Plotz has described an anaerobic, gramme-positive, bacillus which
he now identifies with Rickettsia prowazeki. (For similar disease-
carrying by body-lice, see TRENCH FEVER.)
Morbid Anatomy. There are no specific anatomical lesions. A certain amount of oedema of the lungs and hypostatic pneumonia is often present. The spleen is enlarged, usually of a dark red colour and juicy red pulp. The liver and kidney show cloudy swelling, and punctate haemorrhage may be present. In the intestine there are no changes in Peyer's patches, and the mesenteric glands are not enlarged. The heart muscle may show cloudy swelling and fatty degeneration. The cerebral spinal fluid may present a slight lymphocytosis.
Symptomatology. Incubation varies from 4 to 21 days, but is usually about to to 12 days. The onset is usually sudden, being characterized by severe headache, pains in various parts of the body, often rigours; marked rise of the temperature, quick pulse, flushed face and suffused eyes, and quickened respirations. The patient complains of extreme weakness. The duration of the fever on an average is 14 to 15 days. During the first 2 or 3 days the tem- perature continues to rise at night, with remission in the morning, to a maximum of 104 to 105 on the second to fourth day. During this time the tongue becomes dry, swollen, and coated with a thick brown deposit on the dorsum, while the tip and sides of the organ are red. The patient quickly becomes apathetic, drowsy, with dull expression. As the disease progresses, the rapidity of the pulse increases and may reach i a minute, and is usually small and of low tension. The respirations are generally quickened and there are usually signs of laryngitis and bronchitis and occasionally bronchial pneumonia. Delirium is known, especially at night.
Definite preliminary rashes are rare. What one generally sees the first two or three days of the disease is a very marked flushing of the face, neck and upper portion of the chest, with a subcuticular mottling of the skin of the lower part of the chest and abdomen (cutis marmorata). It should be noted at once that this symptom is far from being specific, a similar flushing being very often notice- able in many cases of Pappataci fever. The true typhus rash appears generally on the fourth or fifth day in the form of small roseolar spots, indistinguishable from typhoid roseola but often more abun- dant. According to some of the old authorities, it appears first on the arms and legs, but, in the writer's experience of Serbian and Polish epidemics, the rash generally starts on the abdomen and then spreads to the chest, arms and legs. The spots are at first roseolar and disappear completely on pressure, then some of the spots slowly fade away, while others become of darker hue and do not disappear completely on pressure, becoming petechiae, though it is rare for them to develop the dark blue appearance of petechiae in such eruptions as those of purpura. The rash, in a few cases, may remain
furely roseolar-like, without any of the spots becoming petechial. n exceptional cases, the rash may be absent altogether: typhus exanthematicus sine exanthema. The medical man with little expe- rience of typhus should be on his guard not to mistake for true typhus rash a petechial rash, the so-called Balkanic rash, due to bites of innumerable fleas, composed of numerous perfectly circular dark red petechiae, which is extremely common in the Balkans and in Galicia in peasants and soldiers. Anyone who has not been to those countries can hardly believe how profuse this rash can be. The whole body, with the exception perhaps of the face, is com- pletely covered with it, while the shirt of the sufferer may be abso- lutely black from the number of living fleas upon it. With a little Cractice one soon learns to distinguish the two rashes. Each flea- ite shows at first a central haemorrhagic spot surrounded by a hyperemic circular zone, which disappears on pressure. This peripheral hyperemic zone fades away spontaneously within a day or two, while the central haemorrhagic spot remains as a petechial area, which is, as a rule, perfectly circular, not raised, and of a dark red, sometimes copper-like, colour which does not disappear on pressure. In the blood there is often a marked leucocytosis, and a differential count shows a large increase of polymorphonu- clears. An interesting feature is the complete absence of eosinophiles in practically every case.
Termination. On or about the fifteenth day, the temperature generally falls by crisis, or, much more frequently, by rapid lysis which may extend through three to five days.
Convalescence may be slow, and fairly frequently there is danger during this stage, as the general condition may not improve after the cessation of the fever, and death may occur some two to three weeks after defervescence. In certain cases, while the temperature has become normal, the pulse does not improve, and the patient becomes weaker and weaker until he dies.
Complications and Sequelae. The most usual complications are: parotitis, ending often in suppuration, gangrene of feet and poly- arthritis; neuritis, hemiplegia, severe mental depression amounting almost to melancholia (seen during convalescence) may be men- tioned, also bubonic swellings; otitis media, abscesses and boils occur, while jaundice, endocarditis, and meningitis are rare, but myocarditis is fairly common.
It is interesting to note that different epidemics of typhus have been reported as being characterized by special features in regard to complications and sequelae; thus, the Serbian epidemic in 1914-5
showed a great tendency to gangrene of the feet, while those of Ireland have generally been associated with bronchial and pneu- monic complications. On the other hand, in the recent epidemics in Poland and Galicia, complications have been comparatively rare.
Diagnosis. The principal data on which to base the diagnosis are as follows:
(a) Incipient Typhus. (l) The sudden onset, often with head- ache, rigours, and vomiting. (2) The congested eyes and face and the subcuticular mottling of the skin over the chest. (3) The mental confusion and stupor, associated with the log-like attitude of the whole body. (4) The increased percentage of polymorphonu- clear in the differential count.
_(&) Fully Developed Typhus. (i) The typical rash. (2) The history of the sudden onset, etc. (3) Leucocytosis and increased polymorphonuclear percentage. (4) The Weil-Felix reaction, viz.,' the blood of typhus patients agglutinates a proteus-like germ, iso-j lated from the urine of some cases of typhus by Weil and Felix and called by them Proteus Xig.
Prognosis. The case mortality may be from 10 to 50% and, greatly varies in different epidemics. It is low in the young and very high in the old. The malady is slightly more fatal in males than in females, while alcoholism and kidney disease are bad prognostics. 1
Treatment. This is merely palliative. Patients suffering from typhus should be placed, whenever possible, in airy, well-ventilated wards, and in the summer months tents may be used with advantage. ', Cleanliness and good nursing are essential. During the febrile attack the diet should consist of broths and milk and soft solids, \vhilei plenty of water is allowed to be drunk. The temperature should be controlled by cool sponging and the nervous symptoms by ice to the head, hyoscin, bromides or morphine, while the heart is supported by hypodermic injections of strychnine and digitalin. Special atten- tion should be paid to the mouth and throat. The legs and feet should be kept warm and pressure on the feet, even from the bed- clothes, should be avoided, lest it contribute to the production of gangrene. Prostration is extreme in most typhus cases, and a most striking fact is the occurrence of many deaths after the period of defervescence, even when severe complications have not developed. To combat this extreme exhaustion, the administration of alcohol in moderate doses is sometimes useful.
Attempts at specific medication have been made by various authors, and Nicolle has prepared a serum, by injecting horses with emulsions of spleen and adrenals of guinea-pigs artificially inocu- lated, said to have good results, the dosage being 20 c.c. daily.
Prophylaxis. This consists in taking every possible measure for the destruction of lice. There is no doubt that heat, whenever it can be employed, is the most satisfactory means for the destruction of lice and their eggs in clothes, blankets, bedsheets, etc. When dry heat is used, a temperature of 68 C. for 15 minutes is the safe; standard for routine practice. When steam is used, articles should be submitted to a temperature of 100 C. for 30 minutes to allowi the steam to thoroughly penetrate all parts of the clothing. For disinfestation of rooms, barracks, etc., sulphur fumigation is prob-i ably the most satisfactory routine method. The rooms, whenever possible, should be sealed and rendered approximately airtight, and then the sulphur fumigation is carried out, using 5 to 8 Ib. of' sulphur per 1,000 cub. ft., the rooms remaining sealed up for a period: of not less than 12 hours.
With regard to the usual chemical insecticides, their utility is somewhat limited; among the liquid ones, petrol is, in practice, prob- ably the best ; guaiacol is a powerful licecide but is expensive. Among 1 solid insecticide substances, naphthalene is the most useful and con-| venient. It is interesting to note that according to Jackson's and 1 the writer's experiments in Serbia insecticide chemicals do not act; equally well on lice, bugs and fleas; for instance, pyrethrum (many patent insecticide powders are merely pyrethrum) acts powerfully on bugs while its action on lice is very slight; on the other hand,, iodoform, which will kill lice in 10-15 minutes, has no action on bugsj and very little on fleas. When an insecticide for general use is required therefore, several chemical substances should be combined, and the following powder has been found fairly efficacious, viz., naphthalene, previously soaked in guaiacol or creosote 3'j pyrethrum 3ij zinc oxide ad. 8- The wearing of undergarments made liceproof by soaking in crude carbolic acid and soft soap, as recommended by Bacot and others, has been found useful.
In badly infected districts a large number of bathing and disinfecting stations should be established and a general disinfection of people should be carried out. The following procedure, as adopted by the American Typhus Commission with most satisfactory results in the Serbian epidemic of 1914-5, is recommended. The infested person goes into a room, takes off the clothes, which are steamed or boiled, passes into another room where he is bathed, then into a third room where he is sprayed with petrol, and finally into a fourth room in which he receives clean or sterilized clothes. The sterilization of the clothes may be conducted by boiling, but better still by making them into lightly packed bundles and placing them in a truck or room into which steam is blown.
AUTHORITIES. Arkwright, Bacot and Duncan, Trans. Soc. Trap. Med. (1919) ; Borrel, Cantacuzene, Jonesco and Nasha, C.R. Soc. Biol. (1919); Gumming, Buchanan, Castellani and Visbecq, Report
