TYPHUS FEVER, TRENCH FEVER, ETC. 935 



over Serbia during the winter of 1914 to 1915 ; and the disease 

 occurred in the Russian, Hungarian, Austrian, Balkan and Turkish 

 Armies throughout the subsequent years. At the present writing 

 there is much typhus in Russia, Serbia, Poland and in parts of 

 Turkey. 



The Disease. Among clinical descriptions of typhus the first 

 important scientific ones were those of Gerhard, Jenner and Murchi- 

 son. The differentiation between typhoid and typhus exanthematicus 

 was first made by Gerhard in 1837. Since then, the disease has been 

 clinically well characterized and, indeed, is not easy to mistake for 

 any other malady if once observed in a typical case. 



The incubation time may range from five to twenty-one days. 

 A case of autopsy infection published during the war took exactly 

 twelve days to develop. 



The onset may vary from extreme abruptness to a more gradual 

 one. We take the main points of our description from a recent study 

 by George C. Shattuck 1 on cases observed during the Serbian 

 epidemic. 



The temperature rises rapidly, often to from 103 to 104, with 

 chills, great depression, weakness, pains in the head and limbs. The 

 eruption appears on the fourth or fifth day after the onset and, 

 except in times of epidemic, the diagnosis is extremely difficult in 

 the pre-eruptive stage. As the eruption appears the fever is apt 

 to rise. The rash begins to appear usually on the shoulders and 

 trunk, extending secondarily to the extremities, the backs of the 

 hands and feet, and sometimes to the palms and soles. It becomes 

 more abundant during the subsequent second and third days, but 

 it is seen very rarely on the face and forehead. The rash is at first 

 composed of pink spots which disappear on pressure, but soon it 

 becomes purplish, more deeply brownish-red and finally fades into 

 a brown color. Hemorrhagic centers may later develop which persist 

 for considerable lengths of time. Shattuck saw no eruptions on 

 the mucous membranes of the mouth and pharynx. It is important 

 to remember (a thing which Shattuck points out and which we have 

 confirmed) in connection with the differential diagnosis between 

 typhus and purpura haemorrhagica that in the purpura, eruption 

 the spots are hemorrhagic from the beginning and are more sharply 



1 Kliattuck, Typhus TYvor, etc., Rep. Amor. Rod. Cross, Sorb. Epidemic, 

 Harvard Univ. Press, 1920. 



