Of Typhus: Division into Mitior and Gravior, and into Cerebral, Thoracic, and Abdominal. Typhus Mitior, with Subacute Cerebral Affection; with Acute Cerebral Affection; with Thoracic Affection; with Abdominal Affection. Typhus Gravior: in what it really consists: dangerous Nature of the Error that it consists in Debility.

The appearance of a person labouring under typhus is so different from that of a person affected with synochus, that no one ignorant of the disease, who saw these two patients for the first time, would believe that both were afflicted with one and the same malady. And yet dissection after death demonstrates, that the physical condition of the organs is precisely the same in both; and careful examination of the symptoms during life, shews that they are really identical, both in their nature and their succession, however, at first view, they may appear to differ. The difference between these two diseases arises entirely from a difference in intensity: still this difference produces a very important modification in the character of the disease; important, because it materially affects both the safety of the patient, and the nature of the remedies that are best adapted to rescue him from his danger.

Typhus, like synochus, presents itself under two degrees of intensity, which, like those of the latter, may be conveniently designated by the terms mitior and gravior. All the important symptoms which belong to both are found in the same cavities, and relate to the same organs, as in synochus, and, therefore, must in like manner be divided into cerebral, thoracic, and abdominal.

I. Typhus Mitior, with Cerebral Affection.

Cerebral affection in typhus, as in synochus, presents itself under two degrees of intensity, which may be distinguished by the same terms as in the latter, the subacute and the acute.

1. Typhus Mitior with Subacute Cerebral Affection.

The symptoms which denote this affection in typhus, are perfectly similar to those which have been stated to characterise it in synochus, but they undergo certain modifications, the true nature of which appears to me to have been greatly mistaken, and, after the most careful attention which I have been able to give the subject, the mistake seems to me to be of so much magnitude, that I think whosoever shall effectually correct it, will do the greatest possible service to medicine, and, through it, to his fellow men.

1. There can be no question that, from the very first commencement of the attack, as well as through the whole course of the disease, the prostration of strength, both physical and mental, is greater in typhus than it is in synochus. This greater loss of energy is indicated by every sign that can be conceived to denote it. The loss of power in the muscles which support and move the body is oftentimes so complete, as to be most alarming to the patient and his friends; while the contrast between the vigor and the torpor of the mind, in the course only of a few hours, is most striking. From the full and active exercise of its faculties, it becomes, in that short space of time, quite incapable of performing any intellectual operation. It is confused and stupid, always in a greater degree than in synochus, and sometimes to such a degree, even on the very first day of the attack, as to excite the utmost apprehension in every one around the patient who takes any interest in his fate.

2. The chilliness is, upon the whole, greater and longer-continued than in synochus: yet there is less constantly shivering, and the heat, when it succeeds this state of chilliness, is seldom as great as in the latter; while there are cases in which the heat never exceeds the natural standard.

3. The febrile uneasiness is greater; the restlessness is incessant; the face is pallid; the features are shrunk; the expression of the countenance is most peculiar; it is strikingly indicative of weakness and suffering; the experienced eye can tell at a single glance, even at this early period, to which of the two types that countenance belongs. The pulse is always weaker and more rapid than in the corresponding stage in synochus.

4. There are cases in which the pain of the head is equally severe as in synochus: but this may be justly considered as rare. In general it is less acute. Dullness, confusion, stupor, giddiness, are more common than severe pain, and are often the substitutes for it. Though some degree of pain be generally present, yet it is by no means uncommon for one or more of these sensations to occupy its place completely. Question the patient as much as you please, and he will tell you that he has no pain; but it is evident, from his aspect and his manner, that he has little sensation of any kind. The eye is dull, heavy, stupid, without lustre: the old English word “lac-lustre” expresses its character truly and strikingly. But it is remarkable, that while the pain in the head is only slight, the pains in the back, loins, and extremities, and, as the patient himself says, in the bones, are severe.

5. When pain is present it diminishes sooner and disappears more completely than in synochus: when it is not present, the advancement of the disease is indicated by increasing insensibility, and by the rapid transition of dullness or confusion into a state of stupor approaching to coma. The eye is already muddy, and it soon becomes injected and suffused. The skin over the body is generally warm, sometimes hot: over the head it is often hot. The face is usually pallid, but the pallidness frequently alternates with flushing. The change of dullness into insensibility more or less profound sometimes takes place as early as the second or the third day: it is seldom that it is as late as the seventh or the eighth: it is postponed, when not prevented, by active and appropriate treatment.

6. There is little or no sleep; the restlessness is great; there may be no violence; but there is abundance of inquietude.

7. Delirium is more constantly present than in synochus; and when it comes it comes earlier: its presence is not unusual as early as the sixth or the seventh day; and it may appear still sooner, but that is rare. It consists of low muttering incoherence rather than of loud and violent talkativeness; and is expressed in moaning rather than in screaming.

8. The connexion between delirium and muscular tremor, between muscular tremor and subsultus tendinum, and between both, and the passing of the stools and the urine unconsciously, has already been pointed out. Like delirium, muscular tremor is much more constantly present in typhus than in synochus; and its relation to delirium is so close that it is sometimes observed to supervene on the very same day; frequently on the day following; and, if it appear at all, it is seldom longer absent than the third. Its degree likewise is commonly in proportion to the violence of the delirium; and though early and great delirium may appear without it, yet it very rarely appears without delirium; and in general all these symptoms form one series or train; pain disappearing, confusion of mind increasing, muttering incoherence supervening, and muscular tremor and involuntary and unconscious stools rapidly succeeding.

9. In the commencement of typhus the pulse is sometimes of good strength, and it may not exceed 90 in frequency; but as the disease advances it uniformly becomes weaker, smaller and quicker; so that death rarely takes place before it has reached 120. In the severer cases it is weak, quick, and easily compressed at a very early period.

10. The respiration is often not very obviously affected, but if it be attentively observed it will usually be found to be shorter and quicker than natural.

11. The tongue is always foul on the first or second day; it seldom continues moist longer than three or four days; it is often quite dry as early as the fourth, especially on the body and at the root; the apex and the edges sometimes remain moist a day or two longer; but in a short time the whole tongue becomes perfectly dry and of a brown colour; as the disease advances the colour often changes to a darker and darker hue until it becomes quite black; it is then frequently fissured into deep chaps, while the lips and teeth soon become covered with a black sordes. Were the sensibility not greatly altered, such a condition of the mouth and tongue must be attended with insatiable thirst; yet thirst is often not felt, although at other times it is considerable.

12. In the early stage of typhus the skin is frequently hot; as the disease advances the heat lessens: through the greater portion of the disease it is moderately warm; towards its termination it becomes cool, and some days before death it falls below the natural standard. It is always of a darker colour than in synochus: the whole surface is of a dull and dusky tinge. Sometimes it is covered with dun coloured petechiÆ, at others with petechiÆ of a florid colour.

13. During its progress, erysipelas, first appearing on the face, then extending over the scalp, and often down the shoulders and back, is very apt to occur. Excoriation on the back and hips often form sloughing sores of great malignity and extent, while enlargement, inflammation and suppuration of glands situated in different parts of the body frequently appear.

14. Typhus terminates much earlier, whether favourably or unfavourably, than synochus; if it terminate unfavourably death frequently takes place as early as the 10th or the 14th day, although if early and appropriate treatment be employed, the force of the disease is sometimes so much lessened that it is as protracted as synochus.

Towards the termination of the disease more or fewer of the symptoms which it has been stated occasionally to occur in synochus,^[25] supervene; but, as these depend upon particular conditions of the brain, they will be detailed under the pathology.

2. Typhus Mitior, with Acute Cerebral Affection.

In typhus with acute cerebral affection the pain of the head is often not more severe than it is in the subacute; but there is a greater degree of heaviness, or weight, or stupor, or giddiness; the eyes are more and sooner injected and more suffused; the insensibility comes on sooner and is deeper; the delirium appears earlier and is more violent, frequently requiring restraint, and the whole train of symptoms already enumerated, and which it is needless to repeat, are more intense in degree, and succeed each other with greater rapidity.

James Solden, Æt. 44, plaisterer. Admitted on the 7th day of fever: attack came on with chilliness; great debility; some pain of head; sense of giddiness and weight; together with symptoms of thoracic disease. At present pain of head entirely gone; it has passed into insensibility; mind quite delirious; almost constant moaning; pulse 96, weak; tongue brown and dry; stools passed in bed; respiration short and hurried; cough without expectoration; tenderness of abdomen on full pressure.

8th. Insensibility more profound; restlessness and delirium increased; respiration more hurried; cough the same; stools passed in bed: pulse 92.

9th. No change.

10th. Died.

John Clark, Æt. 17. Admitted on the 4th day of fever: attack commenced with ordinary symptoms, and was attended with severe pain of the head, which continues at present, and which is attended with a sense of weight; eyes injected and suffused; expression of countenance extremely dejected; sleeps none; skin pungently hot, especially over the scalp; pulse 108, of good power; tongue already brown and quite dry; some thirst; respiration hurried; some uneasiness of chest on coughing; considerable tenderness of abdomen.

5th. Eight ounces of blood which were drawn not sizy; crassamentum loose; pain of head not at all relieved; sense of weight distressing; no sleep; much restlessness; heat over the scalp pungent; pulse 104; tongue more dry; tenderness of abdomen the same; six stools.

6th. Pain of head still severe; mind more confused; passed a more restless night; pulse 116.

10th. Pain of head undiminished; eyes more suffused; extremely restless night, during which delirium came on; this morning muscular tremor has appeared; pulse 124.

12th. Pain of head entirely gone; scarcely at all sensible; constant muttering delirium; muscular tremor with subsultus tendinum; two stools passed in bed; pulse 124; abdomen still painful on firm pressure, and has become swollen and tense.

13th. Insensibility and delirium increased; constant incoherent muttering; extreme prostration; erysipelas has appeared on the forehead, and is spreading to the scalp: pulse 128; two stools passed in bed.

14th. Died.

II. Typhus Mitior, with Thoracic Affection.

Prominent thoracic affection, as we have seen, is not infrequent in synochus; in typhus it is more constant; and the signs which denote its existence are more obvious, but they are not precisely the same. The pain in the chest is less severe; it is more often absent altogether; while the sense of stricture and the dyspnoea are more urgent. The cough is more constantly attended with mucous rattle; the respiration is shorter and more hurried. The skin in general is cooler, and it is always more dusky. The dark colour of the skin, in severe cases, becoming quite livid, is one of the most characteristic marks of intense thoracic affection. The colour of the cheek is at first of a deep and vivid red; as the disease advances it becomes of a purple tinge, and at length it is quite livid. In these cases it is not uncommon for the respiration to be from forty to fifty in a minute. The pulse is invariably rapid and weak. The cerebral affection is equally peculiar and characteristic; it never consists of intense excitement; it is never accompanied with violent delirium; it is indicated by confusion and stupor passing rapidly into coma; and is attended with low muttering incoherence or disjointed rambling, the trains of ideas that pass through the mind being extremely faint, and linked together by no distinguishable affinity. We know that one of the most essential conditions to the due exercise of the sensorial faculties is the due supply of the brain with arterial blood; but in this state of the system arterial blood does not and cannot circulate through the brain, because it is not formed in the lung: the patient is in a state approaching to asphyxia, and in very severe cases he remains for several days in as perfect a state of asphyxia as seems to be compatible with life. Why debility should, in these cases, be carried to the utmost possible extent; why such cases should form the most exquisite specimens of the adynamic state, need not be pointed out: the disease is concentrated in the very organ which elaborates the pabulum of life, and that stream which should convey its vivifying and animating influence to every nook and point of the system is corrupted at its source.

It is in these cases, too, that the tongue becomes dryer than in any other; in its advanced stage it is sometimes quite black and even hard, and is altogether incapable of being protruded. Sometimes it is covered with a thick, black and hard crust; at other times it is cut into deep fissures, so as to give it a cracked appearance. These states of the tongue without doubt arise in part from the excessive dryness, occasioned by the mouth being kept always open, on account of the difficulty of respiring.

Such are the most characteristic marks of thoracic affection in typhus; as an illustration of which, as it occurs, perhaps, in the severest form ever witnessed in this country, the following case may be cited.

Alexander Crombie, Æt. 19, seaman.

The mate of his vessel states that, notwithstanding some previous indisposition, three days ago he was on duty; that while on watch, about eleven o’clock at night, he became too ill to remain at his post, and that, since that time, he has scarcely spoken a word. At present he is incapable of giving any account of himself. He is dull, stupid, and, when roused, is scarcely able to answer coherently; he does not speak, but he is constantly picking at the bed-clothes; there is extreme restlessness; the countenance is heavy and inexpressive; the features in general are swollen, the lips especially, which are also extremely parched. The entire skin is dusky, but the cheeks are of a deep red colour, approaching to a purple hue; the integuments of the eye are dark; the conjunctiva injected; the tongue brown and quite dry; the lips and teeth sordid; respiration oppressed; occasional cough; pulse from 130 to 140; small and thrilling; skin, especially over the scalp, hot; tenderness of abdomen on full pressure.

4th. Cerebral symptoms the same; cough frequent, difficult; respiration short and hurried; pupils dilated, not contracting on exposure to light; conjunctiva injected; pulse small, hurried, irregular; all the stools passed in bed; pressure over the abdomen induces cough and apparently excites pain. Died in the evening. See pathology.

To the account of abdominal affection in typhus, it is necessary to add nothing to that already given of abdominal affection in synochus, excepting that, in the former, pain in the abdomen is scarcely ever felt; tenderness on pressure is less acute, and it is more common for both to be absent. On the other hand, the abdomen is more often swollen, hard, tense and tympanitic, while the stools are more early and more constantly passed involuntarily. It is in this type of fever, also, that hÆmorrhage from the bowels most frequently takes, place—an event not very uncommon in the severest and the most protracted examples of the disease. The tongue, also, is less constantly red than in the abdominal affection of synochus; but it is more uniformly dry, black and cracked.

Since the full exposition of pathology requires that many examples of this affection should be detailed under that head, and since, however numerous and striking such examples may be, they can illustrate no characteristic symptom beyond what has been already stated, it is unnecessary to cite any cases of it here.

Whenever the brain, the lungs, and the intestines become simultaneously and prominently affected in typhus, the case no longer assumes the mild, but lapses into the severer form. We shall, therefore, speak of this complication under—

II. Typhus Gravior.

The typhus gravior of authors is extinct; at least I have seen no example of it in London. I have witnessed nothing bearing a tolerable resemblance to this disease, even as it is depicted by Cullen, much less as it is portrayed in the darkly vivid, yet apparently but too faithful colouring of Huxham. This malady seems to have disappeared with the epidemic intermittents and the epidemic dysenteries of the good old times. Whatever there may have been in the condition of our ancestors to excite our envy, there is certainly nothing to provoke it in their diseases.

All the examples of fever which approach in likeness to the descriptions on record of typhus gravior which I have seen, have consisted of the mixed cases of typhus. They have been cases in which the brain, the lungs, and the intestines were all simultaneously and intensely affected. The symptoms may not always denote an equal degree of affection in all these organs; but I have never seen a case in which there were not the most unequivocal signs of intense affection in all of them. For the reason already assigned, such cases must necessarily be the severest that can occur, because the patient may be said to have three diseases instead of one to contend with, each of which alone is sufficient to destroy life, and each of which alone frequently does destroy it.

All the examples of this form of fever which I have observed are referrible to two classes; one in which the arterial action is excessive; the other in which it is oppressed, or rather overwhelmed.

1. In the first, the patient lies insensible, with delirium, perhaps so violent that he cannot be kept in bed without restraint; with extreme restlessness and constant watchfulness; with rapid and panting respiration; with a tender abdomen, perhaps with frequent and involuntary stools, a dry, black, and hard tongue, a quick, yet weak pulse, and the skin universally and pungently hot.

2. In the second he lies insensible, with a cold and dusky skin; with a swollen and livid countenance; with a heavy and oppressed respiration; with a pulse perhaps not to be felt, or, if distinguishable, either so rapid that it cannot be counted, so small that it is like a thread beneath the finger, and so weak that it is lost by the slightest pressure, or else slow, irregular, and intermittent. In this state, the patient is almost as completely paralyzed as in apoplexy, and the attack is almost as rapidly fatal as apoplexy. It constitutes what has been called congestive fever.

Fortunately, these intense forms of the disease are of rare occurrence: they are witnessed only in solitary instances, and they arise either from exposure to a highly-concentrated poison, or from some condition of the constitution, by which that power to resist the influence of noxious agents, which is characteristic of life, is more than commonly diminished or exhausted. They have been conceived to form exquisite specimens of diseases of debility. But where is the debility? Not in the disease, for that is of giant strength; not in the patient, for remove, if you can but remove, a part of the load that oppresses him, and instantly an intensity of action will be set up in the whole system, perhaps as great as it is capable of exerting, and certainly greater than it is capable of sustaining without the most imminent danger. The brain is overwhelmed by the intensity of its affection; the energy that should animate the system, and of which it is the great source, is withheld: but that energy is suspended, not destroyed; and the debility which seems to be the result is not real, but apparent, not direct, but indirect. The giant that lies prostrate on the earth, mastered by superior power, has still a giant’s strength, though he does not at that moment put it forth: give him but the chance of throwing off the load that keeps him down, and he will soon shew you that he is not weak. I have always been struck with the extraordinary clearness and decision with which the acuteness of Sydenham enabled him to make this important distinction, perhaps in the very first case that occurred to him, in which the discrimination was required. Having described, in his own powerful manner, an excellent specimen of congestive fever to which he was called, he states that he ordered the patient to be bled: that the bye-standers regarded the suggestion with horror: that the man seemed at the point of death; that to them it appeared that the abstraction of blood must inevitably extinguish the last remaining spark of life; while to him it was manifest that the patient was in this alarming condition, because he was oppressed by an overwhelming load, and if that could only be lessened, his condition would be the very reverse of what it now seemed: that accordingly, on the removal of some ounces of blood, the state of oppression ceased at once, and fever arose of a true inflammatory nature, for the subdual of which repeated bleedings were required.

It is remarkable, and it is highly characteristic of these intense forms of disease, that their pathology exhibits a striking contrast to that of the less severe affections. No morbid appearances are visible in the organs which seem capable of accounting for death. There are signs of vascularity; the vessels are turgid with blood, and consequently the organs on which they are spent are in a state of congestion. But they seldom if ever exhibit any real appearance of inflammation, and still less do they contain any true inflammatory product. Why? Not on account of debility; but because the force of the disease is so great as to overwhelm the powers of life at the first onset, allowing even of no reaction, and much less of that continued excitement which is part and parcel of the inflammatory state, and which is indispensable to an inflammatory product. Reduce the intensity of the disease a little, bring it just within the limit that is compatible with the continuance of life for a given time, and then the products of inflammation at once appear in the greatest possible purity, variety, and extent.

And this is precisely the fact, as is demonstrated by the condition of the organs, in those ordinary types of fever, the essence of which has been supposed to consist in debility, and which have recently assumed the dignified name of adynamic. That men who are capable of looking only at the most obvious appearances of things, who, satisfied with what they find at the surface, give themselves no concern to discover its source, should continue to mistake the effect for the cause, and to consider as in its own primary and essential nature, that to be debility which is the last result of long-continued and most destructive energy of action, is highly probable; but, on that very account, the fallacy is the more deeply to be deplored; because to these men must sometimes be committed the care of human beings who will fall certain victims to the error. It is easy to disregard the voice of reason when opposed to specious, however fallacious appearances; but it is difficult to withstand the evidence of sense. In justification of the strength of the language I use, I therefore appeal to the pathology I adduce. The notion of debility in the intense forms of fever I look upon to be an error no less palpable in its nature than destructive in its consequences; and if the havoc it produces do not confer upon it a pre-eminence as bad as that of the very disease of which it is supposed to constitute the essence, it at least entitles it, in comparison with every other error in medicine, to the distinction recognized in society, between the hero and the murderer: the one destroys a single human being now and then; but the other numbers its victims by thousands. It may be difficult to eradicate this mischievous opinion where it was first engendered, and where it still continues to be fostered, in the study of the falsely reasoning theorist; but it is easy to confute it at the table of the pathological anatomist; and it must ultimately fall, if not by the pen, by the scalpel.