect than one of simple delirium tremens. ”

“ While typhus fever is a disease of overcrowding and poverty, typhoid may occur where such conditions are entirely excluded; and the connexion of this malady with specific emanations given off from decomposing organic or fæculent matters, or with contamination of food or water by the products of the disease, is now almost universally admitted. Alike in sporadic cases and in extensive epidemic outbreaks the existence of insanitary conditions in house drainage, water supply, &c., can in the majority of instances be made out. ”